Improving the scientific rigour of nutritional recommendations for adults with type 2 diabetes: A comprehensive review of the American Diabetes Association guideline-recommended eating patterns.

AIMS: The global rate of type 2 diabetes (T2D) continues to rise. Guidelines that influence the worldwide treatment of this disease are central to changing this trajectory. We sought in this review to evaluate the appropriateness of sources cited in the American Diabetes Association's (ADA) guidelines on eating patterns for T2D management, identify additional relevant sources, and evaluate the evidence. MATERIALS AND METHODS: We reviewed the evidence behind the ADA's recommendations on eating patterns in the 2018 and 2019 ADA Standards of Care and the 2014 ADA Nutrition Therapy Recommendations for Adults with Diabetes. Additionally, we conducted a comprehensive search to identify any additional studies not included in the cited evidence. To determine appropriateness of inclusion in the guidelines, the following criteria were applied: 1) it was a clinical trial or systematic review/meta-analysis of clinical trials; 2) it involved persons with T2D; 3) one of the study arms followed one of the eating patterns currently recommended; 4) its reported outcomes included glycaemic control; 5) outcomes were reported separately for persons with T2D. RESULTS: We found a wide variation in the evidence for each eating pattern. Issues that have hampered the guideline process include: lack of a rigorous literature review, resulting in the omission of pertinent studies; an overreliance on prospective cohort studies; inconsistent standards for evidence; inclusion of studies not on persons with T2D; and bias. CONCLUSIONS: The ADA Guidelines recommended eating patterns fall short of rigorous standards of scientific review according to state-of-the-art systematic review and guideline creation practices.

Associations of family meal frequency with family meal habits and meal preparation characteristics among families of youth with type 1 diabetes.

BACKGROUND: While benefits of family mealtimes, such as improved dietary quality and increased family communication, have been well-documented in the general population, less is known about family meal habits that contribute to more frequent family meals in youth with type 1 diabetes. METHODS: This cross-sectional study surveyed 282 youth ages 8-18 years with type 1 diabetes and their parents on measures regarding diabetes-related and dietary behaviours. T-tests determined significant differences in youth's diet quality, adherence to diabetes management and glycaemic control between those with and without regular family meals (defined as ≥ 5 meals per week). Logistic regression analyses determined unadjusted and adjusted associations of age, socio-demographics, family meal habits, and family meal preparation characteristics with regular family meals. RESULTS: 57% of parents reported having regular family meals. Families with regular family meals had significantly better diet quality as measured by the Healthy Eating Index (P < 0.05) and the NRF9.3 (P < 0.01), and adherence to diabetes management (P < 0.001); the difference in glycaemic control approached statistical significance (P = 0.06). Priority placed on, pleasant atmosphere and greater structure around family meals were each associated with regular family meals (P < 0.05). Meals prepared at home were positively associated with regular family meals, while convenience and fast foods were negatively associated (P < 0.05). Families in which at least one parent worked part-time or stayed at home were significantly more likely to have regular family meals than families in which both parents worked full-time (P < 0.05). In the multivariate logistic regression model, greater parental priority given to family mealtimes (P < 0.001) and more home-prepared meals (P < 0.001) predicted occurrence of regular family meals; adjusting for parent work status and other family meal habits. CONCLUSIONS: Strategies for promoting families meals should not only highlight the benefits of family meals, but also facilitate parents' skills for and barriers to home-prepared meals.

A brief structured education programme enhances self-care practices and improves glycaemic control in Malaysians with poorly controlled diabetes.

