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©2012 by the American Diabetes Association, Inc.® All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including duplication, recording, or any information storage and retrieval system, without the prior written permission of the American Diabetes Association.

Printed in the United States of America

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The suggestions and information contained in this publication are generally consistent with the Clinical Practice Recommendations and other policies of the American Diabetes Association, but they do not represent the policy or position of the Association or any of its boards or committees. Reasonable steps have been taken to ensure the accuracy of the information presented. However, the American Diabetes Association cannot ensure the safety or efficacy of any product or service described in this publication. Individuals are advised to consult a physician or other appropriate health care professional before undertaking any diet or exercise program or taking any medication referred to in this publication. Professionals must use and apply their own professional judgment, experience, and training and should not rely solely on the information contained in this publication before prescribing any diet, exercise, or medication. The American Diabetes Association—its officers, directors, employees, volunteers, and members—assumes no responsibility or liability for personal or other injury, loss, or damage that may result from the suggestions or information in this publication.

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American Diabetes Association

1701 North Beauregard Street

Alexandria, Virginia 22311

DOI: 10.2337/9781580404723

Library of Congress Cataloging-in-Publication Data

American Diabetes Association guide to nutrition therapy for diabetes / [edited by] Marion J. Franz, Alison Evert. -- 2nd ed.

p. ; cm.

Guide to nutrition therapy for diabetes

Rev. ed. of: American Diabetes Association guide to medical nutrition therapy for diabetes. c1999.

Includes bibliographical references and index.

Summary: “This book will help the reader guide patients towards medical nutrition therapy, through nutrition assessment, nutrition diagnosis, nutrition interventions (education, counseling, and goal setting), and nutrition monitoring and evaluation”--Provided by publisher.

ISBN 978-1-58040-472-3 (alk. paper)

I. Franz, Marion J. II. Evert, Alison B. III. American Diabetes Association. IV. American Diabetes Association guide to medical nutrition therapy for diabetes. V. Title: Guide to nutrition therapy for diabetes.

[DNLM: 1. Diabetes Mellitus--diet therapy--Practice Guideline. WK 818]

616.4'620654--dc23

2012009189

eISBN: 978-1-58040-488-4

Contents

Preface/Acknowledgments

Marion J. Franz, MS, RD, CDE Alison B. Evert, MS, RD, CDE

Foreword

John P. Bantle, MD

Diabetes Nutrition Therapy

1. Effectiveness of Medical Nutrition Therapy in Diabetes

Joyce Green Pastors, MS, RD, CDE, and Marion J. Franz, MS, RD, CDE

2. Macronutrients and Nutrition Therapy for Diabetes

Marion J. Franz, MS, RD, CDE

3. Micronutrients and Diabetes

Joshua J. Neumiller, PharmD, CDE, CGP, FASCP

4. Alcohol and Diabetes

Marion J. Franz, MS, RD, CDE

Diabetes Nutrition Therapy Interventions

5. Nutrition Therapy for Adults with Type 1 and Insulin-Requiring Type 2 Diabetes

Alison B. Evert, MS, RD, CDE

6. Nutrition Therapy for Adults with Type 2 Diabetes

Hope S. Warshaw, MMSc, RD, CDE, BC-ADM

7. Nutrition Therapy for Youth with Diabetes

Gail Spiegel, MS, RD, CDE

8. Nutrition Therapy for Older Adults with Diabetes

Kathleen Stanley, MSEd, RD, CDE, BC-ADM

9. Nutrition Therapy for Pregnancy, Lactation, and Diabetes

Diane M. Reader, RD, CDE

10. Diabetes Nutrition Therapy for Sports and Exercise

Carla Cox, PhD, RD, CDE, CSSD

11. Nutrition Therapy for the Hospitalized and Long-Term Care Patient with Diabetes

Carrie S. Swift, MS, RD, BC-ADM, CDE

Diabetes Nutrition Therapy and Diabetes-Associated Complications

12. Nutrition Therapy for Diabetes: Hypoglycemia and Sick Days

Janine Freeman, RD, CDE

13. Nutrition Therapy for Diabetes and Lipid Disorders

Wahida Karmally, DrPH, RD, CDE, CLS, and Jacqueline Santora Zimmerman, MS, RD

14. Nutrition Therapy for Diabetes and Hypertension

Karin Aebersold, MPH, Natania Wright Ostrovsky, PhD, and Judith Wylie-Rosett, EdD, RD

