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Recommendations Summary

DM: Energy Intake (2015)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    DM: Encourage Healthful Eating Plan for Appropriate-Weight Adults with Diabetes

    For appropriate-weight adults with diabetes, the registered dietitian nutritionist (RDN) should encourage consumption of a healthful eating plan, with a goal of weight maintenance and prevention of weight gain. A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes.

    Rating: Consensus
    Conditional

    DM: Encourage Reduced Energy Healthful Eating Plan for Overweight or Obese Adults with Diabetes

    For overweight or obese adults with diabetes, the RDN should encourage a reduced energy, healthful eating plan, with a goal of weight loss, weight loss maintenance and prevention of weight gain. Studies based on reduced energy interventions reported significant reductions in HbA1c of 0.3% to 2.0% in adults with type 2 diabetes and of 1.0% to 1.9% in adults with type 1 diabetes, as well as optimization of medication therapy and improved quality of life.

    Rating: Strong
    Conditional

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      • The recommendation DM: Encourage Healthful Eating Plan for Appropriate-Weight Adults with Diabetes applies to adults with diabetes who are at appropriate weight
      • The recommendation DM: Encourage Reduced Energy Healthful Eating Plan for Overweight or Obese Adults with Diabetes applies to adults with diabetes who are overweight or obese
      • The registered dietitian nutritionist may refer to the following Academy of Nutrition and Dietetics Evidence-Based Practice Guidelines:

       

