American Diabetes Association Guide to Nutrition Therapy for

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DOI: 10.2337/9781580404723

Library of Congress Cataloging-in-Publication Data

American Diabetes Association guide to nutrition therapy for diabetes / [edited by]
Marion J. Franz, Alison Evert. -- 2nd ed.
p. ; cm.
Guide to nutrition therapy for diabetes
Rev. ed. of: American Diabetes Association guide to medical nutrition therapy for
diabetes. c1999.
Includes bibliographical references and index.
Summary: “This book will help the reader guide patients towards medical nutrition
therapy, through nutrition assessment, nutrition diagnosis, nutrition interventions
(education, counseling, and goal setting), and nutrition monitoring and evaluation”-
-Provided by publisher.
ISBN 978-1-58040-472-3 (alk. paper)
I. Franz, Marion J. II. Evert, Alison B. III. American Diabetes Association. IV. Amer-
ican Diabetes Association guide to medical nutrition therapy for diabetes. V. Title:
Guide to nutrition therapy for diabetes.
[DNLM: 1. Diabetes Mellitus--diet therapy--Practice Guideline. WK 818]

616.4'620654--dc23
2012009189
Contents

Preface/Acknowledgmentsvii
Marion J. Franz, MS, RD, CDE
Alison B. Evert, MS, RD, CDE

Forewordxi
John P. Bantle, MD

Diabetes Nutrition Therapy 1

1. Effectiveness of Medical Nutrition Therapy in Diabetes 1
Joyce Green Pastors, MS, RD, CDE
Marion J. Franz, MS, RD, CDE
2. Macronutrients and Nutrition Therapy for Diabetes 19
Marion J. Franz, MS, RD, CDE
3. Micronutrients and Diabetes 41
Joshua J. Neumiller, PharmD, CDE, CGP, FASCP
4. Alcohol and Diabetes 69
Marion J. Franz, MS, RD, CDE

Diabetes Nutrition Therapy Interventions 95

5. Nutrition Therapy for Adults with Type 1 and
Insulin-Requiring Type 2 Diabetes 95
Alison B. Evert, MS, RD, CDE
6. Nutrition Therapy for Adults with Type 2 Diabetes 117
Hope S. Warshaw, MMSc, RD, CDE, BC-ADM

   iii
iv  American Diabetes Association Guide to Nutrition Therapy for Diabetes

7. Nutrition Therapy for Youth with Diabetes 143

Gail Spiegel, MS, RD, CDE
8. Nutrition Therapy for Older Adults with Diabetes 169
Kathleen Stanley, MSEd, RD, CDE, BC-ADM
9. Nutrition Therapy for Pregnancy, Lactation, and Diabetes 181
Diane M. Reader, RD, CDE
10. Diabetes Nutrition Therapy for Sports and Exercise 204
Carla Cox, PhD, RD, CDE, CSSD
11. Nutrition Therapy for the Hospitalized and
Long-Term Care Patient with Diabetes 229
Carrie S. Swift, MS, RD, BC-ADM, CDE

Diabetes Nutrition Therapy and Diabetes-Associated Complications 247

12. Nutrition Therapy for Diabetes: Hypoglycemia and Sick Days 247
Janine Freeman, RD, CDE
13. Nutrition Therapy for Diabetes and Lipid Disorders 265
Wahida Karmally, DrPH, RD, CDE, CLS
Jacqueline Santora Zimmerman, MS, RD
14. Nutrition Therapy for Diabetes and Hypertension 295
Karin Aebersold, MPH
Natania Wright Ostrovsky, PhD
Judith Wylie-Rosett, EdD, RD
15. Nutrition Therapy for Diabetic Kidney Disease 307
Madelyn L. Wheeler, MS, RD, CDE, FADA
16. Nutrition Therapy for Diabetes and Celiac Disease 319
Carol Brunzell, RD, CDE
17. Nutrition Therapy for Cystic Fibrosis–Related Diabetes 341
Carol Brunzell, RD, CDE
18. Nutrition Therapy for Diabetic Gastropathy 355
Meghann Moore, MPH, RD, CDE
19. Nutrition Therapy for Bariatric Surgery and Diabetes 371
Margaret Furtado, MS, RD, LDN
Alison B. Evert, MS, RD, CDE
 Contents   v