15. Nutrition Therapy for Diabetic Kidney Disease

Madelyn L. Wheeler, MS, RD, CDE, FADA

16. Nutrition Therapy for Diabetes and Celiac Disease

Carol Brunzell, RD, CDE

17. Nutrition Therapy for Cystic Fibrosis–Related Diabetes

Carol Brunzell, RD, CDE

18. Nutrition Therapy for Diabetic Gastropathy

Meghann Moore, MPH, RD, CDE

19. Nutrition Therapy for Bariatric Surgery and Diabetes

Margaret Furtado, MS, RD, LDN, and Alison B. Evert, MS, RD, CDE

Diabetes Nutrition Therapy and Technology

20. Integrating Nutrition Therapy, Blood Glucose Monitoring, and Continuous Glucose Monitoring

Margaret A. Powers, PhD, RD, CDE, and Mary M. Austin, MA, RD, CDE, FAADE

21. Integrating Nutrition Therapy into Insulin Pump Therapy

Alison B. Evert, MS, RD, CDE

Diabetes Nutrition Therapy Education

22. Effective Nutrition Education and Counseling

Jackie Boucher, MS, RD, CDE

23. Health Literacy and Numeracy in Diabetes Nutrition Therapy and Self-Management Education

Marjorie Cypress, PhD, CNP, CDE

24. Cost-Effectiveness of Diabetes Medical Nutrition Therapy

Carolyn C. Harrington, RD, CDE

Nutrition Therapy for Prevention of Diabetes

25. Nutrition Therapy and Prediabetes

Gretchen Youssef, MS, RD, CDE

26. Integrating Nutrition Therapy into Community-Based Diabetes Prevention Programs

Ann Albright, PhD, RD, and Heather Devlin, MA

Preface/Acknowledgments

Nutrition therapy is the implementation of evidence-based nutrition recommendations and interventions. As new discoveries in the science of nutrition and diabetes are reported, nutrition therapy, if needed, changes. In 1971, the American Diabetes Association (ADA) published its first report on diabetes nutrition recommendations (ADA 1971). These recommendations have been updated in five position statements (ADA 1979, 1987, 1994, 2002, 2008), technical reviews (Franz 1994, 2002), and a systematic review (Wheeler 2012). A summary of the position statements is also incorporated into the annual ADA Standards of Care. The 1994 recommendations perhaps drew the most attention by the public when they reported that total, not the type of, carbohydrate affected blood glucose levels and sugary foods could be substituted for starchy foods. Additionally, before the 1994 recommendations, all position statements attempted to identify an “ideal” nutrition prescription with ideal percentages of carbohydrate, protein, and fat that would apply to everyone with diabetes. Although the need for individualization was stressed in all prior position papers, nutrition prescriptions, which were commonly given by physicians, for specific calorie levels and/or percentages of macronutrients, really did not allow for much, if any, individualization. The 1994 position statement also recommended that individualized nutrition prescriptions be based on metabolic profiles, treatment goals, and, perhaps most importantly, changes the person with diabetes is willing and able to make.

The Academy of Nutrition and Dietetics (Acad Nutr Diet, formerly the American Dietetic Association) published its first set of nutrition practice guidelines for type 2 and type 1 diabetes in 1995 and 1998, respectively (Monk 1995; Kulkarni 1998). Both sets of guidelines were field-tested in randomized clinical trials and shown to be effective (Franz 1995; Kulkarni 1998). Updates were published in 2001 and in the Acad Nutr Diet Evidence Analysis Library (American Dietetic Association 2001; Acad Nutr Diet 2008a). The guidelines for nutrition therapy for gestational diabetes were also published and field-tested (Reader 2006) and updated (Acad Nutr Diet 2008b). Nutrition practice guidelines for type 1 and type 2 diabetes in adults also have been updated and published (Franz 2010). Medical nutrition therapy has repeatedly been shown to be effective and essential in the prevention of diabetes and in the management of diabetes and its complications. However, just as there is no one medication or insulin therapy that applies to all people with diabetes, there is no one nutrition therapy intervention that applies to all people with diabetes. A goal of this guide is to assist health care providers in the selection of appropriate individualized nutrition therapy interventions.

