waist circumference-Nutrition recommendations and interventions
Nutrition Recommendations and Interventions for Diabetes A position statement of the American Diabetes Association
AMERICAN DIABETES ASSOCIATION
M edical nutrition therapy (MNT) isimportant in preventing diabetes,managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications. It is, therefore, important at all levels of di- abetes prevention (see Table 1). MNT is also an integral component of diabetes self-management education (or training). This position statement provides evi- dence-based recommendations and inter- ventions for diabetes MNT. The previous position statement with accompanying technical review was published in 2002 (1) and modified slightly in 2004 (2). This statement updates previous position statements, focuses on key references published since the year 2000, and uses grading according to the level of evidence available based on the American Diabetes Association evidence-grading system. Since overweight and obesity are closely linked to diabetes, particular attention is paid to this area of MNT.
The goal of these recommendations is to make people with diabetes and health care providers aware of beneficial nutri- tion 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 nu- trition-related goals requires a coordi- nated team effort that includes the person with diabetes and involves him or her in the decision-making process. It is recom- mended that a registered dietitian, knowl- edgeable and skilled in MNT, be the team member who plays the leading role in providing nutrition care. However, it is
important that all team members, includ- ing physicians and nurses, be knowledge- able about MNT and support i ts implementation.
MNT, as illustrated in Table 1, plays a role in all three levels of diabetes-related prevention targeted by the U.S. Depart- ment of Health and Human Services. Pri- mary prevention interventions seek to delay or halt the development of diabetes. This involves public health measures to reduce the prevalence of obesity and in- cludes MNT for individuals with pre- diabetes. Secondary and tertiary prevention interventions include MNT for individuals with diabetes and seek to prevent (sec- ondary) or control (tertiary) complica- tions of diabetes.
GOALS OF MNT FOR PREVENTION AND TREATMENT OF DIABETES
Goals of MNT that apply to individuals at risk for diabetes or with pre-diabetes To decrease the risk of diabetes and car- diovascular disease (CVD) by promoting healthy food choices and physical activity leading to moderate weight loss that is maintained.
Goals of MNT that apply to individuals with diabetes 1) Achieve and maintain
● Blood glucose levels in the normal range or as close to normal as is safely possible
● A lipid and lipoprotein profile that re- duces the risk for vascular disease
● Blood pressure levels in the normal
range or as close to normal as is safely possible
2) To prevent, or at least slow, the rate of development of the chronic complica- tions of diabetes by modifying nutrient intake and lifestyle 3) To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change 4) To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence
Goals of MNT that apply to specific situations 1) For youth with type 1 diabetes, youth with type 2 diabetes, pregnant and lactat- ing women, and older adults with diabe- tes, to meet the nutritional needs of these unique times in the life cycle. 2) For individuals treated with insulin or insulin secretagogues, to provide self- management training for safe conduct of exercise, including the prevention and treatment of hypoglycemia, and diabetes treatment during acute illness.
EFFECTIVENESS OF MNT
Recommendations ● Individuals who have pre-diabetes or
diabetes should receive individualized MNT; such therapy is best provided by a registered dietitian familiar with the components of diabetes MNT. (B)
● Nutrition counseling should be sensi- tive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes. (E)
Clinical trials/outcome studies of MNT have reported decreases in HbA1c (A1C) of �1% in type 1 diabetes and 1–2% in type 2 diabetes, depending on the duration of diabetes (3,4). Meta- analysis of studies in nondiabetic, free- living subjects and expert committees report that MNT reduces LDL cholesterol by 15–25 mg/dl (5,6). After initiation of MNT, improvements were apparent in 3–6 months. Meta-analysis and expert committees also support a role for lifestyle modification in treating hypertension (7,8).
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Originally approved 2006. Revised 2007. Writing panel: John P. Bantle (Co-Chair), Judith Wylie-Rosett (Co-Chair), Ann L. Albright, Caroline M.
Apovian, Nathaniel G. Clark, Marion J. Franz, Byron J. Hoogwerf, Alice H. Lichtenstein, Elizabeth Mayer- Davis, Arshag D. Mooradian, and Madelyn L. Wheeler.
