August 2018 Issue

Diabetes Management & Nutrition Guide: Diabetes Nutrition Throughout the Lifecycle
By Kathy W. Warwick, RD, CDE
Today's Dietitian
Vol. 20, No. 8, P. 33

While there's no one-size-fits-all dietary pattern to manage type 2 diabetes, children and teens, adults, and seniors have different nutrition needs and management goals.

The diagnosis of type 2 diabetes can be daunting, if not devastating, for many individuals. Well-meaning family members, friends, and colleagues will offer advice about all the foods and beverages they should avoid. However, the days of the so-called "diabetic diet" are long gone. Diabetes care has shifted to an approach that places patients and their families at the center of the care model, working in collaboration with a team of health care professionals. RDs address nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness and ability to make behavioral changes, and barriers to change, all the while considering their patient's age and season of life—as nutrition requirements and management goals differ for children and adolescents, younger adults, and older adults. In other words, children and adolescents with type 2 diabetes will have different nutrient needs and management goals than a young adult, and an older adult will have different nutrient needs and management goals than a younger adult or child with type 2 diabetes.1,2

In general, there's no ideal distribution of calories from carbohydrates, fats, and proteins for people with diabetes, and therefore dietitians must individualize macronutrient distribution while keeping total calorie and metabolic goals in mind. The good news is there's a wide variety of eating patterns that are acceptable for the management of type 2 diabetes.3,4 This article will discuss MNT throughout the lifecycle for type 2 diabetes to help dietitians better counsel clients of all ages.

Children and Adolescents
The medical community first began to officially identify children with type 2 diabetes about 20 years ago. Researchers involved in the SEARCH for Diabetes in Youth study released data collected from 2000 to 2012 that suggested there are 5,300 new cases of type 2 diabetes annually in US children aged 10 to 19. Cases of type 1 diabetes are more prevalent in children, but the incidence of type 2 has risen along with obesity rates. Because of the increase in obesity among youth, it can be challenging for clinicians to accurately diagnose type 1 vs type 2 diabetes.5 Stephen Ponder, MD, CDE, FAAP, a pediatric endocrinologist with the Baylor Medical System in Temple, Texas, and the 2018 AADE Educator of the Year, says he was practicing in south Texas when he first saw cases of type 2 diabetes in Hispanic youth. Type 2 diabetes disproportionately affects youth of ethnic/racial minorities from disadvantaged backgrounds. "Excess weight is the driving factor for type 2 diabetes," Ponder says. "We have learned that obesity is a family affair, and effective treatment plans must involve the entire family. Many at-risk families are living on the edge with limited time and food budgets so the challenge is to meet them where they are with our nutrition guidance." Ponder and his colleague Meaghan Anderson, MS, RD, LD, CDE, developed the acronym S.A.F.E. to describe basic changes families can make to decrease the risk of obesity and type 2 diabetes (see sidebar below).

RDs can present these options and ask families to choose one or two of these interventions. "For example, a 16-year-old girl seen in our clinic lost 22 lbs in six months by substituting sugar-free beverages for sugary drinks," Ponder says. "Encouraging families to make small, simple changes that can easily be maintained is much more likely to impact long-term health than an impractical, complicated eating plan." Adolescents present a greater challenge because they can be particularly resistant to lifestyle modification interventions, Ponder adds, and "because they dislike being singled out or feeling they are different from their peers. Puberty also decreases insulin sensitivity."2 When it comes to setting goals for weight loss, Ponder discourages giving specific numbers to families. Instead, he counsels parents of younger children that weight maintenance may be an appropriate goal if children are still growing. Older adolescents may become discouraged if health care providers set unrealistic goals of 100 lbs to reach "ideal" body weights. In general, a 7% to 10% weight loss should be the target.1 RDs should always praise positive behavior changes instead of focusing on medical outcomes.