    • Potential Costs Associated with Application

      Costs of MNT sessions and reimbursement vary; however, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      • In adults with type 2 diabetes, 21 study arms from 18 studies reported that MNT provided by RDNs significantly lowered HbA1c levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Bastiaens et al, 2009; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Goldhaber-Fiebert et al, 2003; Franz et al, 1995; Imai et al, 2011; Laitinen et al, 1993; Lemon et al, 2004; Takahashi et al, 2004; UKPDS 1990; UKPDS 2000; Wolf et al, 2004). At three months, HbA1c levels decreased by 0.3% to 2.0% and with ongoing MNT support decreases in HbA1c levels were maintained or improved for more than 12 months. An initial series of RDN encounters (three to 11, with a total of two to 16 hours) with continued RDN encounters throughout the studies were reported. Although nutrition therapy interventions were effective throughout disease duration, the decrease in HbA1c was largest in studies in which participants were newly diagnosed or had higher baseline HbA1c levels. RDNs implemented a variety of nutrition therapy interventions all resulting in a reduced energy intake.
      • In adults with type 1 diabetes, three studies reported that MNT provided by RDNs contributed to significantly decreased HbA1c levels (DAFNE 2002; DCCT 1993; Laurenzi et al, 2011). At six months, HbA1c levels decreased by 1.0% to 1.9%. An initial series of RDN encounters (four to six) were reported. Ongoing MNT support resulted in maintenance of the reduced HbA1c levels at one year and in the Diabetes Control and Complications Trial (DCCT) throughout the 6.5 years of the trial.
      • In adults with type 1 and type 2 diabetes, nine studies reported that MNT provided by RDNs decreased fasting blood glucose levels at three months by 18mg to 61mg per dL (Al-Shookri et al, 2012; Barnard et al, 2006; Coppell et al, 2010; DCCT 1993; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Laitinen et al, 1993; Lemon et al, 2004; UKPDS 1990). With ongoing MNT support, decreased levels were maintained to 12 months and in the DCCT throughout the 6.5 years of the trial. Grade I
      • In adults with type 2 diabetes, 12 study arms from 11 studies reported that MNT provided by RDNs resulted in decreases in doses or the number of glucose-lowering medications used (Al-Shookri et al, 2012; Andrews et al, 2011; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Lemon et al, 2004; UKPDS 2000; Wolf et al, 2004). An initial series of RDN encounters (three to ten, with a total two to six hours) with continued RDN encounters throughout the studies were reported. The United Kingdom Prospective Diabetes Study (UKPDS) reported significantly improved glucose outcomes for approximately two years. However, due to the normal progression of type 2 diabetes, additional medications were needed to achieve optimal glycemic control. Weight gain with medication use can be ameliorated by an intensive intervention provided by RDNs.
      • In two studies of adults with type 1 diabetes, RDNs implemented carbohydrate counting for the adjustment of pre-meal insulin doses (DAFNE 2002, Laurenzi et al, 2011). In both studies, a series of RDN encounters (four to six) were reported. Although the number of insulin injections increased, HbA1c improved without an increase in total insulin doses. Grade I
      • In six studies in which RDNs implemented MNT, improvements in quality of life were reported (Bastiaens et al, 2009; DAFNE 2002; DCCT 1993; Laurenzi et al, 2011; Lemon et al, 2004; Wolf et al, 2004). An initial series of three to six RDN encounters (2.5 to six hours) with long-term RDN encounters were reported. Grade I
      • In adults with type 2 diabetes, body weight outcomes from MNT provided by RDNs were mixed (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Laitinen et al, 1993; Lemon et al, 2004; Takahashi et al, 2004; UKPDS 1990). At study end, 11 study arms reported MNT provided by RDNs significantly decreased baseline body weights by 2.4kg to 6.2kg, whereas six study arms reported non-significant weight changes at study end. In persons with type 1 diabetes, weight outcomes were also mixed (DAFNE 2002, DCCT 1993).
      • In adults with type 2 diabetes, body mass index (BMI) outcomes from MNT provided by RDNs were mixed (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010, Izquierdo et al, 2010; Wolf et al, 2004). At study end, nine study arms reported significant decreases in baseline BMIs by 0.3kg/m2 to 2.1kg/m2, whereas eight study arms reported non-significant changes in BMI at study end. In persons with type 1 diabetes, one study reported a significantly decreased BMI of 0.3kg/m2 from MNT provided by RDNs (Laurenzi et al, 2011).
      • In adults with type 2 diabetes, waist circumference outcomes from MNT provided by RDNs were mixed (Al-Shookri et al, 2012; Andrews et al, 2011; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Bastiaens et al, 2009; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert 2003; Imai et al, 2011; Izquierdo et al, 2010; Lemon et al, 2004; UKPDS 1990, UKPDS 2000). At study end, nine study arms reported decreases of 1.0cm to 5.5cm, whereas three study arms reported non-significant changes in waist circumference at study end. In persons with type 1 diabetes, one study reported a significantly decreased waist circumference of one cm from MNT provided by RDNs (Laurenzi et al, 2011). Grade II
      • In adults with type 2 diabetes and normal to mildly elevated cholesterol levels, 19 study arms in 16 studies reported that MNT provided by RDNs had mixed effects on cholesterol levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Laitinen et al, 1993; Lemon et al, 2004; Takahashi et al, 2004; UKPDS 2000; Wolf et al, 2004). Eight study arms reported significant decreases in cholesterol ranging from 8mg to 28mg per dL.
      • In adults with type 2 diabetes and normal to mildly elevated LDL-cholesterol levels, 17 study arms in 15 studies reported that MNT provided by RDNs had mixed effects on LDL-cholesterol levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Lemon et al, 2004; UKPDS 2000; Wolf et al, 2004). Seven study arms reported significant decreases in LDL-cholesterol ranging from 8mg to 22mg per dL.
      • In adults with type 2 diabetes and normal to mildly low HDL-cholesterol levels, 19 study arms in 16 studies reported that MNT provided by RDNs had mixed effects on HDL-cholesterol levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Laitinen et al, 1993; Lemon et al, 2004; UKPDS 2000; Wolf et al, 2004). Three studies reported significant increases in HDL-cholesterol ranging from 2.4mg to 6mg per dL.
      • In adults with type 2 diabetes and normal to elevated triglyceride levels, 19 study arms in 16 studies reported that MNT provided by RDNs had mixed effects on triglyceride levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Laitinen et al, 1993; Lemon et al, 2004; UKPDS 2000; Wolf et al, 2004). Seven study arms reported significant decreases in triglycerides ranging from 15mg to 153mg per dL.
      • In adults with type 2 diabetes and with near-normal blood pressure levels, 12 study arms in 10 studies reported that MNT provided by RDNs had mixed effects on blood pressure levels (Andrews et al, 2011; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Lemon et al, 2004). Seven study arms reported significant decreases in systolic BP and diastolic BP of 3.2mm Hg to 9.0mm Hg/2.5mm Hg to 5.3mm Hg.
      • In adults with type 1 diabetes and near-normal lipid and blood pressure levels, two studies reported that MNT provided by RDNs led to non-significant changes in total cholesterol, HDL-cholesterol, triglycerides and blood pressure (DAFNE 2002, DCCT 1993). The Diabetes Control and Complications Trial (DCCT), at five years, reported that LDL-cholesterol was significantly decreased.
      • Subjects did not have or were not described as having any disorders of lipid metabolism or hypertension. The effectiveness of MNT may have been confounded by lipid-lowering or anti-hypertensive medications. Additional long-term studies are needed to ascertain the effectiveness of MNT on lipid profiles and blood pressure in adults with diabetes and disorders of lipid metabolism and hypertension. Grade II
      From the 2013 American Diabetes Association Nutrition Therapy Recommendations
      • For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss. Grade A
      • Modest weight loss may provide clinical benefits (improved glycemia, blood pressure or lipids) in some individuals with diabetes, especially those early in the disease process. To achieve modest weight loss, intensive lifestyle interventions (counseling about nutrition therapy, physical activity and behavior change) with ongoing support are recommended. Grade A
      • A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another. Grade E
      From the 2015 American Diabetes Association Standards of Medical Care in Diabetes

      Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care and Immunization
      • For overweight or obese adults with type 2 diabetes or at risk for diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss. Grade A
      • Modest weight loss may provide clinical benefits in some individuals with diabetes, especially those early in the disease process. To achieve modest weight loss, intensive lifestyle interventions with ongoing support are recommended. Grade A

    • Recommendation Strength Rationale

      • Conclusion Statements in support of these recommendations were given Grades I and II
      • The 2013 American Diabetes Association Nutrition Therapy Recommendations received Grades A and E
      • The 2015 American Diabetes Association Standards of Medical Care in Diabetes received Grade A

    • Minority Opinions

      Consensus reached.