NEW ORLEANS — Providers should take a shared decision-making approach when creating a nutrition plan for people with diabetes, according to a speaker at the American Diabetes Association Scientific Sessions.

Alison Evert, MS, RDN, CDCES, head of nutrition and diabetes education programs at the University of Washington Neighborhood Clinics, reviewed published data on the structure, timing, and macronutrient composition of the dietary habits of people with diabetes. Different eating patterns can have different benefits, and it’s important for providers to determine a person’s goal to create a nutrition plan that works best for them.

“Use shared decision making,” Evert said during the presentation. “If you don’t have time for a 20-minute appointment, refer your patient to a dietitian or diabetes education program. Personalize the meal plan. Ultimately, the diet that your patient is willing and able to follow will likely be the most effective. »

Create a meal plan

Frequently asked questions by health care providers of people with diabetes include how often and how much they should eat. Evert noted that it’s common for providers to recommend people with diabetes eat three meals and three snacks a day. However, supporting evidence is lacking, with most trials being small, short in duration and inconclusive in their results.

Alison Evert

“Promoting three meals a day and three snacks a day without any strong evidence is likely to provide unnecessary calories, especially if they’re not hungry,” Evert said. “When we look at the pathophysiology of type 2 diabetes, reduced beta cell function, insulin resistance as well as the first phase of the insulin response, telling someone to eat frequently throughout throughout the day can lead to chronic hyperglycemia. Greater fluctuations in blood sugar can occur after infrequent and large meals that are not planned.

Providers recommended by Evert coordinate a meal plan for people with type 2 diabetes to align with their medications to optimize clinical outcomes and reduce medication side effects.

There is more evidence regarding meal frequency for people with type 1 diabetes. Several studies have shown that smaller, more frequent meals, as well as avoiding snacks, are associated with better heart disease management. blood sugar in type 1 diabetes.

Several studies support eating breakfast as well as consuming more calories earlier in the day than later in the day. In a review of systematic reviews and meta-analyses, skipping breakfast may increase the risk of cardiovascular disease and type 2 diabetes. For people with type 2 diabetes, data from a dietary study week-long controlled study showed that those who ate a heavy breakfast had a greater reduction in daytime postprandial hyperglycaemia than those who ate a light breakfast.

For people participating in intermittent fasting or time-restricted eating, Evert said, providers should get details about eating habits, such as whether intermittent fasting is alternate fasting or normal eating for 5 days. followed by fasting for 2 days. Time-restricted meals can also vary depending on a person’s desired meal times. Evert said more studies are needed on the effectiveness, mechanisms and durability of the time-restricted diet.

Individualization of macronutrients

The percentages of macronutrients consumed by people with diabetes in the United States are similar to those consumed by the general public. According to data from the Look AHEAD trial and the National Health and Nutrition Examination Survey, about 45% of the macronutrients consumed by people with diabetes are carbohydrates, 36% to 40% are fats and 16% to 18% are proteins.

In the ADA Nutrition Consensus Report published in 2019, there is no evidence supporting an ideal percentage of macronutrients for people with diabetes. Similarly, there is no evidence to support a set number of calories per day for people with diabetes.

To find a regimen that works best, Evert said, providers need to ask open-ended questions to allow the patient to express their goals in a shared decision-making session.

“What do you want to do with your health? Is it glucose management? Is it something to do with improving your lipid profile, blood pressure, or weight loss? Evert said.

For people with diabetes, managing blood sugar with diet is less about rules and formulas and more about trial and error, according to Evert. She described blood sugar monitoring as a way to assess how certain foods affect glucose levels, which can help inform changes in the type or amount of food one eats in the future.

For those trying to lose weight, any approach should include behavior modification, Evert said. Patients should aim for a minimum weight loss of 5%, and the benefits increase with the greater amount of weight loss. Some dietary patterns with evidence to support weight loss include the very low calorie dietary pattern from the Diabetes Remission Clinical Trial, a Mediterranean style dietary pattern, and a low carb dietary pattern.

“To lose weight, you can prescribe drug therapy by optimizing diabetes medications or adding weight-loss medications,” Evert said. “There is also bariatric surgery.”

Reference:

• Evert AB, et al. Diabetic treatments. 2019;doi:10.2337/dci19-0014.

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American Diabetes Association Scientific Sessions