ADA Nutrition Therapy for Adults with Diabetes—2019 Consensus Report
Alison B. Evert, MD
UW Neighborhood Clinics, UW Medicine, University of Washington, Seattle, WA, USA Janice MacLeod, MA, RDN, CDE
Companion Medical, San Diego, CA, USA William S. Yancy, Jr., MD, MHS
Duke University, Durham, NC, USA W. Timothy Garvey, MD
University of Alabama, Birmingham, AL, USA Ka Hei Karen Lau, MS, RD, LDN, CDE
Joslin Diabetes Center, Boston, MA, USA Christopher D. Gardner, PhD
Stanford Prevention Research Center, Stanford, CA, USA Kelly M. Rawlings, MS
Vida Health, San Francisco, CA, USA
Much progress has been made to improve evidence-based nutrition recommendations for prevention and management of diabetes since the 2014 ADA nutrition position statement.
Today, strong evidence supports the efficacy and cost-effectiveness of nutrition therapy as a component of quality diabetes care, including its integration into the medical management of diabetes.
It is important that all members of the health care team know and champion the benefits of nutrition therapy and key nutrition messages.
Nutrition counseling–that works toward improving or maintaining glycemic targets, achieving weight management goals, and improving cardiovascular risk factors within individualized treatment goals–is recommended for all adults with diabetes and prediabetes.
This Consensus Report is intended to provide clinical professionals with evidence-based guidance about individualizing nutrition therapy for adults with diabetes or prediabetes.
These clinicians and researchers overviewed the 2019 ADA Consensus Report on Nutrition Therapy for Adults with Diabetes or Prediabetes. This newly-updated report is intended to provide clinical professionals with evidence-based guidance on how to individualize nutrition therapy for adults with diabetes or prediabetes.
Today, there is strong evidence to support both the efficacy and cost-effectiveness of nutrition therapy as a key component of integrated management of individuals with diabetes. This is increasingly relevant as it is evident that “one-size-fits-all” eating plan is not suitable for prevention or management of diabetes, also considering diverse cultural backgrounds, personal preferences, comorbidities, and socioeconomic settings. The American Diabetes Association (ADA) is now emphasizing that medical nutrition therapy (MNT) is fundamental for optimal diabetes management, and the new report also includes information on prediabetes.
As highlighted, educational interventions are important in achieving the goals of nutritional therapy, namely promoting healthy eating patterns, appropriate portion sizes, and address individual nutrition needs, while maintaining the pleasure of eating and providing practical tools for planning meals. MNT, at least in the USA, refers to evidence-based application of nutritional care by a registered nutritionist.
One of the key recommendations is to refer adults living with type 1 or type 2 diabetes to individualized, diabetes-focused MNT at diagnosis and as needed throughout the life span, particularly during times of changing health status to achieve treatment goals.
The MNT plan must also be coordinated and aligned with the overall management strategy, including use of medications, physical activity, etc., on an ongoing basis. In addition, people with prediabetes and overweight/obesity should be referred to an intensive lifestyle intervention program that includes individualized goal-setting components, such as the Diabetes Prevention Program (DPP) and/or to individualized MNT.
Another major recommendation is to refer adults with diabetes to comprehensive diabetes self-management education and support (DSMES) services according to national standards.
Eating patterns are made up of combinations of different foods or food groups, representing the totality of all foods and beverages consumed.
These differ from eating plans, which can be considered as guides that individuals use to plan what, when, and how much to eat on a daily basis.
The new consensus recommendations consider that a variety of eating patterns are acceptable for the management of diabetes.
In the absence of additional strong evidence on the comparative benefits of different eating patterns in specific individuals, healthcare providers should focus on the key factors that are common among the patterns, including emphasizing non-starchy vegetables, minimizing added sugars and refined grains, and preferring whole foods over highly processed foods.
Reducing overall carbohydrate intake for individuals with diabetes is associated with the most evidence for improving glycemia and may be applied in a variety of eating patterns.
For selected adults with type 2 diabetes who are not meeting glycemic targets or where reducing anti-glycemic medications is a priority, reducing overall carbohydrate intake with low or very low carbohydrate eating plans is also a viable approach.