Diabetes Nutrition Therapy and Technology 391

20. Integrating Nutrition Therapy, Blood Glucose
Monitoring, and Continuous Glucose Monitoring 391
Margaret A. Powers, PhD, RD, CDE
Mary M. Austin, MA, RD, CDE, FAADE
21. Integrating Nutrition Therapy into Insulin Pump Therapy 405
Alison B. Evert, MS, RD, CDE

Diabetes Nutrition Therapy Education 425

22. Effective Nutrition Education and Counseling 425
Jackie Boucher, MS, RD, CDE
23. Health Literacy and Numeracy in Diabetes
Nutrition Therapy and Self-Management Education 441
Marjorie Cypress, PhD, CNP, CDE
24. Cost-Effectiveness of Diabetes Medical Nutrition Therapy 461
Carolyn C. Harrington, RD, CDE

Nutrition Therapy for Prevention of Diabetes 469

25. Nutrition Therapy and Prediabetes 469
Gretchen Youssef, MS, RD, CDE
26. Integrating Nutrition Therapy into
Community-Based Diabetes Prevention Programs 501
Ann Albright, PhD, RD
Heather Devlin, MA

Index527
Preface/Acknowledgments

N
utrition therapy is the implementation of evidence-based nutrition recom-
mendations and interventions. As new discoveries in the science of nutri-
tion and diabetes are reported, nutrition therapy, if needed, changes. In
1971, the American Diabetes Association (ADA) published its first report on diabe-
tes nutrition recommendations (ADA 1971). These recommendations have been
updated in five position statements (ADA 1979, 1987, 1994, 2002, 2008), technical
reviews (Franz 1994, 2002), and a systematic review (Wheeler 2012). A summary of
the position statements is also incorporated into the annual ADA Standards of
Care. The 1994 recommendations perhaps drew the most attention by the public
when they reported that total, not the type of, carbohydrate affected blood glucose
levels and sugary foods could be substituted for starchy foods. Additionally, before
the 1994 recommendations, all position statements attempted to identify an “ideal”
nutrition prescription with ideal percentages of carbohydrate, protein, and fat that
would apply to everyone with diabetes. Although the need for individualization was
stressed in all prior position papers, nutrition prescriptions, which were commonly
given by physicians, for specific calorie levels and/or percentages of macronutri-
ents, really did not allow for much, if any, individualization. The 1994 position
statement also recommended that individualized nutrition prescriptions be based
on metabolic profiles, treatment goals, and, perhaps most importantly, changes the
person with diabetes is willing and able to make.
The Academy of Nutrition and Dietetics (Acad Nutr Diet, formerly the
American Dietetic Association) published its first set of nutrition practice guide-
lines for type 2 and type 1 diabetes in 1995 and 1998, respectively (Monk 1995;
Kulkarni 1998). Both sets of guidelines were field-tested in randomized clinical
trials and shown to be effective (Franz 1995; Kulkarni 1998). Updates were pub-
lished in 2001 and in the Acad Nutr Diet Evidence Analysis Library (American
Dietetic Association 2001; Acad Nutr Diet 2008a). The guidelines for nutrition
therapy for gestational diabetes were also published and field-tested (Reader
2006) and updated (Acad Nutr Diet 2008b). Nutrition practice guidelines for
type 1 and type 2 diabetes in adults also have been updated and published (Franz
2010). Medical nutrition therapy has repeatedly been shown to be effective and
essential in the prevention of diabetes and in the management of diabetes and its
complications. However, just as there is no one medication or insulin therapy
that applies to all people with diabetes, there is no one nutrition therapy inter-
vention that applies to all people with diabetes. A goal of this guide is to assist

