From starvation diets to personalized plans: Diabetes nutrition therapy through the years
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So-called “diabetes diets” have come a long way since the discovery of insulin in 1921, yet common themes underlying many eating plans today were first developed by registered dietitians more than a century ago, according to two speakers.
“Nutrition is not something new that we are just beginning to pay attention to,” Melinda D. Maryniuk, MEd, RDN, CDCES, FADA, senior consultant with Melinda Maryniuk & Associates in Boston, told Healio. “Back in the 1920s, people were already focusing on cultural foods and individualized diets in diabetes. As dietitians, we act like we are doing this for the first time. It is helpful to look back in history and realize that there was great work that was laid before us, and there are some things we should learn from.”
Diets before, after insulin
Prior to the discovery of insulin in 1921, regulating food intake — typically severely limiting carbohydrate and calories — was the only treatment for type 1 diabetes, Maryniuk said during a virtual presentation at the American Diabetes Association Scientific Sessions.
In 1915, Frederick M. Allen, MD, first wrote about “total dietary regulation” in the treatment of diabetes, noting that a very low-carbohydrate/low calorie diet was the best way to “clear glucose from the urine and extend life.”
The approach included three steps:
- Strict calorie reduction for 1 to 4 days, with a diet alternating coffee and whiskey (1 oz every 2 hours) until the urine was “free of sugar;”
- Preparing “thrice boiled vegetables” for 1 to 3 days; and
- A gradual addition of protein and fat to avoid a fast rise in glucose.
“Whiskey is not essential — it merely furnishes calories and keeps the patient comfortable,” the text states.
Insulin was heralded as a “miracle” cure, allowing children to consume enough calories to return to a healthy weight. Yet even in insulin’s early days, Elliott Joslin stressed the important of the “treatment triad” for diabetes management: insulin, exercise and diet, and the challenge to “get all three to work together,” Maryniuk said. Joslin was a proponent of the weighted diet in the post-insulin era.
“It was very restricted in terms of the kinds of foods allowed — how much grapefruit, how much orange, potato, oatmeal and cream one could have,” Maryniuk said. “In one of the Joslin books, grapefruit and oranges were the only recommended fruits in the early years. It said, ‘What should a diabetic do if given an apple?’ The answer was, ‘Throw it away.’”
Joslin diets included lists for food values every clinician was expected to memorize, Maryniuk said. Early plans were tightly structured, though diets became progressively more adapted and individualized, allowing for variation in quantity and food type. Still, other clinicians recommended very different diabetes eating plans, and there was debate on the optimal eating plan for diabetes.
“I visited Camp Joslin several times in the late 1970s as a new dietitian,” Maryniuk said. “I remember the boys taking their peaches from lunch, carving off the flesh, and weighing them on the gram scale until they had the precise amount they were prescribed, usually about 150 g. And then I moved to Florida, and their approach to meal planning at a diabetes camp there was so different. Healthy foods were served family style, kids selected what their appetite dictated. I realized then that there was no one approach to meal planning.”
Edward Tolstoi, MD, best known for advocating “the free diet,” recommended a diet that did not include a gram scale. People with diabetes could choose foods that do not differ from the diet consumed by other family members, as long as choices were healthy. Many other clinicians also pushed for an increase in carbohydrates to allow for a more normal life as early as 1933, Maryniuk said.
The Exchange Lists for Diabetes Meal Planning booklet was first published in 1950 by the Academy of Nutrition and Dietetics, the ADA and the U.S. Public Health Service Diabetes Branch to address a need for standardization in food values and terminology and to simplify nutrition messages. Even in 1950, individualized plans that “suit the special needs” of the person with diabetes were highlighted, Maryniuk said.
Individualized plans key
Today, the message of individualized nutrition therapy has become central, Hope Warshaw, MMSc, RD, CDE, BC-ADM, FADCES, said during the presentation, where she shared nutrition history from the 1980s into the future. Knowledge gained from the U.K. Prospective Diabetes Study (UKPDS), U.S. government food and nutrition polices, and the role of registered dietitians and registered dietitian nutritionists pushing the field forward have kept a focus on a critical need for person-centered care, Warshaw said.
“While over the years since the 1980s there have been tweaks made in the macronutrient recommendations — particularly carbohydrate and fat — and the addition of recommendations regarding the types of fats to consume and not consume, a consistent message has been to consider all elements of the person’s lifestyle, life schedule and eating habits,” Warshaw, owner of Hope Warshaw Associates, LLC, a nutrition and diabetes-focused consultancy based in Asheville, North Carolina, told Healio.
That message is even stronger in the ADA’s 2019 nutrition therapy consensus report, which states individual nutrition needs should be based on personal and cultural needs, literacy, numeracy, access to healthy foods, willingness and ability to make behavior changes and understanding a person’s barriers.
“Another important statement to guide our recommendations was added to the ADA nutrition recommendations in 2013,” Warshaw said. “That is, in clinician guidance, strive to maintain the pleasure of eating, limiting food choices only when indicated by scientific evidence.”
Eating habits are a challenge to change, Warshaw said; clinicians should strive to work with people from where they are and how they eat. She outlined four “common denominators” of healthy eating patterns, highlighted in the 2019 consensus report:
- Emphasize consumption of non-starchy vegetables;
- Minimize consumption of added sugars and refined grains;
- Choose whole foods over highly processed foods; and
- Replace sugar-sweetened beverages with water as often as possible.
“There is great interest in food, nutrition and eating patterns today,” Warshaw told Healio. “I expect that with continued interest and exploding research in this area, new findings for the general public as well as for people with different types of diabetes will impact future guidance. Areas to watch are the role of the gut microbiome in glycemic dysfunction and potential management, precision nutrition for diabetes care, optimizing artificial intelligence and machine learning to ease management burdens, and optimized strategies and programs, like online coaching platforms, to support necessary behavior changes to achieve positive outcomes.”
Perspective
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This session was a fantastic distillation of the evolution of the evidence-base that has informed diabetes medical nutrition therapy during the last 100 years. We could not think of two better registered diabetes nutritionists to present on this topic.
The RDN team member typically has the luxury of time when individualizing the eating plan for people with diabetes and prediabetes. At my institution, a new appointment with the RDN is 1 hour, and follow-up appointments are typically 30 minutes. It is very difficult to individualize a diabetes eating plan when the busy primary care provider, in a typical 20-minute return office visit, tries to provide an answer to the question, “What can I eat?" There are so many important things that need to be done during these appointments that often overshadow lifestyle behavior change opportunities.
Unfortunately, referrals to the RDN for a diabetes medical nutrition therapy session or to diabetes self-management education continue to be underutilized. We know from research, unless the person with diabetes receives ongoing support, it is difficult to maintain lifestyle behavior change over time. When an RDN with knowledge and expertise in diabetes management is not a member of the diabetes care team, the person with diabetes can often be provided with only a brief answer, a patient education booklet on the topic, or a recommendation for a diet that may not be evidence-based.
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Maryniuk M; Warshaw H. Diabetes “diets” since the discovery of insulin — looking back, then to the future. Presented at: American Diabetes Association Scientific Sessions, June 25-29, 2021 (virtual meeting).
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