Medical Nutrition Therapy

Healthy lifestyle and nutritional choices can delay or prevent the development type II diabetes for many years. Simmons, Harding et al. found an inverse relationship between achievement of five life changes and the progression from pre-diabetes to diabetes. Study participants who were able to meet five goals prevented or significantly delayed the onset of diabetes.

  1. BMI <25 kg/m2,
  2. fat intake <30% of energy intake,
  3. saturated fat intake <10% of energy intake,
  4. fiber intake ≥15 g/4,184 kJ,
  5. physical activity >4 h/week)

Of course the challenge is meeting these health goals and maintaining their benefits. Your patient teaching could begin with online CDC and ADA infographics. By familiarizing yourself with these available learning aids you may be able to leverage the the public and private investment that has been made in the National Diabetes Prevention Program . Their evidence-based lifestyle change programs can reduce participants risk of T2DM. Click the infographic example.

The CDC, Medicare and the American Diabetes Association (ADA) supports the use of medical nutrition therapy (MNT) as part of a multidisciplinary approach in the treatment of diabetes. MNT applies nutrition and behavioral science to treat a specific physical condition. MNT for diabetes includes assessment of the patient's nutritional status and the collaborative development and implementation of an individualized diabetes self-management plan. The ADA also recommends "a registered dietitian, knowledgeable and skilled in MNT, should serve as an inpatient team member.

The dietitian is responsible for integrating information about the patient's clinical condition, eating, and lifestyle habits and for establishing treatment goals in order to determine a realistic plan for nutrition therapy". In the outpatient setting the Registered Dietician assists the patient to determine nutritional needs based upon desired weight, lifestyle, medication, and comorbidities, such as hypercholesterolemia, hypertension, renal or liver disease, etc.

The diabetes nurse educator can assist the patient to incorporate knowledge and behaviors into daily diabetes self-care.

Goals of nutrition therapy (Evert, 2019)

Adapted from The American Diabetes Association (ADA) Standards of Care in Diabetes - 2022
Medical nutrition therapy
Implementation of nutrition therapy

The (ADA) Standards of Care in Diabetes - 2023 recommendation is for timely, individualized medical nutrition therapy by consultation with a registered dietitian nutritionist with expertise in diabetes care for individuals with type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus.
Energy balance Behavioral and dietary modification to achieve and maintain at least a 5% weight loss for all individuals with overweight or obesity.
Eating patterns and
macronutrient
distribution

There is no single ideal macronutrient pattern for people with diabetes. Meal plans for people with diabetes need to consider the individual's access to minimally processed nutrients, total calorie intake, and personal metabolic goals.

Discuss various eating patterns for managing type 2 diabetes and preventing prediabetes

Reduce overall carbohydrate intake to improve glycemia for individuals with diabetes, and adapt their eating patterns to meet their individual needs and preferences.

Carbohydrates

Emphasize carbohydrate sources that are nutrient-dense, high in fiber (at least 14 g fiber per 1000 kcal), and minimally processed. Emphasize nonstarchy vegetables, fruits, legumes, whole grains, and dairy products with minimal added sugars.

While beans and pulses are generally considered to be a healthy food choice for people with diabetes, some research suggests that consuming a high-protein, carbohydrate-containing meal can cause a delayed drop in blood sugar levels in people with diabetes. This is because protein can stimulate the release of insulin, which can cause blood sugar levels to drop. In some cases, this delayed hypoglycemia can occur several hours after the meal.

Replace sugary drinks with water or low/no calorie beverages to control blood sugar, manage weight, and reduce the risk of cardiovascular disease and fatty liver. Limit consumption of added sugar foods to prioritize nutrient-dense options.

Personalize education regarding the glycemic impact of carbohydrates, fats, and proteins with attention to to optimize mealtime insulin dosing in flexible insulin therapy.

Educate individuals on the importance of consistent carbohydrate intake patterns (time and amount) when using a fixed insulin doses to improve glycemia and reduce hypoglycemia risk.
Protein T2DM persons experiencing hypoglycemia should avoid high-protein foods including beans, lentils, and other pulses until the hypoglycemia is controlled. Certain dietary cationic amino acids like arginine and alanine can cause pancreatic β cells to depolarize and secrete insulin that can exaccerbate hypoglycemia (Yanagisawa Y. 2023).
CLICK HERE for an interactive explanation of insulin secretion
Dietary Fat A Mediterranean-style eating plan with healthy n-3 long chain polyunsaturated fatty acids (n-3 LCPUFA) may improve glucose metabolism and reduce cardiovascular disease risk.
Micronutrients and
herbal supplements

There is no clear evidence that dietary supplementation with vitamins, minerals (such as chromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) can improve outcomes in people with diabetes who do not have underlying deficiencies, and they are not generally recommended for glycemic control. There may be evidence of harm for certain individuals with β carotene supplementation.