We assessed the effectiveness of a brief structured diabetes education programme based on the concept of self-efficacy on self-care and glycaemic control using single-blind study design. One hundred and sixty-four participants with poorly controlled diabetes from two settings were randomized using computer-generated list into control (n = 82) and intervention (n = 82) groups, of which 151 completed the study. Monthly interventions over 12 weeks addressed the self-care practices of diet, physical activity, medication adherence and self-monitoring of blood glucose (SMBG). These self-care practices were assessed at Weeks 0 and 12 using pre- and post-questionnaires in both groups together with glycated haemoglobin A1c (HbA1c) and diabetes knowledge. In the intention-to-treat analysis (n = 164), the intervention group improved their SMBG (P = <0.001), physical activity (P = 0.001), HbA1c (P = 0.03), diabetes knowledge (P = <0.001) and medication adherence. At Week 12, HbA1c difference adjusted for SMBG frequency, medication adherence and weight change remained significant (P = 0.03) compared with control group. For within group comparisons, diabetes knowledge (P = <0.001), HbA1c level (P = <0.001), SMBG (P = <0.001) and medication adherence (P = 0.008) improved from baseline in the intervention group. In the control group, only diabetes knowledge improved (P = <0.001). These findings can contribute to the development of self-management diabetes education in Malaysia.

Are children with type 1 diabetes consuming a healthful diet?: a review of the current evidence and strategies for dietary change.

PURPOSE: The purpose of this study is to review the literature on usual dietary intake in children with type 1 diabetes (T1D) and to discuss approaches to promote dietary change with potential efficacy. METHODS: Search strategies included a MEDLINE search for English-language articles that estimated usual dietary intake in children with T1D and a screening of the reference lists from original studies. The keywords used were diet, dietary intake, nutrition, type 1 diabetes, children, adolescents, and youth. Studies were included if they were observational, contained a sample of children with T1D, and estimated usual dietary intake. RESULTS: Nine studies fulfilled the criteria (6 US, 3 European). Of the 4 studies with a control group, 3 reported that both total fat and saturated fat intake were higher in the children with T1D. Six studies examined the percent of total calories from saturated fat; mean intake ranged from 11 to 15%, exceeding ADA recommendations (< 7%). Fruit, vegetable, and fiber intakes were low among children with T1D. No prior studies have addressed dietary change in this population. The behavior-change literature suggests that nutrition education alone is unlikely to be adequate, but that incorporation of behavioral approaches offers potential efficacy in promoting healthful dietary change. CONCLUSIONS: Children with T1D are not meeting dietary guidelines, and in some areas their diets are less healthful than children without diabetes. As these dietary behaviors may affect the risk of long-term complications, the incorporation of behavioral approaches promoting healthy eating into routine clinical practice is warranted.

A scoping review of best practice guidelines for the dietary management of diabetes in older adults in residential aged care.

Over the last two decades guidelines have been published on the subject of the care and liberalised nutrition management of older adults with diabetes in residential aged care, recognising that they may have different needs to those older adults in their own home. This study aimed to scope and appraise these guidelines using the AGREE II tool. Overall physician developed guidelines were more robust, but there was discordance in their recommendations compared to guidelines developed by dietitians; particularly regarding the use of therapeutic diets. A lack of standardised approach has implications for optimal dietary management of diabetes in aged care.

Changes in nutrient intake and dietary quality among participants with type 2 diabetes following a low-fat vegan diet or a conventional diabetes diet for 22 weeks.

