Nutrition Therapy Recommendations for People … · Web viewNational Diabetes Education ProgramNutrition Therapy Recommendations for People with Diabetes Webinar Transcript Thursday,

National Diabetes Education ProgramNutrition Therapy Recommendations for People with Diabetes Webinar Transcript Thursday, March 20, 2014

JOANNE GALLIVAN: Welcome to the Nutrition Therapy Recommendations for People Managing Diabetes webinar. I am Joanne Gallivan. I’m Director of the NDEP at the National Institutes of Health, and I will be moderating today’s webinar.

As many of you know, the NDEP is a joint program of the NIH and the CDC and hundreds of partners. Our mission is to reduce the burden of diabetes in the U.S. by facilitating the adoption of proven approaches to prevent or delay the onset and progression of diabetes and its complications.

We offer topic-specific webinars throughout the year to help support the efforts of all of you, our partners, who are working to improve the lives of people both with and at risk for diabetes. We really appreciate you joining today’s webinar and we really hope and we think this session will provide you with valuable information and resources that you can take back to your organizations and in your community.

So March is National Nutrition Month, and this year, the Academy of Nutrition and Dietetics’ theme is Enjoy the Taste of Eating Right. We all know that nutrition is the cornerstone of successful management for people with diabetes. This webinar will review the latest nutrition recommendations to help people with diabetes manage their disease and we are very, very pleased to have nutrition expert Marion Franz as our guest speaker for today’s program.

Most of you, I am sure, know Marion Franz. She is a nutrition and health consultant with Nutrition Concepts by Franz, Inc., and for over 20 years she directed the Nutrition and Health Professional Education Division at the International Diabetes Center in Minneapolis. She co-edited the 2012 American Diabetes Association Guide to Nutrition Therapy for Diabetes and was the lead author on the Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines for type 1 and type 2 diabetes. She has authored numerous position statements, nutrition position statements, and was the editor of the AADE’s core curriculum for diabetes education, the fourth and fifth editions. Ms. Franz has contributed to journals and textbooks and lectures frequently throughout the U.S. and internationally, and in recognition of all her wonderful work she has received many, many awards, including the 2001 American Diabetes Association Charles H. Best Award for Distinguished Service in the Cause of Diabetes, the 2006 American Dietetic Association Medallion Award, and the 2012 American Association of Diabetes Educators Living Legend Award. Marion, welcome, and I turn the webinar over to you.

MARION FRANZ: Thank you very much, Joanne. It is really an honor to be able to present this webinar looking at nutrition therapy recommendations for people managing diabetes.

With the webinar goals, the first goal is to review with you the highlights of the

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American Diabetes Association 2013 nutrition therapy recommendations. Secondly, I am going to review with you the evidence for the effectiveness of nutrition therapy. We will then look at some areas of controversy. Two of them often involve the role of weight loss in diabetes management, as well as macronutrients. And then, finally, hopefully, I hope to leave you with a take-home message as to what is really important in the real world as we, as clinicians and educators, provide education, counseling, and support for persons with diabetes.

We have a couple polling questions and we will start with the first polling question. Which is the most accurate statement for weight loss in adults with or at risk of type 2 diabetes? Weight loss improves glucose throughout the progression of type 2 diabetes. Two, weight loss is most effective in prediabetes or early after diagnosis. Three, low carbohydrate diets are preferred for weight loss, or four, low-fat diets are essential for weight loss.

We can see that the majority of you have selected the first two answers. Weight loss improves glucose throughout the progression of type 2 diabetes or, and the second one, it’s most effective in prediabetes or early after diagnosis. And what I hope to show you the evidence for is that weight loss is most effective in people who are at risk of diabetes or are prediabetes or early after the diagnosis and we will review the evidence for that.

So let’s move on to the second polling question, please. Which is the most accurate statement regarding carbohydrate intake for persons with diabetes? Fiber intake improves glycemic control. High-glycemic-index foods are absorbed into the bloodstream rapidly. Total calories or total energy intake is more important than total carbohydrate intake for glucose control, and four, adding protein to carbohydrate snacks slows absorption of carbohydrates.

And again, we see that the majority of you have selected that fiber improves glycemic control and then secondly, that adding protein slows the absorption of carbohydrate, and the one with the smallest response has been that total energy is more important than total carbohydrate, and actually that is what the information I hope to present to you, that what is really most important is how much people eat. So we will look at the evidence for these two polling questions as the seminar progresses.