At least two key recommendations have been changed with regards to previous guidance in the previous consensus statement.
One is that a low carbohydrate diet is now recognized as a safe, viable, and important option for patients with diabetes, and the other is that greater emphasis is now placed on weight loss in patients who are overweight/obese for the prevention of diabetes and its treatment.
The new report states that healthful eating patterns should be promoted, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, in order to improve overall health and to improve HbA1C, blood pressure, and cholesterol levels, although the goals can be individualized depending on the specific characteristics of the patient.
Patients should be encouraged to achieve and maintain body weight goals in order to delay or prevent diabetes-related complications.
Indeed, in type 2 diabetes, 5% weight loss is recommended to achieve clinical benefits, with a goal of 15%, when feasible and safe, in order to achieve optimal outcomes.
In select individuals with type 2 diabetes, an overall healthy eating plan that results in energy deficit in conjunction with weight loss medications and/or metabolic surgery should be considered to help achieve weight loss and maintain goals, lower HbA1c , and reduce cardiovascular risk.
In conjunction with lifestyle therapy, medication-assisted weight loss can be considered for people at risk for type 2 diabetes when needed to achieve and sustain 7–10% weight loss.
In prediabetes, the goal is 7–10% for preventing progression to type 2 diabetes.
For macronutrients, the available evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.
When counseling people with diabetes, a key strategy to achieve glycemic targets should include an assessment of current dietary intake followed by individualized guidance on self-monitoring carbohydrate intake to optimize meal timing and food choices and to guide medication and physical activity recommendations.
People with diabetes and those at risk for diabetes are encouraged to consume at least the amount of dietary fiber recommended for the general population; increasing fiber intake, preferably through food (vegetables, pulses (beans, peas, and lentils), fruits, and whole intact grains) or through dietary supplement, may help in modestly lowering HbA1C.
Several recommendations were also made with regards to insulin dosing:
For individuals with type 1 diabetes, intensive insulin therapy using a carbohydrate counting approach can result in improved glycemia and is recommended.
For adults using fixed daily insulin doses, consistent carbohydrate intake with respect to time and amount, while considering the insulin action time, can result in improved glycemia and reduce the risk for hypoglycemia.
When consuming a mixed meal that contains carbohydrate and is high in fat and/or protein, insulin dosing should not be based solely on carbohydrate counting.
A cautious approach to increasing mealtime insulin doses is suggested; continuous glucose monitoring or self-monitoring of blood glucose should guide decision-making for administration of additional insulin.
Considering the excess intake of sweetened beverages overall, two recommendations were made in this regard.
Firstly, sugar-sweetened beverages should be replaced with water as often as possible.
Secondly, if sugar substitutes are used to reduce overall calorie and carbohydrate intake, people should be counseled to avoid compensating with intake of additional calories from other food sources.
For alcohol, it is recommended that adults with diabetes or prediabetes who drink alcohol do so in moderation (one drink or less per day for adult women and two drinks or less per day for adult men).
Also, educating people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended.
To reduce hypoglycemia risk, the importance of glucose monitoring after drinking alcohol beverages should be emphasized.
Translation to Practice
Ideally, an individualized eating plan should be developed in collaboration with the person with prediabetes or diabetes and a registered dietician through participation in diabetes self-management education when a diagnosis of prediabetes or diabetes is made.
Nutrition therapy recommendations need to be adjusted regularly based on changes in an individual’s life circumstances, preferences, and disease course. Regular follow-up with a diabetes healthcare provider is also critical to adjust other aspects of the treatment plan as indicated.
Jose C. Florez, MD, PhD
Chair, ADA Scientific Sessions Meeting Planning Committee
The 79th American Diabetes Association’s Scientific Sessions were held in San Francisco, California from June 7-11, 2019. The meeting was attended by over 15,000 professional attendees from 115 countries, … [ Read all ]
Presented by: Alison B. Evert, MD; Janice MacLeod, MA, RDN, CDE; William S. Yancy, Jr., MD, MHS; W. Timothy Garvey, MD; Ka Hei Karen Lau, MS, RD, LDN, CDE; Christopher D. Gardner, PhD; Kelly M. Rawlings, MS