Abbreviations: CHD, coronary heart disease; CKD, chronic kidney disease; CVD, cardiovascular disease; DPP, Diabetes Prevention Program; FDA, Food and Drug Administration; GDM, gestational diabetes mel- litus; MNT, medical nutrition therapy; RDA, recommended dietary allowance; USDA, U.S. Department of Agriculture.
DOI: 10.2337/dc08-S061 © 2008 by the American Diabetes Association.
P O S I T I O N S T A T E M E N T
DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S61
ENERGY BALANCE, OVERWEIGHT, AND OBESITY
Recommendations ● In overweight and obese insulin-
resistant individuals, modest weight loss has been shown to improve insulin resistance. Thus, weight loss is recom- mended for all such individuals who have or are at risk for diabetes. (A)
● For weight loss, either low-carbohy- drate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year). (A)
● For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with ne- phropathy), and adjust hypoglycemic therapy as needed. (E)
● Physical activity and behavior modifi- cation are important components of weight loss programs and are most helpful in maintenance of weight loss. (B)
● Weight loss medications may be con- sidered in the treatment of overweight and obese individuals with type 2 dia- betes and can help achieve a 5–10% weight loss when combined with life- style modification. (B)
● Bariatric surgery may be considered for some individuals with type 2 diabetes and BMI �35 kg/m2 and can result in marked improvements in glycemia. The long-term benefits and risks of bariatric surgery in individuals with
pre-diabetes or diabetes continue to be studied. (B)
The importance of controlling body weight in reducing risks related to diabe- tes is of great importance. Therefore, these nutrition recommendations start by considering energy balance and weight loss strategies. The National Heart, Lung, and Blood Institute guidelines define overweight as BMI �25 kg/m2 and obe- sity as BMI �30 kg/m2 (9). The risk of comorbidity associated with excess adi- pose tissue increases with BMIs in this range and above. However, clinicians should be aware that in some Asian pop- ulations, the proportion of people at high risk of type 2 diabetes and CVD is signif- icant at BMIs of �23 kg/m2 (10). Visceral body fat, as measured by waist circumfer- ence �35 inches in women and �40 inches in men, is used in conjunction with BMI to assess risk of type 2 diabetes and CVD (Table 2) (9). Lower waist cir- cumference cut points (�31 inches in women, �35 inches in men) may be ap- propriate for Asian populations (11).
Because of the effects of obesity on insulin resistance, weight loss is an im- portant therapeutic objective for individ- uals with pre-diabetes or diabetes (12). However, long-term weight loss is diffi- cult for most people to accomplish. This is probably because the central nervous sys- tem plays an important role in regulating energy intake and expenditure. Short- term studies have demonstrated that
moderate weight loss (5% of body weight) in subjects with type 2 diabetes is associ- ated with decreased insulin resistance, improved measures of glycemia and li- pemia, and reduced blood pressure (13). Longer-term studies (�52 weeks) using pharmacotherapy for weight loss in adults with type 2 diabetes produced modest re- ductions in weight and A1C (14), al- though improvement in A1C was not seen in all studies (15,16). Look AHEAD (Ac- tion for Health in Diabetes) is a large Na- tional Institutes of Health–sponsored clinical trial designed to determine if long-term weight loss will improve glyce- mia and prevent cardiovascular events (17). When completed, this study should provide insight into the effects of long- term weight loss on important clinical outcomes.
Evidence demonstrates that struc- tured, intensive lifestyle programs involv- ing participant education, individualized counseling, reduced dietary energy and fat (�30% of total energy) intake, regular physical activity, and frequent participant contact are necessary to produce long- term weight loss of 5–7% of starting weight (1). The role of lifestyle modifica- tion in the management of weight and type 2 diabetes was recently reviewed (13). Although structured lifestyle pro- grams have been effective when delivered in well-funded clinical trials, it is not clear how the results should be translated into clinical practice. Organization, delivery, and funding of lifestyle interventions are all issues that must be addressed. Third- party payers may not provide adequate benefits for sufficient MNT frequency and time to achieve weight loss goals (18).