The first question that is always most important, then, is, is diabetes nutrition therapy effective? Because always, I think it is essential that we have evidence that what we are asking people with diabetes to do does have evidence that it is important. And I think most of you are familiar with the studies done on prediabetes, and we realize how important nutrition therapy is along with physical activity for decreasing the risk of type 2 diabetes. And I think we are all familiar with the studies of the Diabetes Prevention Program. But what has been, perhaps, most encouraging has been the follow-up to these studies that has shown that participants in the DPP who continued with their lifestyle

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changes have actually reduced their risk and maintained that reduced risk for up to 14 years.

If we look, then, at people, though, with diabetes what we find evidence for is that nutrition therapy provided by registered dieticians, on average, lowers A1C by about 1% to 2%, and it depends upon the type of diabetes people have, how long they have had diabetes, and their level of glycemic control.

We also have evidence for the role of nutrition therapy in improving lipids and blood pressures, but, again, what I think is very important to know is when to evaluate outcomes. What the research shows is that clearly we will know the outcome of our nutrition therapy intervention by six weeks, clearly by three months. So at that point generally people have made the lifestyle changes that they are willing and able to make or maybe there are some additional ones they can make, but if goals have not been met then it is important to look at the overall diabetes management picture to see if there are additional changes or in medications that need to be made.

So these are some examples of some of the research looking at type 2 diabetes and the effectiveness of nutrition therapy. The first example is from the United Kingdom Perspective Diabetes Study, where people were newly diagnosed with an A1C of 9%, and after 3 months of active nutrition therapy intervention their A1C was lowered by 2% and they were randomized into the study arm, so a 2% drop. In another study done in Great Britain, here individuals with type 2 diabetes were newly diagnosed with an A1C of 6.7%, and they were randomized into usual care or intensive nutrition therapy and here, again, you see the improvement in A1C from 6 months to 12 months of 0.4%, which was statistically significant and was achieved with the use of fewer diabetes drugs. But here with the lower A1C at diagnosis you can see the drop in A1C is lower, still highly significant.

Now, a fascinating study was done in New Zealand where they looked at individuals who had a longer duration of diabetes, approximately 9 years, and they were considered in poor glycemic control despite what they considered optimized drug therapy and this was the use of two drugs at this point. So the question was, should they implement intensive lifestyle-intervention nutrition therapy or a third drug? And so they compared the intensive lifestyle intervention to a control and, again, you can see the improvement of a half a percent with the intensive lifestyle therapy, again, statistically significant. And the authors made note that they compared this outcome. It was the same effect as would have been achieved by adding a new drug but was certainly more cost-effective.

So we do have a lot of strong evidence from different types of studies that, in people with type 2 diabetes, nutrition therapy is effective across the progressive nature of type 2 diabetes. But we do know that over time medications are usually needed, but even with the use of medications they clearly work better when people also pay attention to what

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they eat.

And in type 1 diabetes, then, we have several examples, as well. A flexible, intensive insulin therapy trial was done, which used insulin to carbohydrate ratios. The first study was called Dose Adjusted for Normal Eating, and individuals either maintained their previous way of adjusting or managing type 1 diabetes, which was to eat consistently and then someone else adjusted the insulin, or they were taught how to adjust their insulin therapy based on their planned carbohydrate intake. And with this new approach A1Cs were lowered by 1%, and it was predicted if this was allowed that people would have more problems with hypoglycemia, which they did not, and not surprisingly they reported improvement in their quality of life. And these individuals have been followed up in Germany and Australia, who implemented a similar type of program, showing continued improvement in A1C and continued improvement in their quality of life when individuals learn how to use insulin-to-carbohydrate ratios.

So for individuals on multiple daily injections or insulin pumps the recommendation is that they adjust their insulin based on planned carbohydrate intake, however, we know that there are always some individuals who don’t want to adjust their own insulin and so they are often on fixed daily insulin doses. And so then the question is what is important? And what has been shown to be important is that these individuals, then, are consistent in their carbohydrate, both in the timing of their meals and the amount of carbohydrate in their meals and then somebody else has to adjust their insulin to cover their usual carbohydrate intake.