The 1999 American Diabetes Association Guide to Medical Nutrition Therapy for Diabetes served as the basis for this guide. Authors were asked to update the available 1999 chapters by reviewing the evidence published after 1998. If evidence analysis was available in the current reviews by the Acad Nutr Diet and ADA (www.adaevidence; Franz 2010; Acad Nutr Diet 2008), they were asked to briefly summarize this evidence. Chapter authors also conducted a literature search for evidence published after these summaries. Chapters include tables of the new evidence, conclusions from the evidence, and recommendations for integrating diabetes nutrition therapy into the management of diabetes and its complications or for the prevention of diabetes. This guide is intended to serve as a resource for all health care professionals interested in the evidence supporting nutrition therapy interventions, not just for macro- and micronutrients, but for all the related areas of diabetes management in which nutrition therapy is essential.

It has been an honor and a pleasure to edit this text. We are truly indebted to the talented chapter authors for the thoroughness and thoughtfulness given to writing their chapters. They truly represent the many excellent clinicians and researchers interested in the field of diabetes nutrition. We also thank the reviewers, especially Stephanie Dunbar, Director of Nutrition and Clinical Affairs for the ADA, who directed the review. Special thanks go to Victor Van Beuren, our editor, who kept us on target and committed to the proposed timeline. And, of course, thanks go to the American Diabetes Association for its ongoing recognition of the integral role of nutrition therapy in the treatment of diabetes and its dedication to providing professionals with the latest available evidence.

Marion J. Franz, MS, RD, CDE

Alison B. Evert, MS, RD, CDE

Bibliography

Academy of Nutrition and Dietetics: Evidence Analysis Library. Available at http://www.adaevidencelibrary.com. Accessed January 2012

Academy of Nutrition and Dietetics: Diabetes Type 1 and 2 for Adults Evidence-Based Nutrition Practice Guidelines, 2008a. Available at http://www.adaevidencelibrary.com/topic.cfm?=3251. Accessed January 2012

Academy of Nutrition and Dietetics: Gestational Diabetes Mellitus (GDM) Evidence-Based Nutrition Practice Guidelines, 2008b. Available at http://www.adaevidencelibrary.com/topic.cfm?=3731. Accessed January 2012

American Diabetes Association: Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 25:202–212, 2002

American Diabetes Association: Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 31 (Suppl. 1):S61–S78, 2008

American Diabetes Association: Nutrition recommendations and principles for individuals with diabetes mellitus: 1986 (Position Statement). Diabetes Care 10:126–132, 1987

American Diabetes Association: Nutrition recommendations and principles for people with diabetes mellitus (Position Statement). Diabetes Care 17:519–522, 1994

American Diabetes Association: Principles of nutrition and dietary recommendations for individuals with diabetes mellitus: 1979 (Special Report). Diabetes 28:1027–1030, 1979

American Diabetes Association: Principles of nutrition and dietary recommendations for patients with diabetes mellitus: 1971 (Special Report). Diabetes 9:633–634, 1971

American Dietetic Association: Nutrition Practice Guidelines for Type 1 and Type 2 Diabetes [CD-ROM]. Chicago, American Dietetic Association, 2001

Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson J-L, Garg A, Holzmeister LA, Hoogwerf B, Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M: Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications (Technical Review). Diabetes Care 25:148–198, 2002

Franz MJ, Horton ES, Bantle JP, Beebe CA, Brunzell JD, Coulston AM, Henry RR, Hoogwerf BJ, Stacpoole PW: Nutrition principles for the management of diabetes and related complications (Technical Review). Diabetes Care 17:490–518, 1994

Franz MJ, Monk A, Barry B, McLain K, Weaver T, Cooper N, Upham P, Bergenstal R, Mazze RS: Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. J Am Diet Assoc 95:1009–1017, 1995