Goals of MNT in children and adolescents include the following:

• achieving adequate nutrition for normal growth and development;
• emphasizing a variety of nutrient-rich food choices—fruits, vegetables, whole grains, and dairy to supply nutrients of concern such as calcium, potassium, dietary fiber, vitamin D, and iron;
• reducing sodium and added sugars;
• substituting solid fats with liquid oils6; and
• assessing food insecurity and providing a referral to community resources as needed.2,7

When describing eating patterns or presenting alternative food choices, RDs should use nonjudgmental language. Avoiding the use of labels such as "bad" or "good" for individual foods is important when dealing with children, who may internalize they're "bad" if they eat a "bad" food. This idea can set the stage for an unhealthful relationship with food and disordered eating behavior. Screening adolescents for eating disorders and referral to psychological services may be appropriate.2,7

Adults
According to the Centers for Disease Control and Prevention, there were 13.7 million adults aged 18–64 with diagnosed type 2 diabetes in 2015. In addition, 5.6 million had diabetes but were unaware of their condition. Prevalence was higher among American Indians/Alaska Natives, non-Hispanic blacks, and people of Hispanic ethnicity than among non-Hispanic whites and Asians. Prevalence varied significantly by education level, which often is an indicator of socioeconomic status. Specifically, 12.6% of adults with less than a high school education had diagnosed diabetes vs 9.5% of those with a high school education, and 7.2% of those with more than a high school education.8

Nearly all adults with a new diagnosis of type 2 diabetes already have at least one comorbid condition such as hypertension, overweight or obesity, hyperlipidemia, and CVD.9 By the time clients arrive for a consultation with a dietitian, they're confused and their first question is "What can I eat?" Dietitians can play a pivotal role in guiding this population through the maze of eating plans and food choices so they can achieve optimal health. According to the 2018 ADA Standards of Medical Care for Diabetes, lifestyle management is the foundation of diabetes care and includes diabetes self-management education and support (DSMES), MNT, physical activity, smoking cessation counseling, and psychosocial care.1

Goals of MNT for Adults
MNT for adults involves meal planning that takes carbohydrates, fats, and protein into consideration.

• Carbohydrates in meal planning. When counseling adults with type 2 diabetes, many may have questions about very low-carb diets and carb counting to control blood sugar. Although carbohydrate is the macronutrient that most affects blood glucose, the amount of carbohydrate included in the meal plan can vary greatly (39% to 57% of energy) without significant changes in A1c.4,10 The Academy of Nutrition and Dietetics (the Academy) Evidence Analysis Library systematic review of current research identified energy reduction and weight loss as the dominant driver of A1c change. Many healthful eating patterns can be adapted for adults with type 2 diabetes to achieve and maintain a 5% to 7% weight loss.3,4,10

Before recommending carb counting, dietitians should assess client interest and numeracy skills. Carb counting and use of insulin-to-carb ratios is beneficial for those on meal-time insulin or insulin pumps. Patients prescribed fixed insulin doses or secretagogues may find consistent carbohydrate intake is helpful for glycemic control and avoidance of hypoglycemia. The monitoring of carbohydrate intake generally is recommended for those on other medications or lifestyle therapy alone.10 RDs can encourage carbohydrate intake from vegetables, fruits, legumes, whole grains, and dairy products, with an emphasis on foods higher in fiber and lower in added sugars.1 Simplified meal plans (ie, plate method, portion control, food lists with carb choices) all can be effective.4,10 According to Janice MacLeod, MA, RDN, LDN, CDE, director of clinical innovation for WellDoc in Columbia, Maryland, and lead author of the Academy's nutrition practice guidelines, "A useful strategy is to encourage blood glucose monitoring before and after meals to determine how much carbohydrate an individual can tolerate without causing postprandial hyperglycemia. Blood glucose monitoring should be used strategically to help patients learn if the treatment plan components—including food, medication, and activity—are working in synergy." Using these data, RDs can help clients problem solve to improve postprandial glucose readings.

• Fats in meal planning. In the past, low-fat diets were recommended to help prevent heart disease, a chief comorbidity of type 2 diabetes in adults. But the type of fat included in the eating pattern is more important than the amount. Again, the Evidence Analysis Library guidance shows that 27% to 40% of energy may be derived from fat with no significant change in A1c, independent of weight loss. Consistent with the 2015–2020 Dietary Guidelines for Americans, the recommendations for people with diabetes are to modify the type of fat consumed. Substituting unsaturated fats for saturated and trans fat may reduce total and LDL cholesterol.4,10 The Mediterranean eating pattern has been shown to reduce the risk of hypertension, hyperlipidemia, and CVD.11 Dietitians should offer practical tips for making these fat substitutions in snack choices or cooking methods. Eating foods rich in omega-3s is associated with cardioprotective benefits, while fish oil supplementation isn't.1

