Tailored, sugar-reduced nutrition therapy needed to boost diabetes treatment: experts

24 Apr 2019 --- Personalized, diabetes-focused medical nutrition therapy is imperative in treating adults with diabetes or prediabetes. This is according to a recent American Diabetes Association (ADA) consensus statement. The ADA supports that a personalized approach in nutrition should be a lifelong commitment, to limit the adverse health outcomes of the condition. The report stresses that patients should have their medical nutrition plans frequently monitored by health specialists and be better educated on the matter. The association is now calling on industry to reduce sugar content, limit sweetener use and promote whole foods.

The ADA report defines medical nutrition therapy as an evidence-based application of the nutrition care process provided by a registered dietitian nutritionist. Essential components include assessment, nutrition diagnosis, interventions (education and counseling) and monitoring with ongoing follow-up to support lifestyle changes.

The new guidance report, Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report, comes as targeted medical nutrition is gaining attention for its potential to prevent disease and/or hospital stays. The report is the work of 14 experts who reviewed over 600 nutrition manuscripts and is now incorporated into the ADA’s Standards of Medical Care in Diabetes.

“Prescribing a ‘one-size-fits-all’ eating plan is unrealistic given the broad spectrum of people affected by diabetes and prediabetes, their cultural backgrounds, personal preferences and comorbidities,” says William S. Yancy, Associate Professor of Medicine at Duke University School of Medicine in Durham, North Carolina. 

Sugar reduction is an industry matter?
Yancy tells NutritionInsight that industry should aim for a further reduction of added sugars without always adding an alternative sweetener. He asserts that a focus on whole foods is important, but it is hard for whole foods to “compete” with sweetened food and beverages once consumers acquire a taste for them.

William S. Yancy, Associate Professor of Medicine at Duke University School of Medicine in Durham, North Carolina “I don’t think there are any obvious safety concerns regarding alternative sweeteners, but I think that sugars and alternative sweeteners both drive our tastes to crave sweet foods, which in turn leads to weight gain, insulin resistance and diabetes.” 

Reducing sugar intake remains a top priority for consumers, as they become increasingly aware of the negative health effects of sugar. In an Innova Consumer Lifestyle and Attitudes Survey (2018), nearly 7 out of 10 consumers across the countries surveyed (US, UK, France, Germany, China and Brazil) have reduced their sugar intake. This is particularly so among the 55+ age group, with consumers in France and Brazil the most likely to be reducing sugar in their diet. 

“A focus on promoting non-starchy vegetables, reducing added sugars and refined grains and emphasizing whole, unprocessed foods to the extent possible would provide more options for people living with diabetes to make healthy choices,” Shamera Robinson, Associate Director, Nutrition, ADA, tells NutritionInsight.

“For example, introducing more unsweetened drink options made with natural flavors is a shift that makes it easier for people with diabetes or prediabetes to minimize their daily sugar intake,” she notes.

Robinson says, however, that the US Food and Drug Administration (FDA) has reviewed and approved several types of sugar substitutes for consumption by the public, including people with diabetes. 

“If sugar substitutes are used to replace sugar, they may help to reduce daily calorie and carbohydrate intake, however, using sugar substitutes does not make an unhealthy option healthy. Instead, using sugar substitutes in place of sugar makes an unhealthy option a little less unhealthy,” she warns.

Prevention and prediabetes focus
The report updated the ADA’s 2014 position statement on nutrition therapy for adults with diabetes and now includes adults with prediabetes as well. The report notes that practitioners should familiarize themselves with the various options to accommodate patients’ unique needs to maximize success. The statement also recognized that carbohydrates are the most important contributor to blood glucose and weight loss, and cutting down on this food group is one of the most effective strategies for diabetes management. 

“Prediabetes is becoming increasingly recognized in medical practice and the evidence shows that it responds very well to nutritional changes and weight loss, more so than it does to medication,” Yancy says. “Given this and the increasing prevalence of Type 2 diabetes, the ADA wanted to make sure to include guidance for practitioners who are working with people who are at risk for developing Type 2 diabetes.”

The statement provides an overview of several popular eating patterns and their potential benefits, including the Mediterranean-style diet, vegetarian or vegan eating patterns, low-fat, low carbohydrate, paleo eating plan, intermittent fasting and the Dietary Approaches to Stop Hypertension (DASH) diet.

Can personalized nutrition tackle diabetes?
The use of nutrition counseling strategies that aim to personalize guidance based on genetic and metabolomic data is a growing area of research. While more research is needed to identify personalization based on genetic, metabolomic and microbiome information, the current evidence also suggests no ideal macronutrient distribution exists for people with or at risk for diabetes, according to Robinson. 

“The percentage of calories from carbohydrate, protein and fat should be based on individualized assessment of current eating patterns, food preferences, food access and metabolic goals. Many different eating patterns can help manage diabetes and prediabetes and an individualized plan that considers all personal factors is critical for maintaining overall health,” she notes.

According to Yancy, non-personalized changes to nutritional intake can still have a profoundly beneficial impact on overall health, as shown by scores of randomized clinical trials. Personalizing nutritional counseling, however, has potential for an even greater impact, by helping an individual make dietary changes that are tailored to their health problems and food preferences. 

“Specifically for diabetes, research has shown that nutritional changes can lower hemoglobin A1c by up to 2 percent and reduce the need for diabetes medication. Currently, dietary change, in combination with physical activity and weight loss, is the most effective strategy available for the prevention of diabetes,” Yancy explains. 

The report notes that nutrition therapy that includes an eating plan developed to optimize blood glucose trends, blood pressure and lipid profile is important in managing diabetes and lowering the risk for developing cardiovascular disease. The statement recommends people with diabetes replace dietary saturated fats with monounsaturated and polyunsaturated fatty acids to help reduce LDL cholesterol. 

Concluding points
The majority of people who suffer from diabetes do not receive any nutrition therapy or formal diabetes education. To improve access, the statement recommends that technology-enabled diabetes nutrition therapy be integrated with medical management and community health workers and peer coaches be deployed to provide culturally appropriate, ongoing support and linked care coordination.

“Evaluating nutrition evidence is complex given that multiple dietary factors influence glycemic management and CVD risk factors, and the influence of a combination of factors can be substantial,” the researchers stress. “Based on a review of the evidence, it is clear that knowledge gaps continue to exist and further research on nutrition and eating patterns is needed in individuals with Type 1, Type 2 and prediabetes.”

“Because nutrition therapy guidance needs to be adjusted regularly based on an individual’s life circumstances, preferences and disease course, there are no ‘umbrella’ treatments or eating patterns that will work for all. However, most of the eating patterns reviewed in the Consensus Report share key elements. As nutrition research incorporates more data from CGM (continuous glucose monitors), additional strategies for personalized approaches will likely emerge,” Robinson concludes. 

 By Kristiana Lalou