ResearchCommentary2006-2007 American Diabetes Association Nutrition Recommendations: Issues for Practice Translation
Section snippets
Prevention Continuum
The recommendations are organized to focus on preventing diabetes and controlling the effects diabetes on a variety of body systems. Medical nutrition therapy (MNT) and lifestyle interventions are important in all three levels of diabetes-related prevention (5). Primary prevention interventions are designed to delay or halt the development of diabetes. Secondary and tertiary prevention interventions include MNT for individuals with diabetes and seek to prevent (secondary) or manage (tertiary)
Evidence-Based Review Process for Nutrition Recommendations
The American Diabetes Association clinical practice recommendations (6), including specific nutrition recommendations, undergo an annual review by its Professional Practice Committee (7) and are reissued every year as a January Diabetes Care supplement (6). Periodically, the nutrition recommendations are subjected to more extensive revisions by a writing committee composed of nutrition experts in diabetes and areas important to diabetes management. Figure 1 lists key changes made in the 2006
Tailoring Implementation of the Nutrition Recommendations
The recommendations stress the importance of tailoring nutrition goals to the diverse needs of people who have diabetes or are at risk for developing diabetes. The American Diabetes Association recommendations are flexible with emphasis on achieving desired health and quality of life goals. Thus, translating the nutrition recommendations into practice involves considering the whole person within the context of the individual’s life situation, personal preferences and attitudes, and resources.
Nutrition Recommendations to Delay/Prevent Diabetes (Primary Prevention)
Recommendations to prevent diabetes, which are partially listed in Figure 3, focus on lifestyle strategies, which emphasize reduced energy intake for weight control and increased physical activity. The recommendations are based on the evidence from the multicenter Diabetes Prevention Program (DPP) randomized controlled clinical trial (23), which was conducted in a diverse population with prediabetes, as well as earlier studies in China and Finland (24, 25). Data from the DPP and the Finnish
Nutrition Recommendations to Prevent Complications (Secondary Diabetes Prevention)
An overall goal of diabetes MNT is to prevent diabetic complications by improving the biomarkers, based on the “ABCs” approach (26, 27) focusing on:
“A”: HbA1c (blood glucose levels in the normal range or as close to normal as is safely possible with an overall goal of achieving less than 7% for HbA1c); “B”: Blood pressure (levels in the normal range [120/80 mm Hg] or as close to normal as is safely possible to reduce the risk for micro and macro vascular disease); and “C”: Cholesterol (lipid
Recommendations to Manage and Control Complications (Tertiary Diabetes Prevention)
Research to guide MNT recommendations for diabetic complications is limited. Therefore, extrapolation and expert opinion largely guide the development of recommendations. The issues related to MNT for diabetic complications are listed in Figure 4.
Research Issues
The American Diabetes Association nutrition recommendations (1) are based on current knowledge and with acknowledgement of gaps and limitations in research. Major clinical trials have provided strong evidence for the role of MNT (intensive lifestyle intervention) in primary prevention of diabetes (22, 23, 24); the Cochrane database systematic review (42) has indicated an urgent need for well-designed studies of dietary advice, which examine a range of interventions and MNT approaches in type 2
Putting Evidence into Practice
The nutrition recommendations (1) from the American Diabetes Association provide a framework to address nutrition within the context of overall diabetes clinical care recommendations (6). Figure 5 lists some key recommendations for implementation based on specific patient needs. Achieving the nutrition-related goals outlined in the American Diabetes Association recommendations requires a coordinated team effort that includes the person with or at risk for diabetes, who ultimately makes the
Conclusions
Nutrition recommendations and interventions for diabetes focus on monitoring of metabolic parameters, including glucose, HbA1c, lipids, blood pressure, body weight, and renal function, which are essential to assess the need for changes in therapy and to ensure successful outcomes. Many aspects of MNT for diabetes require additional research to ensure effective translation of recommendations into practice.
J. Wylie-Rosett is a professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.
References (44)
- et al.
Weight management through lifestyle modification for the prevention and management of type 2 diabetes: Rationale and strategiesA statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition
Am J Clin Nutr
(2004) - et al.
An integral role of the dietitian: Implications of the Diabetes Prevention Program
J Am Diet Assoc
(2002) American Diabetes Association position statement: Nutrition recommendations and recommendations for diabetes
Diabetes Care
(2007)American Diabetes Association position statement: Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications
J Am Diet Assoc
(2002)- et al.
Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications
Diabetes Care
(2002) American Diabetes Association position statement: Nutrition principles and recommendations in diabetes
Diabetes Care
(2004)Is diabetes a public-health disorder?
