National Diabetes Education Program
Nutrition Therapy Recommendations for People with Diabetes Webinar Transcript Thursday, March 20, 2014
JOANNE GALLIVAN: Welcome to the Nutrition Therapy Recommendations for People Managing Diabetes webinar. I am Joanne Gallivan. I’m Director of the NDEP at the National Institutes of Health, and I will be moderating today’s webinar.
As many of you know, the NDEP is a joint program of the NIH and the CDC and hundreds of partners. Our mission is to reduce the burden of diabetes in the U.S. by facilitating the adoption of proven approaches to prevent or delay the onset and progression of diabetes and its complications.
We offer topic-specific webinars throughout the year to help support the efforts of all of you, our partners, who are working to improve the lives of people both with and at risk for diabetes. We really appreciate you joining today’s webinar and we really hope and we think this session will provide you with valuable information and resources that you can take back to your organizations and in your community.
So March is National Nutrition Month, and this year, the Academy of Nutrition and Dietetics’ theme is Enjoy the Taste of Eating Right. We all know that nutrition is the cornerstone of successful management for people with diabetes. This webinar will review the latest nutrition recommendations to help people with diabetes manage their disease and we are very, very pleased to have nutrition expert Marion Franz as our guest speaker for today’s program.
Most of you, I am sure, know Marion Franz. She is a nutrition and health consultant with Nutrition Concepts by Franz, Inc., and for over 20 years she directed the Nutrition and Health Professional Education Division at the International Diabetes Center in Minneapolis. She co-edited the 2012 American Diabetes Association Guide to Nutrition Therapy for Diabetes and was the lead author on the Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines for type 1 and type 2 diabetes. She has authored numerous position statements, nutrition position statements, and was the editor of the AADE’s core curriculum for diabetes education, the fourth and fifth editions. Ms. Franz has contributed to journals and textbooks and lectures frequently throughout the U.S. and internationally, and in recognition of all her wonderful work she has received many, many awards, including the 2001 American Diabetes Association Charles H. Best Award for Distinguished Service in the Cause of Diabetes, the 2006 American Dietetic Association Medallion Award, and the 2012 American Association of Diabetes Educators Living Legend Award. Marion, welcome, and I turn the webinar over to you.
MARION FRANZ: Thank you very much, Joanne. It is really an honor to be able to present this webinar looking at nutrition therapy recommendations for people managing diabetes.
With the webinar goals, the first goal is to review with you the highlights of the American Diabetes Association 2013 nutrition therapy recommendations. Secondly, I am going to review with you the evidence for the effectiveness of nutrition therapy. We will then look at some areas of controversy. Two of them often involve the role of weight loss in diabetes management, as well as macronutrients. And then, finally, hopefully, I hope to leave you with a take-home message as to what is really important in the real world as we, as clinicians and educators, provide education, counseling, and support for persons with diabetes.
We have a couple polling questions and we will start with the first polling question. Which is the most accurate statement for weight loss in adults with or at risk of type 2 diabetes? Weight loss improves glucose throughout the progression of type 2 diabetes. Two, weight loss is most effective in prediabetes or early after diagnosis. Three, low carbohydrate diets are preferred for weight loss, or four, low-fat diets are essential for weight loss.
We can see that the majority of you have selected the first two answers. Weight loss improves glucose throughout the progression of type 2 diabetes or, and the second one, it’s most effective in prediabetes or early after diagnosis. And what I hope to show you the evidence for is that weight loss is most effective in people who are at risk of diabetes or are prediabetes or early after the diagnosis and we will review the evidence for that.
So let’s move on to the second polling question, please. Which is the most accurate statement regarding carbohydrate intake for persons with diabetes? Fiber intake improves glycemic control. High-glycemic-index foods are absorbed into the bloodstream rapidly. Total calories or total energy intake is more important than total carbohydrate intake for glucose control, and four, adding protein to carbohydrate snacks slows absorption of carbohydrates.
And again, we see that the majority of you have selected that fiber improves glycemic control and then secondly, that adding protein slows the absorption of carbohydrate, and the one with the smallest response has been that total energy is more important than total carbohydrate, and actually that is what the information I hope to present to you, that what is really most important is how much people eat. So we will look at the evidence for these two polling questions as the seminar progresses.
The first question that is always most important, then, is, is diabetes nutrition therapy effective? Because always, I think it is essential that we have evidence that what we are asking people with diabetes to do does have evidence that it is important. And I think most of you are familiar with the studies done on prediabetes, and we realize how important nutrition therapy is along with physical activity for decreasing the risk of type 2 diabetes. And I think we are all familiar with the studies of the Diabetes Prevention Program. But what has been, perhaps, most encouraging has been the follow-up to these studies that has shown that participants in the DPP who continued with their lifestyle changes have actually reduced their risk and maintained that reduced risk for up to 14 years.
If we look, then, at people, though, with diabetes what we find evidence for is that nutrition therapy provided by registered dieticians, on average, lowers A1C by about 1% to 2%, and it depends upon the type of diabetes people have, how long they have had diabetes, and their level of glycemic control.
We also have evidence for the role of nutrition therapy in improving lipids and blood pressures, but, again, what I think is very important to know is when to evaluate outcomes. What the research shows is that clearly we will know the outcome of our nutrition therapy intervention by six weeks, clearly by three months. So at that point generally people have made the lifestyle changes that they are willing and able to make or maybe there are some additional ones they can make, but if goals have not been met then it is important to look at the overall diabetes management picture to see if there are additional changes or in medications that need to be made.