• Protein in meal planning. The old "diabetic bedtime snack" intended to prevent nocturnal hypoglycemia generally included a carb and a protein related to the idea that added protein would stabilize blood glucose levels. Research shows protein is a potent stimulant for the pancreas to release insulin, but protein doesn't increase blood glucose levels. It's no longer advised to use protein to treat hypoglycemia or prevent hypoglycemia. For this reason, milk has been removed from the list of appropriate carbohydrate sources used to treat low blood sugar. Protein intakes ranging from 20% to 30% of energy or 1–1.5 g/kg are acceptable. Some evidence supports increased satiety with higher protein intakes.1

Putting It All Together
• As for the general population, encourage fiber intake of 14 g per 1,000 kcal, limits on sodium to 2,300 mg per day, and reduction of added sugars to less than 10% of kcal.1,6

• Sucrose and other sugars may be substituted for isocaloric amounts of starch with similar effects on blood glucose levels.3,4,10

• Several eating plans such as DASH (Dietary Approaches to Stop Hypertension), Mediterranean, and plant-based may be adapted by individuals based on preferences, access, willingness to change, barriers, and metabolic goals. The plate method, estimation of carb intake, and portion control are all effective tools.1,4,10

• Energy reduction for modest weight loss can reduce A1c 0.3% to 2% as well as decrease medication use and boost quality of life.10

• Low- and very low-carbohydrate diets have shown benefits in the short term, but over time these diets are similar in efficacy to moderate-carb diets. Drastic dietary changes are difficult to maintain, and most people with diabetes will return to their usual macronutrient distribution. Research shows most people with diabetes report a moderate intake of carbohydrate ranging from 44% to 46% of kcal.1

• Studies lasting longer than 12 weeks report no significant impact of glycemic index or glycemic load on A1c, independent of weight loss. There's mixed evidence of improvement in fasting glucose and endogenous insulin levels.1

• Moderate alcohol use (no more than one drink per day for women and two drinks per day for men) can be incorporated into eating plans. One drink is defined as 12 oz of beer, a 5-oz glass of wine, or 1.5 oz of distilled spirits. Alcohol can increase the risk of delayed hypoglycemia for those taking insulin or secretagogues.1,4,10

• There's no evidence to support reductions in protein intake below the Recommended Dietary Allowance of 0.8 g/kg for those with chronic kidney disease. Studies show no difference based on the source of protein (animal or vegetable) on kidney function.1,4,10

• FDA-approved nonnutritive sweeteners may be helpful for weight reduction and are safe to use within the acceptable daily intake range.1,4,10

• There continues to be no clear evidence of benefit for micronutrient or herbal supplements beyond their use to correct deficiencies. Metformin use has been associated with B12 deficiency, and periodic testing is recommended, especially for those with anemia or peripheral neuropathy.1

Older Adults
One out of four older adults over age 65 has diabetes, and one-half of older adults has prediabetes. This population presents an interesting challenge due to its wide range of functional and cognitive abilities, economic resources, comorbidities, psychosocial issues, and living situations. You may see an 85-year-old who travels the world and a disabled, home-bound 65-year-old in the same day. Seniors may be living alone and receiving home-delivered meals or residing in assisted living or long term care facilities. Even though DSMES is a Medicare benefit, only 5% to 7% of those eligible take advantage of these services.

Diabetes is an independent predictor of admission to long term care facilities, and diabetes alone is the reason for nearly one-half of all hospital admissions in the older adult population. The diagnosis of diabetes significantly increases the risk of dementia and depression. Dementia and depression can lead to poor self care. Goals for glycemic control should be carefully tailored based on these factors. Hypoglycemia risk should be minimized as older adults are at higher risk of hypoglycemia because of the need for insulin therapy, progressive renal insufficiency, cognitive decline resulting in medication errors, living alone, and the potential for food insecurity.12-14

Those with long-standing diabetes may develop gastroparesis and other chronic gastrointestinal issues. Gluten sensitivity is more common in this population and should be investigated if diarrhea, weight loss, unexplained iron deficiency anemia, or other autoimmune disease is present. Moreover, many older adults are at risk of magnesium deficiency related to long-term use of proton pump inhibitors to control gastroesophageal reflux disease. A1c goals should be relaxed, and MNT primarily should focus on nutritional adequacy and quality of life issues for those who are frail and have established CVD or limited life expectancy. Healthy, active older adults and RDs can collaboratively work toward treatment goals similar to those of younger adults.1,12-14

