Medical Nutrition Therapy Options

for Adults Living with Diabetes

Jane Eyre Schuster, RD, LD, CDE

Legacy Health Diabetes and Nutrition Services

Objectives• Discuss Medical Nutrition Therapy considerations in the treatment

of adults living with type 2 diabetes

• Compare and contrast various eating patterns used in the

treatment for diabetes

Disclosures

I, Jane Eyre Schuster, RD, LD, CDE have no relevant financial or

nonfinancial relationships in the products or services described,

reviewed, evaluated or compared in this presentation.

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Diabetes Self-Management Education and Support Services

▪ Patient centered care

▪ Evidence-based

▪ Individualized to meet the needs of the person, including language

and culture

▪ Delivered by trained and competent individuals (educators) who

are quality assured

▪ Delivered in group or individual settings

▪ Supports the person and their family in developing attitudes,

beliefs, knowledge, and skills to self-manage diabetes

▪ Available to patients at critical times (i.e., at diagnosis, annually,

when complications arise, and when transitions occur)

▪ Includes monitoring of patient progress, including health status,

quality of life

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Medical Nutrition Therapy (MNT)▪ To help people adopt heathy eating patterns

▪ To help manage good blood glucose and cardiovascular risk to

reduce common diabetes related complications

▪ To help preserve quality of life and the pleasure of food

▪ No “one” right way optimize carbohydrates, proteins or fats

▪ Focus on individualized eating plans with foods shown to have

health benefits

▪ Avoid foods that have established harm

▪ Involves comprehensive nutrition assessment with consideration

of comorbidities

▪ Assesses and aids in designing individualized meal patterns that

include food preferences, food allergies, eating habits and

cultural background

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Diabetes Dietitian Intervention

▪ Effects of food on blood glucose levels

▪ Carbohydrate, protein and fat sources

▪ Individualized meal planning

▪ Resources for making healthy food choices

▪ Understand portion sizes

▪ Navigate food label reading

▪ Plan and prepare meals

▪ Best times to eat to match their diabetes medications

▪ Able to address additional nutritionally related issues – Renal,

CVD, HTN, Lipids, Cancer, GI issues, etc

▪ Ongoing nutrition requirements over the lifetime

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Eating Patterns – Which is best?

▪ Mediterranean

▪ Dash (Dietary Approaches to Stop Hypertension )

▪ Low Carbohydrate

▪ Low Glycemic Index

▪ High Protein

▪ Carbohydrate Controlled

▪ Low Fat

▪ Nonsurgical Energy restriction for weight loss – Meal

Replacements

▪ Surgical Weight loss intervention

▪ ???

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Mediterranean Diet

Pros Cons

includes fruits, vegetables, whole

grains, beans, moderate intake of

wine and lean meats and low intake

of processed foods

Does not state exact servings

amounts/day, rather the macronutrient

distribution

Promotes heart health Uses terms like: “low to moderate intake”,

“abundance” and “often” which can be

confusing

High in Monounsaturated fats -

olives, olive oil, avocados, nuts and

seeds,

Moderate wine intake vs use of certain

medications, high triglycerides or

pancreatitis

High in cancer-fighting antioxidants Physical activity and calorie totals not

addressed specifically

Promotes regular physical activity

Less processed foods = less

sodium

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DASH Diet (Dietary Approaches to Stop Hypertension)

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Pros Cons

includes fruits, vegetables, whole

grains, beans, lean meats and plant

based fats, low-fat free dairy

Not specifically for weight loss

Free and available access – no

expensive or hard-to-find foods

No pre-package foods

Provided specific calorie levels for

weight loss and maintenance

Can provide up to 55% of calories from

carbohydrates – too high?

Proven health benefits in heart

health

Limited research on it’s effects on

diabetes

Promotes regular physical activity

Less processed foods = less sodium

Is designed to be an “eating

program for life” by including

cooking and shopping

Low Carbohydrate

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Pros Cons

Weight loss in a short time % carbohydrate recommendation varies

from <26%-45% of total calories

Helps with satiety due to protein and

fat intake

Calorie restrictions vary – “all you want”

to “very restricted”

Improves blood glucose control Decreased fiber intake – can promote

constipation

Has positive effects on HDL

cholesterol and triglycerides

May require supplements to replace what

is missing

Decrease in adipose tissue Sustainability?

Decrease food intake and body

weight

Little to no effect on LDL cholesterol and

total cholesterol

Have to pay attention to food

choices

Low Glycemic Index Diet

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Pros Cons

Quick and easy references The rating is only for individual foods. As

the food ripens or if it is paired with

protein or fat it can affect the GI ranking.

Good way to ID how individual foods

effect blood glucose

Misleading if you consider the GI rank to

mean that a food is healthy if it is low.

Can decrease blood glucose, insulin

response and maybe inflammation

GI number is only really valid if the food

is eaten alone.

Helps you feel full longer = more

weight loss

High Protein Diets

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Pros Cons

Targets metabolic targets of satiety

– may be more important than low

carbohydrate

Initial weight loss is temporary due to

water loss

Immediate weight loss Can effect mood, energy

Improves cholesterol Often the fat choices are mostly

saturated fats which may lead to higher

LDL levels

Improved satiety Sustainability?

Improved blood glucose Inflexible rules

Easy to find foods to eat

Have to pay attention to food

choices

Carbohydrate Controlled Diet

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Pros Cons

Consistent intake over the day Portions matter

Provides plenty of fiber, vitamins

and minerals

For some, can be more confusing

Provides structure to the day. Takes practice and discipline

Helps with insulin administration

No “I can’t have” rules

Stabilizes blood glucose

Addresses heart health

What is the right answer?

▪ What is the goal of the patient?

▪ Any eating pattern is most effective when starting where the patient’s

eating patterns are

▪ Eating pattern that is sustainable

▪ Family support is critical

▪ Meets the nutrition status and comorbidity issues, such as renal disease

▪ Has physical and emotional support along the way

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Consensus recommendation*

▪ All people with type 2 diabetes should be offered access to

ongoing DSMES programs

▪ An individualized program of Medical Nutrition Therapy (MNT)

should be offered to all patients.

▪ All overweight/obese patients should be advised of the health

benefits of weight loss and encouraged to engage in a program of

intensive lifestyle management, which may include food

substitution.

Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and

the European Association for the Study of Diabetes (EASD)

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Thank you!

References:

o American Diabetes Association (2018) 4. Lifestyle management:

standards of medical care in diabetes—2018. Diabetes Care

41:S38–S50. https://doi.org/10.2337/dc18-S004

o Beck J, Greenwood DA, Blanton L et al (2017) 2017 national

standards for diabetes self-management education and support.

Diabetes Educ 43:449–464

o Shai I, Schwarzfuchs D, Henkin Y et al (2008) Weight loss with a

low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med

359:229–241. https://doi.org/10.1056/NEJMoa0708681

o Esposito K, Maiorino MI, Ciotola M et al (2009) Effects of a

Mediterranean-style diet on the need for antihyperglycemic drug

therapy in patients with newly diagnosed type 2 diabetes: a

randomized trial. Ann Intern Med 151:306–314

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References:

o Esposito K, Maiorino MI, Petrizzo M et al (2014) The effects of a

Mediterranean diet on the need for diabetes drugs and remission of

newly diagnosed type 2 diabetes: follow-up of a randomized trial.

Diabetes Care 37:1824–1830. https://doi.org/10.2337/dc13-2899

o American Association of Diabetes Educators (2018) Addressing Obesity

in Diabetes – an AADE practice paper, August 2018

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