So these are some examples of some of the research looking at type 2 diabetes and the effectiveness of nutrition therapy. The first example is from the United Kingdom Perspective Diabetes Study, where people were newly diagnosed with an A1C of 9%, and after 3 months of active nutrition therapy intervention their A1C was lowered by 2% and they were randomized into the study arm, so a 2% drop. In another study done in Great Britain, here individuals with type 2 diabetes were newly diagnosed with an A1C of 6.7%, and they were randomized into usual care or intensive nutrition therapy and here, again, you see the improvement in A1C from 6 months to 12 months of 0.4%, which was statistically significant and was achieved with the use of fewer diabetes drugs. But here with the lower A1C at diagnosis you can see the drop in A1C is lower, still highly significant.
Now, a fascinating study was done in New Zealand where they looked at individuals who had a longer duration of diabetes, approximately 9 years, and they were considered in poor glycemic control despite what they considered optimized drug therapy and this was the use of two drugs at this point. So the question was, should they implement intensive lifestyle-intervention nutrition therapy or a third drug? And so they compared the intensive lifestyle intervention to a control and, again, you can see the improvement of a half a percent with the intensive lifestyle therapy, again, statistically significant. And the authors made note that they compared this outcome. It was the same effect as would have been achieved by adding a new drug but was certainly more cost-effective.
So we do have a lot of strong evidence from different types of studies that, in people with type 2 diabetes, nutrition therapy is effective across the progressive nature of type 2 diabetes. But we do know that over time medications are usually needed, but even with the use of medications they clearly work better when people also pay attention to what they eat.
And in type 1 diabetes, then, we have several examples, as well. A flexible, intensive insulin therapy trial was done, which used insulin to carbohydrate ratios. The first study was called Dose Adjusted for Normal Eating, and individuals either maintained their previous way of adjusting or managing type 1 diabetes, which was to eat consistently and then someone else adjusted the insulin, or they were taught how to adjust their insulin therapy based on their planned carbohydrate intake. And with this new approach A1Cs were lowered by 1%, and it was predicted if this was allowed that people would have more problems with hypoglycemia, which they did not, and not surprisingly they reported improvement in their quality of life. And these individuals have been followed up in Germany and Australia, who implemented a similar type of program, showing continued improvement in A1C and continued improvement in their quality of life when individuals learn how to use insulin-to-carbohydrate ratios.
So for individuals on multiple daily injections or insulin pumps the recommendation is that they adjust their insulin based on planned carbohydrate intake, however, we know that there are always some individuals who don’t want to adjust their own insulin and so they are often on fixed daily insulin doses. And so then the question is what is important? And what has been shown to be important is that these individuals, then, are consistent in their carbohydrate, both in the timing of their meals and the amount of carbohydrate in their meals and then somebody else has to adjust their insulin to cover their usual carbohydrate intake.
So the question that comes up, we have evidence that nutrition therapy is effective. The question is what types of nutrition therapy interventions are effective? And what has been shown is that there are a variety of nutrition therapy interventions used in these various studies that I have shown you some examples of. Some studies used reduced energy or fat intake, some carbohydrate counting, simplified meal plans, healthy food choices, we talked about insulin to carbohydrate ratios, physical activity, and behavioral strategy. So if we look and see, is there some type of unifying focus of these interventions, I think what we see is that first of all what is important for people with type 2 diabetes is a reduced energy intake, eating less. Isn't that easy to say? Go home; eat less. It is like telling people with diabetes go home and lose weight. Most people need a little help on how to do this.
And then clearly in type 1, it is matching insulin to carbohydrate intake, but also what comes across very strongly is the importance of a number of individual or group sessions and the absolutely, absolute need for follow-up encounters to provide support for the lifestyle changes that people with diabetes are making.
So we do know that type 2 diabetes is a progressive disease and I am sure many of you are familiar with this graph, but I just want to remind us of the progressiveness of the disease. And if you look at the bottom panel we are all aware that type 2 diabetes begins with insulin resistance, but what is also clear is that as long as an individual’s pancreas can make enough insulin to overcome that resistance glucose levels remain normal. So it is not until that we have insulin deficiency that we have the diagnosis of diabetes being made. And we see that the first defect is usually in the post-meal glucose and then the second defect is in the fasting glucose levels. But if you follow in the bottom panel you will see that as the disease progresses insulin levels also decrease and so it has been reported that if people with diabetes live long enough, which we certainly all hope that they will, eventually, many, many of them will require insulin and it isn't their fault. They have inherited a pancreas that does not work and unfortunately it has been my experience and I suspect your experience that often people with diabetes are made to feel guilty that it is their fault, that they have done something wrong. But what we have truly learned is that diabetes is a progressive disease.
So as we see we know that medications change over the progression of the disease, we see that nutrition therapy also changes over the progression of the disease and so we have prediabetes when people are insulin resistant, we have the onset of diabetes where usually there is still some continuation of insulin resistance but, as the disease progresses and people become more insulin deficient, the focus of nutrition therapy becomes on helping people achieve their metabolic goals.
So let’s look at the role of weight loss first in diabetes, and what have we learned about it? First of all, if there is one term I wish we could get rid of it would be “diet failed,” because the diet doesn’t fail. The diet works wonderfully well when it is used appropriately. What is failing are the individual’s beta cells of their pancreas. What we find is that when weight loss is most beneficial is when people are insulin resistant. When they have prediabetes or they are early in the progression of their disease. But as we will see, as they become more insulin deficient, weight loss may or may not improve glycemic control.