   vii
viii  American Diabetes Association Guide to Nutrition Therapy for Diabetes

health care providers in the selection of appropriate individualized nutrition

therapy interventions.
The 1999 American Diabetes Association Guide to Medical Nutrition Therapy for
Diabetes served as the basis for this guide. Authors were asked to update the available
1999 chapters by reviewing the evidence published after 1998. If evidence analysis
was available in the current reviews by the Acad Nutr Diet and ADA (www.adaevi-
dence; Franz 2010; Acad Nutr Diet 2008), they were asked to briefly summarize
this evidence. Chapter authors also conducted a literature search for evidence pub-
lished after these summaries. Chapters include tables of the new evidence, conclu-
sions from the evidence, and recommendations for integrating diabetes nutrition
therapy into the management of diabetes and its complications or for the preven-
tion of diabetes. This guide is intended to serve as a resource for all health care
professionals interested in the evidence supporting nutrition therapy interventions,
not just for macro- and micronutrients, but for all the related areas of diabetes man-
agement in which nutrition therapy is essential.
It has been an honor and a pleasure to edit this text. We are truly indebted to
the talented chapter authors for the thoroughness and thoughtfulness given to
writing their chapters. They truly represent the many excellent clinicians and
researchers interested in the field of diabetes nutrition. We also thank the review-
ers, especially Stephanie Dunbar, Director of Nutrition and Clinical Affairs for
the ADA, who directed the review. Special thanks go to Victor Van Beuren, our
editor, who kept us on target and committed to the proposed timeline. And, of
course, thanks go to the American Diabetes Association for its ongoing recogni-
tion of the integral role of nutrition therapy in the treatment of diabetes and its
dedication to providing professionals with the latest available evidence.

Marion J. Franz, MS, RD, CDE

Alison B. Evert, MS, RD, CDE

BIBLIOGRAPHY

Academy of Nutrition and Dietetics: Evidence Analysis Library. Available at

http://www.adaevidencelibrary.com. Accessed January 2012
Academy of Nutrition and Dietetics: Diabetes Type 1 and 2 for Adults Evidence-
Based Nutrition Practice Guidelines, 2008a. Available at http://www.adaevi-
dencelibrary.com/topic.cfm?=3251. Accessed January 2012
Academy of Nutrition and Dietetics: Gestational Diabetes Mellitus (GDM) Evi-
dence-Based Nutrition Practice Guidelines, 2008b. Available at http://adaevi-
dencelibrary.com/topic.cfm?=3731. Accessed January 2012
American Diabetes Association: Evidence-based nutrition principles and recom-
mendations for the treatment and prevention of diabetes and related compli-
cations. Diabetes Care 25:202–212, 2002
 Preface/Acknowledgments   ix

