Success of nutrition-therapy interventions in persons with type 2 diabetes: challenges and future directions

Figures & data

Table 1 Academy of Nutrition Dietetics nutrition-practice guideline for T2D: intervention recommendations

Energy intake

• For overweight or obese adults with T2D, encourage a reduced energy, healthy eating plan with a goal of weight loss, weight maintenance, and/or prevention of weight gain.

• For appropriate-weight adults with T2D, encourage consumption of a healthy eating plan with goals of weight maintenance and/or prevention of weight gain.

Macronutrient composition

• In collaboration with the adult with T2D, individualize the macronutrient composition of a healthy eating plan within appropriate energy intake.

Carbohydrate management strategies

For adults on nutrition therapy alone or taking other diabetes medications (other than insulin secretagogues)

• Educate based on abilities, preferences, and management goals on one of the following:

• carbohydrate counting alone;

• plate method, portion control, simplified meal plan;

• food lists and carbohydrate choices.

For adults using fixed insulin doses or insulin secretagogues

• Educate based on abilities, preferences, and management goals on carbohydrate consistency (timing and amount) using one of the carbohydrate-management strategies listed above.

For adults with T2D using multiple daily insulin injections or insulin-pump therapy

• Educate adults on carbohydrate counting using insulin:carbohydrate ratios based on abilities, preferences, and management goals.

Fiber intake

• Encourage consumption of dietary fiber from fruit, vegetables, whole grains, and legumes at levels recommended by Dietary Reference Intakes (21–25 g/day for adult women and 30–38 g/day for adult men, depending on age) or US Department of Agriculture (14 g fiber per 1,000 kcal) due to the overall health benefits of dietary fiber.

Glycemic index (GI) and glycemic load (GL)

• If GI or GL is proposed as a glycemia-lowering strategy, advise that lowering GI or GL may or may not have a significant effect on glycemic control. Studies longer than 12 weeks report no significant influence of GI or GL, independent of weight loss, on HbA1c levels.

Nutritive sweeteners

• Educate that intake of nutritive sweeteners when substituted isocalorically for other carbohydrates will not have a significant effect on HbA1c or insulin levels.

• Advise against excessive intake of nutritive sweeteners to avoid displacing nutrient-dense foods and to avoid excessive calories and carbohydrate intake.

Nonnutritive sweeteners

• Educate that intake of FDA-approved nonnutritive sweeteners (such as aspartame, sucralose, and steviol glycosides) within the acceptable daily intake levels established by the FDA will not have a significant influence on glycemic control.

• Educate that substituting foods and beverages containing FDA-approved nonnutritive sweeteners within the recommended daily-intake levels established by the FDA can reduce overall calories and carbohydrate intake; however, other sources of calories and carbohydrates in these foods and beverages need to be considered.

Protein intake and protein intake for diabetic kidney disease (DKD)

• Educate that adding protein to meals and/or snacks does not prevent or assist in the treatment of hypoglycemia. Ingested protein appears to increase insulin response without increasing plasma-glucose concentrations.

• Educate adults with diabetes and DKD that protein restriction does not have a beneficial effect on glomerular filtration rate (GFR).

• Educate adults with T2D and DKD that the type of protein (vegetable-based vs animal-based) will not have a significant effect on GFR.

Cardioprotective eating patterns

• Encourage a cardioprotective eating pattern within the recommended energy intake.

• Encourage an individualized reduction in sodium intake. The recommendation for the general public to reduce sodium to <2,300 mg/day is also appropriate for adults with diabetes; for adults with diabetes and hypertension, further reductions in sodium intake should be individualized.

Vitamin, mineral, and/or herbal supplementation

• If vitamin, mineral, and/or herbal supplementation is proposed as a diabetes-management strategy, advise there is no clear evidence from supplementation in people who do not have underlying deficiencies.

Alcohol consumption a

• Advise and educate adults that when they choose to drink alcohol, they should do so in moderation (up to one drink per day for adult women and up to two drinks per day for adult men; one drink is equal to 350 mL beer, 150 mL wine, or 45 mL distilled spirits). Alcohol consumption may place adults at increased risk of delayed hypoglycemia when using insulin or insulin secretagogues.

Physical activity a

• Encourage an individualized physical activity plan, unless medically contraindicated, to gradually achieve the following:

• accumulating 150 minutes or more of physical activity per week;

• moderate-intensity aerobic exercise (50%–70% maximum heart rate) spread over at least 3 days per week, with no more than 2 consecutive days without exercise;

• resistance training at least twice per week;

• reduce sedentary time by breaking up extended amount of time (>90 minutes) spent sitting.

• Educate adults taking insulin or insulin secretagogues that physical activity may cause hypoglycemia in cases where medication doses or carbohydrate consumption is not altered.

Glucose monitoring a

• Ensure that adults with T2D are educated about glucose monitoring and using data to adjust therapy.

Notes:

a Recommendations based on American Diabetes Association recommendations.^4,9 Copyright © 2017. Elsevier. Adapted from Franz MJ, MacLeod J, Evert A, et al. Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet. 2017;117:1659–1679. Available from: https://jandonline.org/article/S2212-2672(17)30332-5/pdf.² Data from MacLeod et al.³

Abbreviations: T2D, type 2 diabetes; HbA1c, glycated hemoglobin; FDA, Food and Drug Administration.

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