BACKGROUND: Although vegan diets improve diabetes management, little is known about the nutrient profiles or diet quality of individuals with type 2 diabetes who adopt a vegan diet. OBJECTIVE: To assess the changes in nutrient intake and dietary quality among participants following a low-fat vegan diet or the 2003 American Diabetes Association dietary recommendations. DESIGN: A 22-week randomized, controlled clinical trial examining changes in nutrient intake and diet quality. SUBJECTS/SETTING: Participants with type 2 diabetes (n=99) in a free-living setting. RESEARCH DESIGN AND METHODS: Participants were randomly assigned to a low-fat vegan diet or a 2003 American Diabetes Association recommended diet. MAIN OUTCOME MEASURES: Nutrient intake and Alternate Healthy Eating Index (AHEI) scores were collected at baseline and 22 weeks. STATISTICAL ANALYSES PERFORMED: Between-group t tests were calculated for changes between groups and paired comparison t tests were calculated for changes within-group. Pearson's correlation assessed relationship of AHEI score to hemoglobin A1c and body weight changes. RESULTS: Both groups reported significant decreases in energy, protein, fat, cholesterol, vitamin D, selenium, and sodium intakes. The vegan group also significantly reduced reported intakes of vitamin B-12 and calcium, and significantly increased carbohydrate, fiber, total vitamin A activity, beta carotene, vitamins K and C, folate, magnesium, and potassium. The American Diabetes Association recommended diet group also reported significant decreases in carbohydrate and iron, but reported no significant increases. The vegan group significantly improved its AHEI score (P<0.0001), while the American Diabetes Association recommended diet group did not (P=0.7218). The difference in AHEI score at 22 weeks between groups was significant (P<0.0001). With both groups combined, AHEI score was negatively correlated with both changes in hemoglobin A1c value (r=-0.24, P=0.016) and weight (r=-0.27, P=0.007). CONCLUSIONS: Vegan diets increase intakes of carbohydrate, fiber, and several micronutrients, in contrast with the American Diabetes Association recommended diet. The vegan group improved its AHEI score whereas the American Diabetes Association recommended diet group's AHEI score remained unchanged.

Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Diabetes Care.

There are 30.3 million people with diabetes and 86 million with prediabetes in the United States, underscoring the growing need for comprehensive diabetes care and nutrition for the management of diabetes and diabetes-related conditions. Management of diabetes is also critical for the prevention of diabetes-related complications such as cardiovascular and renal disease. The Diabetes Care and Education Dietetic Practice Group along with the Academy of Nutrition and Dietetics Quality Management Committee have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Diabetes Care. The SOP and SOPP for RDNs in Diabetes Care provide indicators that describe three levels of practice: competent, proficient, and expert. The SOP utilizes the Nutrition Care Process and clinical workflow elements for care and management of those with diabetes and prediabetes. The SOPP describes six domains that focus on professionalism: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs caring for individuals with diabetes or specializing in diabetes care or practicing in other diabetes-related areas, including research. The SOP and SOPP are intended to be used for RDN self-evaluation for ensuring competent practice and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.

Adherence to special diets and its association with meeting the nutrient recommendations in individuals with type 1 diabetes.

AIMS: Not much is known about adherence to special diets in type 1 diabetes, characteristics of individuals with special diets, and whether such practices should raise concerns with respect to meeting the dietary recommendations. In this study, we assessed the frequencies of adherence to special diets, in a population of individuals with type 1 diabetes, and investigated the association between special diet adherence and dietary intake, measured as dietary patterns and nutrient intakes. METHODS: During the Finnish Diabetic Nephropathy Study visit, participants with type 1 diabetes (n = 1429) were instructed to complete a diet questionnaire inquiring about the adherence to special diets. The participants also completed a food record, from which energy and nutrient intakes were calculated. RESULTS: In all, 36.6% participants reported adhering to some special diet. Most commonly reported special diets were lactose-free (17.1%), protein restriction (10.0%), vegetarian (7.0%), and gluten-free (5.6%) diet. Special diet adherents were more frequently women, older, had longer diabetes duration, and more frequently had various diabetes complications. Mean carbohydrate intakes were close to the lower levels of the recommendation in all diet groups, which was reflected in low mean fibre intakes but high frequencies of meeting the sucrose recommendations. The recommendation for saturated fatty acid intake was frequently unmet, with the highest frequencies observed in vegetarians. Of the micronutrients, vitamin D, folate, and iron recommendations were most frequently unmet, with some differences between the diet groups. CONCLUSIONS: Special diets are frequently followed by individuals with type 1 diabetes. The adherents are more frequently women, and have longer diabetes duration and more diabetes complications. Achieving the dietary recommendations differed between diets, and depended on the nutrient in question. Overall, intakes of fibre, vitamin D, folate, and iron fell short of the recommendations.