Words of Wisdom
Type 2 diabetes is a progressive chronic illness. Despite best efforts, people with diabetes likely will see deterioration in glucose control over time related to impaired beta cell function usually requiring treatment with insulin.1 Type 2 in children appears to progress more rapidly than in adults with increased risk of kidney disease and cardiovascular complications.2,7 Diabetes is a complicated and challenging disease. The laundry list of daily diabetes tasks and constant attention to glucose monitoring, food intake, exercise, as well as the financial burden of diabetes can result in diabetes-related distress and burnout.1,15

People with diabetes need uncomplicated, individualized nutrition and activity recommendations based on current eating patterns, preferences, and metabolic goals. MNT delivered by a dietitian is associated with A1c decreases of 0.3% to 2% for people with type 2 diabetes.1 According to the 2015 joint position statement by the Academy, American Diabetes Association, and the American Association of Diabetes Educators, the overall objectives of DSMES are to support informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team to improve clinical outcomes, health status, and quality of life in a cost-effective manner. The need for DSMES in type 2 diabetes should be evaluated by medical care providers and/or multidisciplinary teams, and referrals to RDs made as needed at four critical times: at the time of diagnosis; annually for assessment of education, nutrition, and emotional needs; when new complicating factors (ie, health conditions, physical limitations, emotional issues, or basic living needs) arise that influence self-management; and when transitions in care occur (from childhood and adolescence to older adulthood).16

— Kathy W. Warwick, RD, CDE, is a diabetes educator, freelance writer, speaker, expert witness, and consultant. Warwick currently serves as the print communications chair of the Diabetes Care and Education Practice Group of the Academy of Nutrition and Dietetics. She's the owner of Professional Nutrition Consultants, LLC, in Madison, Mississippi.

References
1. American Diabetes Association. Section 4. Lifestyle management: standards of medical care in diabetes — 2018. Diabetes Care. 2018;41(Suppl 1):S38-S50.

2. Nadeau KJ, Anderson BJ, Berg EG, et al. Youth-onset type 2 diabetes consensus report: current status, challenges, and priorities. Diabetes Care. 2016;39(9):1635-1642.

3. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013;36(11):3821-3842.

4. Diabetes type 1 and 2. Academy of Nutrition and Dietetics Evidence Analysis Library website. www.andeal.org/topic.cfm?menu=5305. Published 2015. Accessed June 6, 2018.

5. Mayer-Davis EJ, Lawrence JM, Dabelea D, et al. Incidence trends of type 1 and type 2 diabetes among youths, 2002–2012. N Engl J Med. 2017;376(15):1419-1429.

6. US Department of Agriculture, US Department of Health and Human Services. Dietary Guidelines for Americans, 2015-2020. 8th ed. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Published December 2015. Accessed June 5, 2018.

7. American Diabetes Association. Section 12. Children and adolescents: standards of medical care in diabetes — 2018. Diabetes Care. 2018;41(Suppl 1):S126-S136.

8. National diabetes statistics report, 2017. Centers for Disease Control and Prevention website. https://www.cdc.gov/diabetes/data/statistics-report/index.html. Published 2017. Accessed June 2, 2018.

9. Schaffer R. Prevalence of comorbidities high in type 2 diabetes. Healio website. www.healio.com/endocrinology/diabetes/news/in-the-journals/%7Be8d2355d-0624-4b22-9870-5047a797b526%7D/prevalence-of-comorbidities-high-in-type-2-diabetes. Published April 25, 2016. Accessed June 2, 2018.

10. MacLeod J, Franz MJ, Handu D, et al. Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: nutrition intervention evidence reviews and recommendations. J Acad Nutr Diet. 2017;117(10):1637-1658.

11. Estruch R, Ros E, Salas-Salvado J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. N Engl J Med. 2018:378(25):e34.

12. American Geriatrics Society Expert Panel on Care of Older Adults with Diabetes Mellitus, Moreno G, Mangione CM, Kimbro L, Vaisberg E. Guidelines abstracted from the American Geriatrics Society guidelines for improving the care of older adults with diabetes mellitus: 2013 update. J Am Geriatr Soc. 2013;61(11):2020-2026.

13. American Diabetes Association. Section 11. Older adults: standards of medical care in diabetes — 2018. Diabetes Care. 2018;41(Suppl 1):S119-S125.

14. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35(12):2650-2664.

15. Gebel E. Diabetes distress. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/complications/mental-health/diabetes-distress.html. Updated July 29, 2014. Accessed June 8, 2018.

16. Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care. 2015;38(7):1372-1382.