American Diabetes Association: Nutrition recommendations and interventions

for diabetes: a position statement of the American Diabetes Association. Dia-
betes Care 31 (Suppl. 1):S61–S78, 2008
American Diabetes Association: Nutrition recommendations and principles for
individuals with diabetes mellitus: 1986 (Position Statement). Diabetes Care
10:126–132, 1987
American Diabetes Association: Nutrition recommendations and principles for
people with diabetes mellitus (Position Statement). Diabetes Care 17:519–522,
1994
American Diabetes Association: Principles of nutrition and dietary recommenda-
tions for individuals with diabetes mellitus: 1979 (Special Report). Diabetes
28:1027–1030, 1979
American Diabetes Association: Principles of nutrition and dietary recommenda-
tions for patients with diabetes mellitus: 1971 (Special Report). Diabetes
9:633–634, 1971
American Dietetic Association: Nutrition Practice Guidelines for Type 1 and Type 2
Diabetes [CD-ROM]. Chicago, American Dietetic Association, 2001
Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson J-L, Garg A, Holzmeister
LA, Hoogwerf B, Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M:
Evidence-based nutrition principles and recommendations for the treatment
and prevention of diabetes and related complications (Technical Review). Dia-
betes Care 25:148–198, 2002
Franz MJ, Horton ES, Bantle JP, Beebe CA, Brunzell JD, Coulston AM, Henry
RR, Hoogwerf BJ, Stacpoole PW: Nutrition principles for the management of
diabetes and related complications (Technical Review). Diabetes Care 17:490–
518, 1994
Franz MJ, Monk A, Barry B, McLain K, Weaver T, Cooper N, Upham P, Bergen-
stal R, Mazze RS: Effectiveness of medical nutrition therapy provided by
dietitians in the management of non-insulin-dependent diabetes mellitus: a
randomized, controlled clinical trial. J Am Diet Assoc 95:1009–1017, 1995
Franz MJ, Powers MA, Leontos C, Holzmeister LA, Kulkarni K, Monk A, Wedel
N, Gradwell E: The evidence for medical nutrition therapy for type 1 and type
2 diabetes in adults. J Am Diet Assoc 110:1852–1889, 2010
Kulkarni K, Castle G, Gregory R, Holmes A, Leontos C, Powers M, Snetselarr L,
Splett P, Wylie-Rosett J: Nutrition practice guidelines for type 1 diabetes mel-
litus positively affect dietitian practices and patient outcomes. J Am Diet Assoc
98:62–70, 1998
Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ: Practice guidelines
for medical nutrition therapy by dietitians for persons with non-insulin-
dependent diabetes. J Am Diet Assoc 95:999–1008, 1995
Reader D, Splett P, Gunderson EP, for the Diabetes Care and Education Dietetic
Practice Group: Impact of gestational diabetes nutrition practice guidelines
x  American Diabetes Association Guide to Nutrition Therapy for Diabetes

implemented by registered dietitians on pregnancy outcomes. J Am Diet Assoc

106:1426–1433, 2006
Wheeler ML, Dunbar SA, Jaacks LM, Karmally W, Mayer-Davis EJ, Wylie-
Rosett J, Yancy WS Jr: Macronutrients, food groups, and dietary patterns in
the management of diabetes mellitus: a systematic review of the literature,
2010. Diabetes Care 35:434–445, 2012
Foreword
John P. Bantle, MD

O
ptimal treatment of diabetes mellitus requires nutrition therapy, an exer-
cise program, and, for most patients, medication(s). When patients fail to
achieve diabetes treatment goals, it is usually because one or more of these
fundamental treatment modalities has not been effectively implemented. For many
patients, the most challenging part of the treatment program (and thus the part of
the program that often is not done well) is nutrition therapy. Patients often have
difficulty understanding nutrition therapy. Moreover, many have difficulty putting
their plan into action.
There are at least five reasons why understanding and adhering to nutrition
therapy is difficult. First, nutrition recommendations have changed over time,
with new recommendations sometimes contradicting previous recommendations.
The contradictions have usually resulted from recommendations made in the
absence of scientific evidence. The recommendations must then be modified or
even abandoned when evidence becomes available. This creates confusion and
erodes confidence in the recommendations. Second, many physicians do not
themselves understand the principles of nutrition therapy and do not emphasize
the importance of strategies to achieve food and nutrition goals. Thus, patients
often do not recognize the importance of nutrition therapy. A third reason that
nutrition therapy is difficult is that adhering to any eating pattern is challenging if
that eating pattern differs from the usual eating pattern followed by family, friends,
and cultural group. Even the most motivated of patients is likely to develop a
sense of deprivation if asked to avoid foods that others are eating and enjoying.
Any recommendation to depart from usual eating habits should be made only if
there is compelling scientific evidence of potential benefit. Fourth, in our society,
food has many purposes in addition to meeting biological needs. Food is often the
focus of social activities and is frequently used as a reward, as a means of express-
ing affection, and as a way to help cope with stress. We are constantly exposed to
appealing advertisements for food that exploit these factors. Even the most moti-
vated of patients can be expected to occasionally succumb to these influences.
Fifth, and very importantly, it is now clear that energy intake, energy expenditure,
and body weight are regulated in the central nervous system. Thus, when we ask
overweight or obese patients with diabetes to reduce energy intake and lose
weight, we are asking them to override a powerful biological control system. Most
of us have great difficulty making this change.

