August 2015 Issue

Optimize Diabetes Nutrition: Going Beyond Glycemic Control and Carbohydrate Restriction Is Critical
By Jill Weisenberger, MS, RDN, CDE, FAND
Today's Dietitian
Vol. 17 No. 8 P. 22

On the advice of his health care provider, Andy, who has type 2 diabetes, scheduled an appointment with a dietitian to help him with meal planning. He handed the dietitian his blood glucose log and a sheet listing his blood pressure measurements and lipid profiles for the last two years. He confessed that he "blew the diet" yesterday in anticipation of having to give up all of his favorite foods after his nutrition appointment today.

Traditionally, people with diabetes and members of their health care team have focused primarily on blood glucose management. Today, diabetes educators and other health care providers recognize the strong link between diabetes and heart disease, and therefore emphasize not just glycemic control but also management of blood pressure, lipids, and other risk factors that may jeopardize heart health. "More people with diabetes will die of heart disease than of diabetes," says Alison Evert, MS, RD, CDE, coordinator of diabetes education programs at the University of Washington Medical Center. "Those people sitting across from us don't just have diabetes. They probably have hypertension and dyslipidemia, too," she says. Not only do blood pressure and lipid disorders increase risk of cardiovascular disease (CVD), diabetes itself confers an independent risk.1 Moreover, CVD is the largest contributor to the direct and indirect costs of diabetes.1 Thus, blood pressure control, lipid management, avoidance of tobacco, and physical activity all must be part of the treatment plan, Evert says.

Given the recent statistics showing that 71% of people with diabetes have blood pressure readings above target, and 65% have LDL cholesterol levels above 100 mg/dL, there's much work to be done.2

In the American Diabetes Association's (ADA) position statement "Nutrition Therapy Recommendations for the Management of Adults With Diabetes," of which Evert is the lead author, several goals of nutrition therapy are identified, including attaining individualized glycemic, blood pressure, and lipid goals; achieving and maintaining body weight goals; and preventing or delaying diabetes complications. Meeting these goals calls for individualizing meal plans to maintain the pleasure of eating and provide recommendations and instruction based on the individual's personal and cultural preferences, literacy, and numeracy skills, and his or her willingness to change.3

This article addresses several of these aspects of MNT for diabetes management.

The ABCs of Diabetes Care
To prevent or delay both microvascular and macrovascular complications of diabetes, patients are guided to manage the ABCs of diabetes care: A1c, blood pressure, and cholesterol, explains Chicago-based dietitian Mary Ann Hodorowicz, MBA, RD, LDN, CDE, CEC. Though blood glucose levels define diabetes, it's now being called a metabolic disease. "Blood pressure and cholesterol must be addressed with as much veracity as blood glucose levels," she says. The ADA encourages patient-specific goals; however, it recommends general targets as a starting point for discussion with the patient's health care provider (See Blood Pressure and Glycemic Goals sidebar).

A: A1c
An A1c of less than 7% is associated with reduced neuropathy, nephropathy, and retinopathy, common microvascular diabetes complications.4 The landmark Diabetes Control and Complications Trial (DCCT), a study of more than 1,400 people with type 1 diabetes, found definitive evidence that tight glycemic control soon after diagnosis confers better outcomes years later.5 Long-term follow up of the DCCT found persistent benefits among the intensively treated cohorts even though their glycemic control and that of the standard arm cohorts became similar.4 People with type 2 diabetes also experience enduring benefits from early blood glucose management, according to the United Kingdom Prospective Diabetes Study (UKPDS).4

Tight glycemic control early in the course of type 1 or type 2 diabetes also has positive effects on macrovascular disease. Subjects with type 1 diabetes randomized to the intensive glycemic control arm of the DCCT had a significantly lower risk of nonfatal myocardial infarction (MI), stroke, or CVD death compared with those randomized to the standard control arm. Notably, this benefit has persisted for several decades. Follow-up of the UKPDS also found long-term reductions in MI and all-cause mortality among individuals with type 2 diabetes.4

But is achieving a lower A1c always better? Risk of microvascular complications drops as A1c drops, so some people may benefit from an A1c goal of less than 6.5%. Conversely, an A1c of 7% may be too low for other people with diabetes. Studies have suggested that individuals with long-standing diabetes or those with advanced atherosclerosis may have detrimental outcomes from tight glycemic control.4 A study of veterans with poorly controlled type 2 diabetes found that duration of diabetes in the intensely treated participants was related to increased mortality.

