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Diabetes and Healthy EatingA CommentaryFrom Nutrition Concepts by Franz, Inc, Minneapolis, Minnesota. Correspondence to Marion J. Franz, MS, RD, CDE, Nutrition Concepts by Franz, Inc, 6635 Limerick Drive, Minneapolis, MN 55439-1260 (marionfranz{at}aol.com). The American Association of Diabetes Educators and the authors of the commentary "Diabetes and Healthy Eating: A Systematic Review of Dietary Interventions"1 are to be commended for their efforts to define and examine the state of self-management evidence. However, it is not surprising that the systematic review of healthy eating did not reveal a clear pattern of food and nutrition interventions leading to outcomes of weight, fat intake, saturated fat, and carbohydrate. In 1994, the American Diabetes Association (ADA) stated, "Today there is no ONE `diabetic' or `ADA' diet."2 To be effective, medical nutrition therapy (MNT) requires an individualized approach, with nutrition recommendations and interventions developed to meet treatment goals and desired outcomes. It is essential that nutrition assessment be used to determine what the individual with diabetes is able and willing to do. Nutrition interventions are then implemented by nutrition education and counseling. This approach to MNT was reaffirmed in the ADA 20023 and 20064 nutrition recommendations for diabetes. Instead of asking about specific healthy eating or dietary interventions, for its evidence-based nutrition practice guidelines, the American Dietetic Association asked a slightly different question: how effective is MNT provided by registered dietitians in the management of type 1 and type 2 diabetes?5 Sixteen studies ranging in length from 6 months to longer than 1 year were reviewed, including 8 randomized controlled trials, 2 retrospective cohort studies, 3 time series studies, 1 descriptive study, and 1 before-after study. Improvements in A1C, lipid profile, and weight loss; a decreased need for medication; and a reduced risk for onset and progression of comorbidities were reported. Of interest was the variety of nutrition therapy interventions implemented, such as reduced energy/fat intake, carbohydrate counting, simplified meal plans, healthy food choices, individualized meal-planning strategies, exchange lists, insulin-to-carbohydrate ratios, and behavioral strategies. Of these 16 studies, only 1 is included in the systematic review of healthy eating, and 1 other study was reviewed but excluded. Missing from the systematic review of healthy eating are some important clinical trials and outcome studies of diabetes nutrition therapy. For example, the first nutrition therapy priority for individuals requiring insulin therapy is to integrate an insulin regimen into the individual's lifestyle.3,4 The Dose Adjustment for Normal Eating, a randomized controlled trial, demonstrated significant improvement in A1C (1% decrease) without a significant increase in severe hypoglycemia, as well as positive effects on quality of life, satisfaction with treatment, and psychological well-being, when patients learned to use glucose testing to match insulin doses to carbohydrate intake.6 Another example, the first nutrition therapy priority for individuals with type 2 diabetes, is to encourage patients to implement lifestyle strategies that will improve glycemia, dyslipidemia, and blood pressure.3,4 In the United Kingdom Prospective Diabetes Study, before being randomized into study groups, subjects received 3 months of intensive nutrition therapy, which resulted in a 1.9% reduction in A1C and a mean 5% weight loss.7 In a randomized controlled trial, MNT provided by dietitians following nutrition practice guidelines for patients with type 2 diabetes resulted in a 0.9% reduction in A1C in patients with a mean 4-year duration of diabetes and a 1.7% decrease in A1C in newly diagnosed patients.8 In a time series study investigating outcomes from physician-referred adults with type 2 diabetes to registered dietitians, reduction in A1C over 6 months was 1.7%.10 A comment about terms: since the early 1990s, the American Dietetic Association and American Diabetes Association have recommended and used the term medical nutrition therapy for what previously had been called dietary therapy or dietary management. It has also become clear that there is no definition for healthy eating. What is healthy eating for one person with diabetes may not be healthy eating for another person. The goals of MNT are to achieve and maintain metabolic goals, prevent the development of chronic complications, address individual nutrition needs, and maintain the pleasure of eating.4 Furthermore, ongoing nutrition self-management education and care must be available for individuals with diabetes.5 In summary, this commentary documents the statement that there is no one set of nutrition recommendations or interventions that apply to all persons with diabetes. This is similar to medical therapy, in which there is no one type of therapy—diabetes medications or insulin regimens—that apply to everyone with diabetes. Nutrition therapy begins with a nutrition assessment and then, together with the individual with diabetes, nutrition interventions are determined. Interventions are based on recommendations that will assist the person with diabetes to meet his or her therapy goals and are implemented through the process of nutrition education and counseling. Outcomes must be measured to determine if goals are being met; if not, changes need to be made in the diabetes management plan.
The Diabetes Educator, Vol. 33, No. 6,
960-961 (2007)
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