   xi
xii  American Diabetes Association Guide to Nutrition Therapy for Diabetes

Although nutrition therapy is difficult and there are barriers to overcome, we

should still do everything we can to implement it effectively. Healthy eating pat-
terns are a key element in establishing good control of glycemia and lipemia and
thereby preventing the complications of diabetes and its companion atherosclero-
sis. Without a strong nutrition component, most treatment plans will fall short.
However, we must keep in mind that only a limited number of dietary strategies
have documented efficacy. Marion Franz and Alison Evert and their chapter
authors have done an outstanding job of describing these strategies in the Ameri-
can Diabetes Association Guide to Nutrition Therapy for Diabetes. They also carefully
point out gaps in our knowledge, allowing us to avoid making unsubstantiated
recommendations. I believe this volume belongs in the bookshelf of every health
care provider who deals with patients who have diabetes mellitus.

John P. Bantle is Professor of Medicine and Director, Division of Endocrinology and

Diabetes, University of Minnesota, Minneapolis, MN.
Chapter 1
Effectiveness of Medical
Nutrition Therapy in Diabetes
Joyce Green Pastors, MS, RD, CDE, and Marion J. Franz, MS, RD, CDE

Highlights

Background on Diabetes Nutrition Therapy

Evidence for the Clinical Effectiveness of MNT in Diabetes

Summary

   1
Highlights
Effectiveness of Medical
Nutrition Therapy in Diabetes

 Medical nutrition therapy (MNT)  MNT is a process that includes a

for the treatment of diabetes is effec- nutrition assessment, nutrition diagno-
tive, with the greatest impact at the sis, nutrition interventions (education,
initial onset of diabetes. Randomized counseling, and goal-setting), and
control and observational studies have nutrition monitoring and evaluation.
shown that within the first 6 months
of diagnosis, A1C can be reduced up  MNT provided by a registered
to ~3% point reductions (range 0.23– dietitian is effective in promoting pos-
2.6%), depending on the type and itive clinical outcomes, especially with
duration of diabetes. However, MNT multiple follow-up encounters involv-
is effective throughout the diabetes ing nutrition education and counsel-
disease process, with an average reduc- ing.
tion of A1C levels of 1–2% point
reductions.
 There are many types of nutrition
interventions that are effective, includ-
 Because type 2 diabetes is a pro- ing decreased calorie and fat intake,
gressive disease, an evaluation of nutri- carbohydrate counting, use of insulin-
tion interventions should be to-carbohydrate ratios, healthy food
completed at 3 months, and if no clini- choices, individualized meal planning,
cal improvement has occurred, a and behavioral strategies.
change in treatment plan should be
recommended, including the addition
 Other clinical outcomes such as
of oral glucose-lowering medication(s)
improved lipid profiles, weight loss,
and/or insulin.
decreased blood pressure, decreased
need for medication, and decreased
risk of onset and progression of
comorbidities can be achieved with
MNT.

2
Effectiveness of Medical
Nutrition Therapy in Diabetes

S
ince the discovery of “sweet urine,” people with diabetes have been given
advice on what to eat and drink, often based more on theories or beliefs than
on facts. Food and nutrition advice has ranged from “starvation diets” to
high- or low-carbohydrate or low-fat diets to nutritional supplements that will
provide a cure.
Over the years, various diabetes organizations have published nutrition rec-
ommendations on the basis of available research and clinical observations. In
recent years, the goal in the development of diabetes nutrition therapy recom-
mendations has been to have the recommendations be based on evidence rather
than theories. For example, it was longstanding advice that people with diabetes
should not eat sugar or foods containing sugars. This information was based on
the assumption that because sugars were small molecules, they would be absorbed
rapidly, causing blood glucose levels to increase at a greater rate than starches
(which are larger molecules). When research first revealed that total amounts of
carbohydrate were more important than the source (Bantle 1983), the public, and
many health professionals, were surprised. However, almost all diabetes nutrition
recommendations now acknowledge that sugary foods can be substituted for
starchy foods.
The primary goals of diabetes medical nutrition therapy (MNT) are to sup-
port the achievement and maintenance of as normal blood glucose levels as safely
possible, a lipid profile that reduces the risk for cardiovascular disease, blood pres-
sure in an ideal range, and improved or continued quality of life. Important ques-
tions then become, what is the evidence that diabetes MNT can achieve these
goals and what types of MNT interventions are effective? It is important that
clinicians, regardless of their field of practice, know expected outcomes from their
interventions, when to evaluate such outcomes, and what interventions contribute
to successful outcomes.