Those with long-standing diabetes had a greater risk of mortality compared with those in the standard treatment arm, but those with shorter duration of diabetes experienced lower risk of mortality compared with subjects in the control arm. The ADA states that individuals with long duration of diabetes, advanced atherosclerosis, advanced age, short life expectancy, frailty, or a history of severe hypoglycemia may benefit from less stringent A1c targets, such as less than 8%.4

B: Blood Pressure
Hypertension is a risk factor for both CVD and microvascular complications and is present in most people with diabetes.1 In type 1 diabetes, high blood pressure frequently is the result of nephropathy. However, among individuals with type 2 diabetes, hypertension commonly coexists with other cardiovascular risk factors, including dyslipidemia and abdominal adiposity. The ADA recommends that all people with diabetes who have blood pressure levels above 120/80 mm Hg engage in blood pressure lowering behaviors such as reducing sodium intake, following a healthful dietary pattern such as the DASH diet, moderating alcohol intake, and participating in physical activity.1 The ADA recommends that people with diabetes restrict sodium to less than 2,300 mg/day and suggests that individuals with both diabetes and high blood pressure may benefit from a greater restriction.3 The ADA also emphasizes that individualized sodium intake recommendations must consider taste, financial constraints, and the difficulty of achieving both a nutrient-dense diet and a sodium-restricted diet.

For individuals with hypertension, the ADA recommends a general target of less than 140/90 mm Hg.1 Over the years, the ADA has liberalized their blood pressure targets to reflect the most current research. The recent ADA Standards of Care identified a diastolic blood pressure goal of less than 90 mm Hg, which is 10 mm Hg higher than the previous goal. The stricter diastolic blood pressure goal, however, is appropriate for some individuals such as younger patients. The systolic blood pressure goal was raised from 130 to 140 mm Hg in 2013. According to the Action to Control Cardiovascular Risk in Diabetes study, systolic blood pressure less than 140 mm Hg didn't reduce the rate of composite outcome of fatal and nonfatal major cardiovascular events. Achieving a systolic blood pressure less than 130 mm Hg reduces stroke risk but greatly increases the risk of adverse events including hypotension and syncope.1 The ADA suggests that a systolic blood pressure goal of less than 130 mm Hg may be appropriate in younger patients and those at high risk of stroke, especially if they can reach this goal with few medications and without side effects.

C: Cholesterol
People with type 2 diabetes have a higher than average prevalence of dyslipidemia. Until this year, the ADA's goal for LDL cholesterol was less than 100 mg/dL. In keeping with the guidance of the American Heart Association and the American College of Cardiology,6 the ADA no longer has a specific LDL cholesterol goal. Instead, it now recommends pharmacological therapy based on CVD risk status rather than LDL cholesterol levels. Having an LDL cholesterol level of 100 mg/dL or higher is considered a risk factor for CVD, as are hypertension, smoking, overweight, and obesity.

To improve lipid profiles, the ADA recommends people with diabetes follow the same guidelines as the general population for saturated fat, trans fat, and dietary cholesterol intake.7 Elevated triglycerides and low levels of HDL cholesterol often improve with optimized glycemic control.1 The ADA encourages weight loss if indicated and increased physical activity. An increase in both long-chain and short-chain omega-3 fatty acids; viscous fibers from oats, barley, legumes, and citrus; and plant stanols/sterols also are indicated. Plant stanols and sterols block the absorption of both dietary and biliary cholesterol. The ADA finds that daily doses of 1.6 g to 3 g of phytosterols or stanols from enriched foods are safe and may modestly reduce LDL cholesterol levels in people with diabetes.3 "This is an easy-peasy nutrition tool to reduce the risk of disease," Hodorowicz says.

Diabetes Meal Planning
With regard to meal planning, there are many eating patterns suitable to diabetes management, including Mediterranean-style, DASH, vegetarian, vegan, low fat, and lower carbohydrate. The ADA, noting that there isn't just one ideal macronutrient distribution, advises health care professionals to individualize dietary recommendations based on metabolic goals, personal preference, economics, culture, health beliefs, and other factors.3 Energy restriction is an important component of diabetes meal planning for overweight and obese individuals. It appears that weight loss of at least 5% of starting weight is necessary for meaningful improvements in A1c, lipids, and blood pressure.8 Even in the absence of weight loss, however, energy restriction can improve glycemic control. In many people, blood glucose levels improve quickly during energy restriction, even before much weight is lost. Once weight loss plateaus, the lowered energy intake may maintain improved glycemia.8

To effect meaningful change, meal planning must be a collaborative process, Evert says. Working with each patient as an individual and focusing on his or her health and nutrition goals should be the priority, she says. Small changes such as replacing sugary drinks with noncaloric beverages, or reducing portions can make a big difference over time. Like Andy, many patients fear being told to give up their favorite foods. Janis Roszler, MS, RD, LD/N, CDE, FAND, author of Diabetes on Your Own Terms, often deals with this concern. "One patient who had diabetes was afraid that she would have to stop eating her daily Hershey's Kiss. I appreciated the value it had in her life. It was one way she pampered herself." Not wanting to discourage self-nurturing, Roszler helped the patient work the chocolate into her individualized meal plan. The patient was relieved to continue her treasured habit and grateful for the personalized attention. "She was much more willing to follow the recommendations I made," Roszler explains.

To begin the meal planning process with clients and patients, the following tips can help.

Look at the Broad View
"Patients need to see the big picture," Hodorowicz says. "It's important to take a wide angle view of key core concepts." When first addressing a topic, avoid the nice to know and stick to the need to know, she says. For example, during the first visit, it's more than enough to identify simple swaps to reduce saturated fat; it's unnecessary to identify the more healthful choices as sources of monounsaturated or polyunsaturated fats.