Exercise and physical activity, by themselves, have only a modest weight loss effect. However, exercise and physi- cal activity are to be encouraged because they improve insulin sensitivity indepen- dent of weight loss, acutely lower blood glucose, and are important in long-term maintenance of weight loss (1). Weight loss with behavioral therapy alone also has been modest, and behavioral ap- proaches may be most useful as an ad- junct to other weight loss strategies.
Standard weight loss diets provide
Table 1—Nutrition and MNT
Primary prevention to prevent diabetes: Secondary prevention to prevent complications: Tertiary prevention to prevent morbidity and mortality: ● Use MNT and public health interventions in those with obesity and pre-diabetes
● Use MNT for metabolic control of diabetes ● Use MNT to delay and manage complications of diabetes
Table 2—Classification of overweight and obesity by BMI, waist circumference, and associ- ated disease risk
BMI (kg/m2) Obesity
WC: men �40 inches; women �35 inches
WC: men �40 inches; women
Underweight �18.5 Normal 18.5–24.9 Overweight 25.0–29.9 Increased High Obesity 30.0–34.9 I High Very high
35.0–39.9 II Very high Very high Extreme obesity �40 III Extremely high Extremely high
*Disease risk for type 2 diabetes, hypertension, and CVD. Adapted from ref. 9. WC, waist circumference.
Nutrition recommendations and interventions
S62 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008
500–1,000 fewer calories than estimated to be necessary for weight maintenance and initially result in a loss of �1–2 lb/ week. Although many people can lose some weight (as much as 10% of initial weight in �6 months) with such diets, without continued support and follow- up, people usually regain the weight they have lost.
The optimal macronutrient distri- bution of weight loss diets has not been established. Although low-fat diets have traditionally been promoted for weight loss, two randomized controlled trials found that subjects on low-carbohy- drate diets lost more weight at 6 months than subjects on low-fat diets (19,20). Another study of overweight women randomized to one of four diets showed significantly more weight loss at 12 months with the Atkins low-carbohy- drate diet than with higher-carbohy- drate diets (20a). However, at 1 year, the difference in weight loss between the low-carbohydrate and low-fat diets was not significant and weight loss was modest with both diets. Changes in se- rum triglyceride and HDL cholesterol were more favorable with the low- carbohydrate diets. In one study, those subjects with type 2 diabetes demon- strated a greater decrease in A1C with a low-carbohydrate diet than with a low- fat diet (20). A recent meta-analysis showed tha t a t 6 months , low- carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cho- lesterol was significantly higher on the low-carbohydrate diets (21). Further research is needed to determine the long-term efficacy and safety of low- carbohydrate diets (13). The recom- mended dietary allowance (RDA) for digestible carbohydrate is 130 g/day and is based on providing adequate glu- cose as the required fuel for the central nervous system without reliance on glu- cose production from ingested protein or fat (22). Although brain fuel needs can be met on lower-carbohydrate di- ets, long-term metabolic effects of very- low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vita- mins, and minerals and are important in dietary palatability (22).
Meal replacements (liquid or solid prepackaged) provide a defined amount of energy, often as a formula product. Use of meal replacements once or twice daily
to replace a usual meal can result in sig- nificant weight loss. Meal replacements are an important part of the Look AHEAD weight loss intervention (17). However, meal replacement therapy must be con- tinued indefinitely if weight loss is to be maintained.
Very-low-calorie diets provide �800 calories daily and produce substantial weight loss and rapid improvements in glycemia and lipemia in individuals with type 2 diabetes. When very-low-calorie diets are stopped and self-selected meals are reintroduced, weight regain is com- mon. Thus, very-low-calorie diets appear to have limited utility in the treatment of type 2 diabetes and should only be con- sidered in conjunction with a structured weight loss program.
The available data suggest that weight loss medications may be useful in the treatment of overweight individuals with and at risk for type 2 diabetes and can help achieve a 5–10% weight loss when combined with lifestyle change (14). Ac- cording to their labels, these medications should only be used in people with dia- betes who have BMI �27.0 kg/m2.