Diabetes Care
(1994)American Diabetes Association Clinical Practice Recommendations
Diabetes Care
(2007)Summary of revisions for the 2007 Clinical Practice Recommendation
Diabetes Care
(2007)- et al.
Dietary carbohydrate (amount and type) in the prevention and management of diabetes: A statement by the American Diabetes Association
Diabetes Care
(2004)
Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids and Cholesterol, Protein and Amino Acids
2002 diabetes nutrition recommendations: Grading the evidence
Diabetes Educ
Long-term weight loss after diet and exercise: A systematic review
Int J Obes
Systematic review of long-term weight loss studies in obese adults: Clinical significance and applicability to clinical practice
Int J Obesity
Look AHEAD (Action for Health in Diabetes)Design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes
Control Clin Trials
The Look AHEAD study: A description of the lifestyle intervention and the evidence supporting it
Obesity
Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: A meta-analysis of randomized controlled trials
Arch Intern Med
The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: One-year follow-up of a randomized trial
Ann Intern Med
A randomized trial of a low-carbohydrate diet for obesity
N Engl J Med
Nutrition and Your Health: Dietary Guidelines for Americans, 2005
Efficacy of pharmacotherapy for weight loss in adults with type 2 diabetes mellitus: A meta-analysis
Arch Intern Med
Bariatric surgery: A systematic review and meta-analysis
JAMA
Cited by (22)
The role of carbohydrate counting in type 1 diabetes
2014, The Lancet Diabetes and EndocrinologyAssociation of circulating visfatin concentrations with insulin resistance and low-grade inflammation after dietary energy restriction in Spanish obese non-diabetic women: Role of body composition changes
2012, Nutrition, Metabolism and Cardiovascular DiseasesCitation Excerpt :Energy content and macronutrient composition of diets were according to the American Diabetes Association nutrition recommendations [18, 19]. Diets were designed to achieve weight losses of 0.5–1 kg per week, such diets are considered as a low risk intervention [18, 20]. To optimize compliance, dietary instructions were reinforced weekly by a dietician.
Novel treatment modalities for nonalcoholic steatohepatitis
2010, Trends in Endocrinology and MetabolismCitation Excerpt :It has been previously shown that a combination of dietary modification with lifestyle intervention can improve insulin sensitivity, a key pathophysiologic risk factor for NASH [15]. Several national practice guidelines exist that are potentially applicable to this population, including those from the the National Heart, Lung and Blood Institute, the American Diabetes Association and the American Heart Association [16–18]. The similarities and differences between these guidelines and their potential effect on NASH are beyond the scope of this paper, and have been recently reviewed elsewhere [19].
Trends in Nutrient Intake among Adults with Diabetes in the United States: 1988-2004
2009, Journal of the American Dietetic AssociationCitation Excerpt :This could be a result of education to change dietary fat composition. Trans fat has been associated with increased risk of CVD (22); however, data on trans-fat consumption were not available in NHANES and thus were not used for these analyses. American Diabetes Association recommendations for cholesterol and sodium consumption are also not being met.
J. Wylie-Rosett is a professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.
A. A. Albright is director, Division of Diabetes Translation, Centers for Disease Control, Atlanta, GA; at the time of the study she was program chief of the California Diabetes Program, Department of Health Services at the University of California, San Francisco.
C. Apovian is associate professor of Medicine at Boston University School of Medicine and the director of Clinical Nutrition at Boston Medical Center, Boston, MA.
N. G. Clark is senior medical advisor, Diabetes/Clinical Research and Medical Affairs, Novo Nordisk Inc, Princeton, NJ.
L. Delahanty is the director of Clinical Nutrition and Behavioral Research, The Massachusetts General Hospital Diabetes Center, Boston.
M. J. Franz is a nutrition and health consultant with Nutrition Concepts by Franz, Inc, Minneapolis, MN.
B. Hoogwerf is a staff physician in the Department of Endocrinology, Diabetes and Metabolism, The Cleveland Clinic, Cleveland, OH.
K. Kulkarni is director, Scientific Affairs, In-Vivo Team, Abbott Diabetes Care, Alameda, CA.
A. H. Lichtenstein is senior scientist, director of the Cardiovascular Nutrition Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging and professor of Public Health and Family Medicine, Tufts University School of Medicine, Boston, MA.
E. Mayer-Davis is professor and associate chair of the Department of Epidemiology and Biostatistics, The Arnold School of Public Health, University of South Carolina, Columbia.
A. D. Mooradian is professor and chair, Department of Medicine, University of Florida College of Medicine, Jacksonville.
M. Wheeler is coordinator, Research Nutrition, Nutritional Computing Concepts, Zionville, IN.