Franz MJ, Powers MA, Leontos C, Holzmeister LA, Kulkarni K, Monk A, Wedel N, Gradwell E: The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc 110:1852–1889, 2010

Kulkarni K, Castle G, Gregory R, Holmes A, Leontos C, Powers M, Snetselarr L, Splett P, Wylie-Rosett J: Nutrition practice guidelines for type 1 diabetes mellitus positively affect dietitian practices and patient outcomes. J Am Diet Assoc 98:62–70, 1998

Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ: Practice guidelines for medical nutrition therapy by dietitians for persons with non-insulin-dependent diabetes. J Am Diet Assoc 95:999–1008, 1995

Reader D, Splett P, Gunderson EP, for the Diabetes Care and Education Dietetic Practice Group: Impact of gestational diabetes nutrition practice guidelines implemented by registered dietitians on pregnancy outcomes. J Am Diet Assoc 106:1426–1433, 2006

Wheeler ML, Dunbar SA, Jaacks LM, Karmally W, Mayer-Davis EJ, Wylie-Rosett J, Yancy WS Jr: Macronutrients, food groups, and dietary patterns in the management of diabetes mellitus: a systematic review of the literature, 2010. Diabetes Care 35:434–445, 2012

Foreword

John P. Bantle, MD

Optimal treatment of diabetes mellitus requires nutrition therapy, an exercise program, and, for most patients, medication(s). When patients fail to achieve diabetes treatment goals, it is usually because one or more of these fundamental treatment modalities has not been effectively implemented. For many patients, the most challenging part of the treatment program (and thus the part of the program that often is not done well) is nutrition therapy. Patients often have difficulty understanding nutrition therapy. Moreover, many have difficulty putting their plan into action.

There are at least five reasons why understanding and adhering to nutrition therapy is difficult. First, nutrition recommendations have changed over time, with new recommendations sometimes contradicting previous recommendations. The contradictions have usually resulted from recommendations made in the absence of scientific evidence. The recommendations must then be modified or even abandoned when evidence becomes available. This creates confusion and erodes confidence in the recommendations. Second, many physicians do not themselves understand the principles of nutrition therapy and do not emphasize the importance of strategies to achieve food and nutrition goals. Thus, patients often do not recognize the importance of nutrition therapy. A third reason that nutrition therapy is difficult is that adhering to any eating pattern is challenging if that eating pattern differs from the usual eating pattern followed by family, friends, and cultural group. Even the most motivated of patients is likely to develop a sense of deprivation if asked to avoid foods that others are eating and enjoying. Any recommendation to depart from usual eating habits should be made only if there is compelling scientific evidence of potential benefit. Fourth, in our society, food has many purposes in addition to meeting biological needs. Food is often the focus of social activities and is frequently used as a reward, as a means of expressing affection, and as a way to help cope with stress. We are constantly exposed to appealing advertisements for food that exploit these factors. Even the most motivated of patients can be expected to occasionally succumb to these influences. Fifth, and very importantly, it is now clear that energy intake, energy expenditure, and body weight are regulated in the central nervous system. Thus, when we ask overweight or obese patients with diabetes to reduce energy intake and lose weight, we are asking them to override a powerful biological control system. Most of us have great difficulty making this change.

Although nutrition therapy is difficult and there are barriers to overcome, we should still do everything we can to implement it effectively. Healthy eating patterns are a key element in establishing good control of glycemia and lipemia and thereby preventing the complications of diabetes and its companion atherosclerosis. Without a strong nutrition component, most treatment plans will fall short. However, we must keep in mind that only a limited number of dietary strategies have documented efficacy. Marion Franz and Alison Evert and their chapter authors have done an outstanding job of describing these strategies in the American Diabetes Association Guide to Nutrition Therapy for Diabetes. They also carefully point out gaps in our knowledge, allowing us to avoid making unsubstantiated recommendations. I believe this volume belongs in the bookshelf of every health care provider who deals with patients who have diabetes mellitus.

John P. Bantle is Professor of Medicine and Director, Division of Endocrinology and Diabetes, University of Minnesota, Minneapolis, MN.

American Diabetes Association Guide to Nutrition Therapy for Diabetes

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