Research
Commentary
2006-2007 American Diabetes Association Nutrition Recommendations: Issues for Practice Translation

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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.

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    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.

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