An analysis by Yang, J., Zhang, Y., Na, X., & Zhao, A. (2022), of 16 reports including 182,788 individuals from 10 unique trials found that β-carotene had no beneficial effects on the CVD incidence, but a risk was found for CVD mortality. The subgroup analyses showed it may be a risk factor for the smoking population and high-risk group.
Alcohol

If alcohol is consumed, it should be limited to no more than one drink per day for adult women and no more than two drinks per day for adult men to reduce the risk avoid alcohol-related delayed hypoglycemia. Patients being treated with insulin, sulfonylureas or insulin secretagogues need to monitor blood glucose for hypoglycemia when using alcohol. Liver metabolism of alcohol can interfere with the glycol
Sodium Limited to 2,300 mg/day. Excessive sodium has been associated with hypertension, cardiovascular disease and kidney disease, all of which are exaccerbated by diabetes.
Nonnutritive
sweeteners

Nonnutritive sweeteners as a sugar replacement can lower calorie and carbohydrate intake, but be mindful of not compensating with increased energy intake from other sources. Consider low- and no-calorie sweetened beverages can substitute for some water.
Obesity and Weight Management

Assessment

BMI For Adults Widget

 

Calculate BMI,  Comorbidities, previous experiences with weight loss

BMI category (kg/m2)
Treatment
25.0–26.9
☞ 23.0–24.9
27.0–29.9
☞ 25.0–27.4
≥30.0
☞ 27.5
Nutrition, physical activity, and behavioral counseling 
❖
❖
❖ 
Pharmacotherapy  
❖
❖
Metabolic surgery     

❖  Treatment may be indicated for select motivated individuals.
☞ Recommended BMI cut-off for Asian American individuals
Educate

Inform the patient of the health risks associated with overweight or obesity, weight distribution patterns, and the benefits of small attainable weight loss ≥5%
Interventions
  • Identify comorbid conditions that will affect weight management programs
  • Foster provider/patient collaboration and assure the patient that individualized supportive and effective behavioral modification programs are available.
  • Behavioral counseling for nutrition changes, increased physical activity and behavioral strategies  ≥ 16 sessions in 6 months to acheive 500-750 Kcal/day energy deficit
  • type 2 diabetes and overweight or obesity who have lost weight should be offered long-term (≥1 year) comprehensive weight loss maintenance programs meeting monthly with trained interventionist

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References

ADA Diabetes Standards of Care 2023, guideline summary. Guideline Central. (2021). https://www.guidelinecentral.com/guideline/14119/#section-anchor-1226429

Diabetesjournals.org. (n.d.). https://diabetesjournals.org/care/article/46/Supplement_1/S68/148055/5-Facilitating-Positive-Health-Behaviors-and-Well 

Dobrow, L., Estrada, I., Burkholder-Cooley, N., & Miklavcic, J. (2022). Potential Effectiveness of Registered Dietitian Nutritionists in Healthy Behavior Interventions for Managing Type 2 Diabetes in Older Adults: A Systematic Review. Frontiers in nutrition, 8, 737410. https://doi.org/10.3389/fnut.2021.737410

ElSayed NA, Aleppo G, Aroda VR, et al., on behalf of the American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl.1):S19–S40.

Evert, A. B., Dennison, M., Gardner, C. D., Garvey, W. T., Lau, K. H. K., MacLeod, J., Mitri, J., Pereira, R. F., Rawlings, K., Robinson, S., Saslow, L., Uelmen, S., Urbanski, P. B., & Yancy, W. S., Jr (2019). Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes care, 42(5), 731–754. https://doi.org/10.2337/dci19-0014

Hales C.M., Carroll M.D., Fryar C.D., Ogden C.L., (2020). Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. Centers for Disease Control and Prevention. National Center for Health Statistics. NCHS Data Brief No. 360. February 2020 https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf

Marincic, P. Z., Salazar, M. V., Hardin, A., Scott, S., Fan, S. X., Gaillard, P. R., Wyatt, C., Watson, L., Green, P., Glover, P., & Hand, M. (2019). Diabetes Self-Management Education and Medical Nutrition Therapy: A Multisite Study Documenting the Efficacy of Registered Dietitian Nutritionist Interventions in the Management of Glycemic Control and Diabetic Dyslipidemia through Retrospective Chart Review. Journal of the Academy of Nutrition and Dietetics, 119(3), 449–463. https://doi.org/10.1016/j.jand.2018.06.303

Simmons, R., Harding, A. et al. (2006) How much might achievement of diabetes prevention behavior goals reduce the incidence of diabetes if implemented at the population level? Diabetologia. 49(5).

Van Dael P. (2021). Role of n-3 long-chain polyunsaturated fatty acids in human nutrition and health: review of recent studies and recommendations. Nutrition research and practice, 15(2), 137–159. https://doi.org/10.4162/nrp.2021.15.2.137

Yanagisawa Y. (2023). How dietary amino acids and high protein diets influence insulin secretion. Physiological reports, 11(2), e15577. https://doi.org/10.14814/phy2.15577

Yang, J., Zhang, Y., Na, X., & Zhao, A. (2022). β-Carotene Supplementation and Risk of Cardiovascular Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients, 14(6), 1284. https://doi.org/10.3390/nu14061284