BACKGROUND ON DIABETES NUTRITION THERAPY

Attempts have been made to identify the efficacy and method of delivery of
diabetes nutrition therapy. For example, a Cochrane review reported on a total of
18 randomized controlled trials of nutrition approaches for individuals with type
2 diabetes and, not surprisingly, could not identify one type of nutrition advice
that was most effective (Nield 2007). They did report that nutrition therapy advice
plus exercise was associated with a statistically significant mean decrease in A1C
of 0.9% (CI 0.4–1.3) at 6 months and of 1.0% (CI 0.4–1.5) at 12 months.
   3
4  American Diabetes Association Guide to Nutrition Therapy for Diabetes

A systematic review of healthy eating by the American Association of Diabetes

Educators also did not reveal a clear pattern of food and nutrition interventions
leading to outcomes of weight, fat intake, saturated fat, and carbohydrate. How-
ever, this review did conclude that there is a tendency for successful healthy eating
interventions to include an exercise dimension and group work (Povey 2007).
Therefore, it seems clear that a single approach to diabetes MNT does not
exist, just as there is no one medication or insulin regimen that applies to all
people with diabetes. Instead of asking about specific eating patterns or food/
nutrient interventions, this review examines the effectiveness of diabetes MNT
provided by nutrition professionals (registered dietitians [RDs] or dietitians in
many countries and nutritionists in some countries) and what interventions con-
tribute to successful outcomes.
MNT for diabetes incorporates a process that, when implemented correctly,
includes the following steps: 1) assessment and reassessment (for follow-up nutri-
tion care); 2) nutrition diagnosis to identify the specific nutrition-related prob-
lems; 3) nutrition interventions that include education, counseling, and
goal-setting; and 4) nutrition monitoring and evaluation, which involves monitor-
ing progress and measuring outcome indicators (Lacey 2003). The fourth step
requires that expected outcomes of nutrition interventions be known.

EVIDENCE FOR THE CLINICAL EFFECTIVENESS OF

MNT IN DIABETES
The evidence for diabetes MNT comes from randomized controlled trials and
observational and outcome studies showing that nutrition interventions improve
metabolic outcomes, such as blood glucose and A1C, in individuals with diabetes.
Randomized controlled trials are considered the gold standard for evidence.
However, when assessing the impact of an intervention in clinical practice, these
trials have limitations. First and foremost, subjects are selected (and rejected) usu-
ally on their perceived ability to complete the study. In clinical practice, patients
are generally offered care regardless of their interest and ability to make lifestyle
changes. Outcome or observational studies usually provide outcome data from all
patients entered into patient care and thus are often a more realistic report on
expected outcomes from clinical care. However, these studies are frequently criti-
cized for their lack of rigorous study design. In general, useful data can be col-
lected from both types of study designs.
Metabolic outcomes are improved in nutrition intervention studies, both
when provided as independent MNT or when nutrition therapy is provided as
part of overall diabetes self-management education (DSME) (Table 1.1). Studies
in Table 1.1 were identified from the literature search published in the Academy
of Nutrition and Dietetics (formerly the American Dietetic Association) Evidence
Analysis Library (Acad Nutr Diet 2008a) and previously published articles (Franz
2008; Pastors 2002; Pastors 2003). MNT studies report the outcomes of nutrition
interventions provided by an RD (or nutritionist). DSME is provided by a multi-
disciplinary team, which in these studies included a minimum of an RD providing
nutrition therapy and a registered nurse. Studies include randomized clinical trials
and longitudinal, retrospective, cohort, time series, descriptive, and observational