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January 3, 2008

2008 ADA Guidelines for Medical Nutrition Therapy

The American Diabetes Association (ADA) has updated its guidelines

regarding medical nutrition therapy (MNT), including the use of

low-carbohydrate diets

to prevent diabetes, manage existing diabetes, and prevent or slow the

rate of development of diabetes complications.

The revised position statement, which is published in the January issue

of Diabetes Care, updates those from 2002 and 2004, presenting

evidence-based data

published since 2000 and grading of recommendations according to the

level of evidence available, based on the ADA evidence-grading system.

P. Bantle, and colleagues from the ADA.write, " The goal of these

recommendations is to make people with diabetes and health care

providers aware of

beneficial nutrition interventions. " " This requires the use of the best

available scientific evidence while taking into account treatment goals,

strategies

to attain such goals, and changes individuals with diabetes are willing

and able to make. Achieving nutrition-related goals requires a

coordinated team

effort that includes the person with diabetes and involves him or her in

the decision-making process. "

In addition to listing major nutritional recommendations and

interventions for diabetes, the updated position statement stresses the

importance of monitoring

metabolic parameters, including glucose and glycated hemoglobin levels,

lipids, blood pressure, body weight, and renal function, during therapy.

Such monitoring

will help evaluate the need for changes in MNT and thereby optimize

outcomes. The authors note that many aspects of MNT require additional

research.

Some of the specific recommendations include the following:

list of 18 items

.. Individuals with prediabetes or diabetes should receive individualized

MNT, preferably administered by a registered dietitian knowledgeable

about the

components of diabetes MNT (.

.. Nutrition counseling should be tailored to the personal needs of the

individual with prediabetes or diabetes and his or her willingness and

ability to

make changes (E).

.. Modest weight loss in overweight and obese insulin-resistant

individuals has been shown to improve insulin resistance and is

therefore recommended for

all such individuals who have or are at risk for diabetes (A).

.. In the short-term (up to 1 year), either low-carbohydrate or low-fat,

energy-restricted diets may be effective for weight loss (A).

.. Patients receiving low-carbohydrate diets should undergo monitoring of

lipid profiles, renal function, and protein intake (in patients with

nephropathy),

and have adjustment of hypoglycemic therapy as needed (E).

.. Physical activity and behavior modification aid in weight loss and are

most helpful in maintaining weight loss (.

.. When combined with lifestyle modification, weight loss medications may

help achieve a 5% to 10% weight loss and may be considered for

overweight and obese

individuals with type 2 diabetes (.

.. For some patients with type 2 diabetes and a body mass index of 35

kg/m2 or more, bariatric surgery can markedly improve glycemia (.

.. Primary prevention for individuals at high risk of developing type 2

diabetes should include structured programs targeting lifestyle changes,

with dietary

strategies of decreasing energy and dietary fat intakes. Goals should

include moderate weight loss (7% body weight), regular physical activity

(150 minutes/week)

(A), dietary fiber intake of 14 g/1000 kcal, and whole grains comprising

half of total grain intake (.

.. Intake of low-glycemic index foods that are rich in fiber and other

vital nutrients should be encouraged (E), both for the general

population and for

those with diabetes.

.. Data do not support recommending alcohol consumption to individuals at

risk for diabetes (.

.. Secondary prevention, or controlling diabetes, should include a

healthy dietary pattern emphasizing carbohydrate from fruits,

vegetables, whole grains,

legumes, and low-fat milk (.

.. A key strategy for achieving glycemic control is to monitor

carbohydrate by counting, exchanges, or experienced-based estimation

(A). Use of glycemic

index and load may be modestly beneficial vs considering only total

carbohydrate (.

.. Sucrose-containing foods should be limited but can be substituted for

other carbohydrates or covered with insulin or other glucose-lowering

medications

(A). Glucose alcohols and nonnutritive sweeteners are safe within daily

US Food and Drug Administration intake levels (A).

.. Saturated fat should be limited to less than 7% of total energy (A),

and trans fat should be minimized (E). In individuals with diabetes,

dietary cholesterol

should not exceed 200 mg/day (E).

.. At least 2 servings of fish per week (except for commercially fried

fish) are recommended for n-3 polyunsaturated fatty acids (.

.. Protein should not be used to treat acute or prevent nighttime

hypoglycemia (A). High-protein diets are not recommended for weight loss

(E).

.. If adults with diabetes choose to use alcohol, intake should be

restricted to 1 drink per day or less for women and 2 drinks per day or

less for men (E)

and consumed with food (E).

list end

Practice Pearls

list of 2 items

.. Previous research has suggested that MNT can reduce glycated

hemoglobin levels by approximately 1% for patients with type 1 diabetes

and 1% to 2% for

patients with type 2 diabetes.

.. The current guidelines do not recommend low-glycemic index or

high-protein diets for the routine treatment of patients with diabetes.

Moreover, most patients

with diabetes should not routinely receive supplements or vitamins.

list end

The ADA has issued practice guidelines for screening, diagnostic, and

treatment interventions that are known or believed to improve health

outcomes of patients

with diabetes. Each recommendation is graded by the ADA as A, B, C, or E

to indicate the level of supporting evidence.

Diabetes Care. 2008;31(Suppl 1):S61-S78.

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