Nonalcoholic fatty liver disease as a feature of the metabolic syndrome.

The main criteria of the metabolic syndrome are obesity, insulin resistance and disturbed lipid metabolism. The same disturbances are regarded to be involved into the pathomechanism of nonalcoholic fatty liver disease which is shown by epidemiological studies and animal models. Thus NAFLD can be regarded a specific feature of the metabolic syndrome and it should be looked for in high risk populations.

An exploratory study into the health beliefs and behaviours of British Indians with type II diabetes.

Aim To explore the influence of health beliefs and behaviours on diabetes management in British Indians, as successful management of diabetes is dependent on underlying cultural beliefs and behaviours. BACKGROUND: British South Asians are six times more likely to suffer from type II diabetes than those in the general population. Yet, little research has been carried out into beliefs about diabetes among the British Indian population. METHOD: The study used semi-structured interviews, a structured vignette and a pile-sorting exercise. In all, 10 British Indians were interviewed at a General Practice in North West London. Findings Those interviewed were informed about their diabetes but had difficulties in adapting their diet. Themes identified included causal beliefs of diabetes, use of alternative therapies, moderation of food, adaption of exercise regimes and sources of information. All were aware of avoiding certain foods yet some still continued to consume these items. Participants expressed the need for culturally sensitive forums to help manage their diabetes.

Diabetes Nutrition and Complications Trial: adherence to the ADA nutritional recommendations, targets of metabolic control, and onset of diabetes complications. A 7-year, prospective, population-based, observational multicenter study.

OBJECTIVE: To know the adherence to the ADA nutritional recommendations and its relation to targets of metabolic control and onset of diabetic complications in a sample of diabetic people in Spain. RESEARCH DESIGN AND METHODS: The Diabetes Nutrition and Complications Trial (DNCT) is a prospective, population-based, observational multicenter study designed to know the nutritional pattern, based on the 7-day food diaries, of a population with long-standing diabetes mellitus (93/99 type 1/type 2 diabetic patients, 20/18 years of duration of diabetes, and 6.9%/6.4% HbA(1c) values) and its relation with the onset of microvascular and macrovascular diabetes complications between 1993 and 2000. RESULTS: After a median follow-up period of 6.5 years, more than 55% of diabetic people complied with the recommendation of protein intake between 15% and 20%, but only 27% consumed less than 10% of saturated fatty acids (SFAs), the 13% achieved up 10% of polyunsaturated fatty acids (PUFAs) intake, the 39% consumed more than 60% from carbohydrate and monounsaturated fatty acids (MUFAs), and the 30% consumed <300 mg/day of cholesterol. In spite of these, more than 90% had an optimal HDL cholesterol and non-HDL cholesterol level, and triglycerides level, while less than 41% of diabetic people had an HbA(1c) value >7.5%. Moreover, more than 69% consumed a MUFAs-to-SFAs ratio >1.5 and the 46% a PUFAs-to-SFAs ratio >0.4. Nonadherence to nutritional recommendation, but MUFAs/SFAs ratio >1.5 and PUFAs/SFAs ratio >0.4, was associated with a reduction between 3.4- and 8.2-fold in the risk of onset of diabetic complications. CONCLUSIONS: The adherence to ADA nutritional recommendations for people with diabetes in Spain is rather poor except for the protein consumption. Only PUFAs/SFAs >0.4 and MUFAs/SFAs>1.5 were associated to near-optimal targets of metabolic control and a reduction in the risk of the onset of diabetic complications. These data suggest that other nutritional recommendations should be taken in mind.

Dietary guidelines for the management of diabetes.

This article outlines contemporary guidelines for the dietary management of diabetes, with the aim of reducing inconsistencies in dietary recommendations.