Unfortunately, many patients perceive working to reach or maintain blood glucose, blood pressure, and cholesterol targets as competing goals. To address this concern, Hodorowicz suggests making analogies to everyday life situations. "The A, B, and C work together synergistically to take care of you, she explains. "It's like taking care of a baby. We don't decide to either feed the baby or change the diaper. We feed [the baby], hydrate [it], and change the diaper to take care of all of the baby's needs."

Address Cultural Differences
"Don't make assumptions," warns Tabitha Miller, RD, LDN, CDE, a bilingual diabetes educator at Esperanza Health Center in Philadelphia. Since each individual is different, ask questions about food preferences, health beliefs, and economics. If the patient describes something you aren't familiar with, you can look it up online during the session, she explains. Likewise, RDs can use pictures of food from the Internet to identify new foods for the patient or recommend foods to buy. Some dietitians use culturally appropriate food models and educational materials in multiple languages to help when counseling patients.

When recommending dietary changes, Miller considers her patients' average food intake. The majority of her patients eat few vegetables. They may consume lettuce and tomatoes only once per week. "I want them to eat the recommended five to nine servings a day, but that isn't going to be my first recommendation. If I do that, I'll offend them, and they will not come back," she explains. Instead, Miller lists various vegetables to determine if her patients have tried them before, and if they're willing to try them in the near future.

Match Information to Patients' Literacy and Numeracy Skills
Many patients are skilled at hiding their poor reading and numeracy skills. Deborah Smith, RD, LD, CDE, who works at a rural federally qualified health center in New Mexico, uses pictures as handouts and low-literacy materials. "Sometimes it's impossible to tell if patients are reading the material or just acting like they're reading," she says. Hodorowicz always recommends using materials at a lower reading level than the patient's because of the complexity of the subject matter.

Improved Patient Care
Diabetes management has evolved over the past several years. Due to the association between diabetes and heart disease, health care practitioners now focus on managing blood glucose, blood pressure, lipids, and other risk factors that may hinder heart health. By staying current with the latest research and guidelines and developing meal plans in accordance with each individual's metabolic goals, food preferences, culture, and health beliefs, dietitians can effect positive change and greatly improve patient care.

— Jill Weisenberger, MS, RDN, CDE, FAND, is a freelance writer and a nutrition and diabetes consultant to the food industry. She specializes in weight management, diabetes, and heart health, and has a private practice in Newport News, Virginia. She's the author of 21 Things You Need to Know about Diabetes and Your Heart and Diabetes Weight Loss — Week by Week.

References
1. American Diabetes Association. (8) Cardiovascular disease and risk management. Diabetes Care. 2015;38(Suppl 1):S49-S57.

2. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Department of Health and Human Services; 2014.

3. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2014;37(Suppl 1):S120-S143.

4. American Diabetes Association. (6) Glycemic targets. Diabetes Care. 2015;38(Suppl 1):S33-S40.

5. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.

6. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/ AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2889-2934.

7. American Diabetes Association. (4) Foundations of care: education, nutrition, physical activity, smoking cessation, psychosocial care, and immunization. Diabetes Care. 2015;38(Suppl 1):S20-S30.

8. Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials [published online April 29, 2015]. J Acad Nutr Diet. doi: 10.1016/j.jand.2015.02.031.

BLOOD PRESSURE AND GLYCEMIC GOALS

The following are the American Diabetes Association's (ADA) general guidelines for glycemia and blood pressure goals in adults. The ADA notes that more or less stringent goals may be appropriate in some individuals.

Glycemic Goals
A1c: < 7%
Fasting and before meals: 80 to 130 mg/dL
One to two hours after eating: < 180 mg/dL

Blood Pressure Goals for Diabetes Patients With Hypertension
< 140/90 mm Hg
*Patients with blood pressure >120/80 mm Hg should engage in lifestyle changes to reduce blood pressure.

— SOURCE: AMERICAN DIABETES ASSOCIATION

CULTURALLY SENSITIVE AND LOW-LITERACY
EDUCATIONAL MATERIALS

• The Association of Clinicians for the Underserved (http://clinicians.org/general-diabetes-patient-education-handouts/) offers eight low-literacy handouts in several languages.

• The Diabetes Care and Education Dietetic Practice Group (www.dce.org/publications/education-handouts/) gives members access to both advanced and basic educational materials.

• American Diabetes Association Diabetes Pro (http://professional.diabetes.org/ResourcesForProfessionals.aspx?cid=77080) offers free reproducible handouts on prediabetes, diabetes, and cardiometabolic disease.

• The National Diabetes Education Program (http://ndep.nih.gov/) provides materials in more than one dozen languages, and targets a variety of populations including many ethnic groups.

• The Vanderbilt University Center for Diabetes Translation Research (www.mc.vanderbilt.edu/root/vumc.php?site=CDTR&doc=37816) offers low-literacy educational materials and literacy and numeracy scales to measure skills specific to diabetes management.

• Learning About Diabetes (www.learningaboutdiabetes.org/) provides easy-to-understand materials in Spanish and English. Materials are free to consumers and available for a fee to health care organizations.

— JW