Gastric reduction surgery can be an effective weight loss treatment for obesity and may be considered in people with di- abetes who have BMI �35 kg/m2. A meta- analysis of studies of bariatric surgery reported that 77% of individuals with type 2 diabetes had complete resolution of diabetes (normalization of blood glu- cose levels in the absence of medications), and diabetes was resolved or improved in 86% (23). In the Swedish Obese Subjects study, a 10-year follow-up of individuals undergoing bariatric surgery, 36% of sub- jects with diabetes had resolution of dia- betes compared with 13% of matched control subjects (24). All cardiovascular risk factors except hypercholesterolemia improved in the surgical patients.
NUTRITION RECOMMENDATIONS AND INTERVENTIONS FOR THE PREVENTION OF DIABETES (PRIMARY PREVENTION)
Recommendations ● Among individuals at high risk for de-
veloping type 2 diabetes, structured programs that emphasize lifestyle changes that include moderate weight loss (7% body weight) and regular physical activity (150 min/week), with dietary strategies including reduced calories and reduced intake of dietary
fat, can reduce the risk for developing diabetes and are therefore recom- mended. (A)
● Individuals at high risk for type 2 dia- betes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fi- ber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). (B)
● There is not sufficient, consistent infor- mation to conclude that low–glycemic load diets reduce the risk for diabetes. Nevertheless, low– glycemic index foods that are rich in fiber and other important nutrients are to be encour- aged. (E)
● Observational studies report that mod- erate alcohol intake may reduce the risk for diabetes, but the data do not sup- port recommending alcohol consump- tion to individuals at risk of diabetes. (B)
● No nutrition recommendation can be made for preventing type 1 diabetes. (E)
● Although there are insufficient data at present to warrant any specific recom- mendations for prevention of type 2 di- abetes in youth, it is reasonable to apply approaches demonstrated to be effec- tive in adults, as long as nutritional needs for normal growth and develop- ment are maintained. (E)
The importance of preventing type 2 diabetes is highlighted by the substan- tial worldwide increase in the preva- lence of diabetes in recent years. Genetic susceptibility appears to play a powerful role in the occurrence of type 2 diabetes. However, given that popu- lation gene pools shift very slowly over time, the current epidemic of diabetes likely reflects changes in lifestyle lead- ing to diabetes. Lifestyle changes char- acterized by increased energy intake and decreased physical activity appear to have together promoted overweight and obesity, which are strong risk fac- tors for diabetes.
Several studies have demonstrated the potential for moderate, sustained weight loss to substantially reduce the risk for type 2 diabetes, regardless of whether weight loss was achieved by life- style changes alone or with adjunctive therapies such as medication or bariatric- surgery (see ENERGY BALANCE section) (1). Moreover, both moderate-intensity and vigorous exercise can improve insulin
DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S63
sensitivity, independent of weight loss, and reduce risk for type 2 diabetes (1).
Clinical trial data from both the Finnish Diabetes Prevention study (25) and the Diabetes Prevention Program (DPP) in the U.S (26) strongly support the potential for moderate weight loss to reduce the risk for type 2 diabetes. The lifestyle intervention in both trials em- phasized lifestyle changes that included moderate weight loss (7% of body weight) and regular physical activity (150 min/week), with dietary strategies to reduce intake of fat and calories. In the DPP, subjects in the lifestyle inter- vention group reported dietary fat in- takes of �34% of energy at baseline and 28% of energy after 1 year of interven- tion (27). A majority of subjects in the lifestyle intervention group met the physical activity goal of 150 min/week of moderate physical activity (26,28). In addition to preventing diabetes, the DPP lifestyle intervention improved several CVD risk factors, including dsylipidemia, hypertension, and in- flammatory markers (29,30). The DPP analysis indicated that lifestyle inter- vention was cost-effective (31), but other analyses suggest that the expected costs needed to be reduced (32).
Both the Finnish Diabetes Preven- tion study and th
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