So the question that comes up, we have evidence that nutrition therapy is effective. The question is what types of nutrition therapy interventions are effective? And what has been shown is that there are a variety of nutrition therapy interventions used in these various studies that I have shown you some examples of. Some studies used reduced energy or fat intake, some carbohydrate counting, simplified meal plans, healthy food choices, we talked about insulin to carbohydrate ratios, physical activity, and behavioral strategy. So if we look and see, is there some type of unifying focus of these interventions, I think what we see is that first of all what is important for people with type 2 diabetes is a reduced energy intake, eating less. Isn't that easy to say? Go home; eat less. It is like telling people with diabetes go home and lose weight. Most people need a little help on how to do this.

And then clearly in type 1, it is matching insulin to carbohydrate intake, but also what comes across very strongly is the importance of a number of individual or group sessions and the absolutely, absolute need for follow-up encounters to provide support for the lifestyle changes that people with diabetes are making.

So we do know that type 2 diabetes is a progressive disease and I am sure many of you are familiar with this graph, but I just want to remind us of the progressiveness of the

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disease. And if you look at the bottom panel we are all aware that type 2 diabetes begins with insulin resistance, but what is also clear is that as long as an individual’s pancreas can make enough insulin to overcome that resistance glucose levels remain normal. So it is not until that we have insulin deficiency that we have the diagnosis of diabetes being made. And we see that the first defect is usually in the post-meal glucose and then the second defect is in the fasting glucose levels. But if you follow in the bottom panel you will see that as the disease progresses insulin levels also decrease and so it has been reported that if people with diabetes live long enough, which we certainly all hope that they will, eventually, many, many of them will require insulin and it isn't their fault. They have inherited a pancreas that does not work and unfortunately it has been my experience and I suspect your experience that often people with diabetes are made to feel guilty that it is their fault, that they have done something wrong. But what we have truly learned is that diabetes is a progressive disease.

So as we see we know that medications change over the progression of the disease, we see that nutrition therapy also changes over the progression of the disease and so we have prediabetes when people are insulin resistant, we have the onset of diabetes where usually there is still some continuation of insulin resistance but, as the disease progresses and people become more insulin deficient, the focus of nutrition therapy becomes on helping people achieve their metabolic goals.

So let’s look at the role of weight loss first in diabetes, and what have we learned about it? First of all, if there is one term I wish we could get rid of it would be “diet failed,” because the diet doesn’t fail. The diet works wonderfully well when it is used appropriately. What is failing are the individual’s beta cells of their pancreas. What we find is that when weight loss is most beneficial is when people are insulin resistant. When they have prediabetes or they are early in the progression of their disease. But as we will see, as they become more insulin deficient, weight loss may or may not improve glycemic control.

So what do we know about weight loss in general? Well, we know in all individuals that at 6 months individuals lose, on average, about 5% to 10% of their starting weight and then at about 6 months they hit a plateau from 6 to 12 months, and that is really expected. And they hit a plateau because compensatory mechanisms take over at that point to protect against weight loss. I always point out to people, to the public, that our bodies don’t know if we are not eating because it is scarce or because it is our choice, and our bodies are set up to protect themselves against starvation. And so we are seeing much research being done looking at these compensatory mechanisms protecting against weight loss. We also know, though, that if treatment is discontinued individuals often regain weight, but I hope to also convince you that with support people can maintain some weight loss.

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So this is a systematic review that we did in subjects, all subjects, not only with diabetes but in all subjects, and the studies had to be a year-long in duration. And we pooled the data and looked at average weight loss from different types of weight-loss interventions and there were over 80 studies. In the top line is what happens when you just tell people to go home and lose weight. Well, someone did point out that at least they didn’t gain. The yellow line is when people tried to do it with exercise alone. The third or blue line is when the focus was primarily on the diet, and then the lines in the middle involve weight-loss interventions with diet plus exercise, meal replacements, and some of the weight-loss meds, and then the bottom line are the very low-calorie diets where people lost a lot of weight and gained it back rather quickly. Now, the first thing I find fascinating is look what happens at six months. You clearly see individuals hitting a plateau regardless of the intervention and the question I am always asked is, can you re-intervene when people hit that plateau and cause them to lose weight again? And I have to say I have not seen any studies that have shown that you can. In fact, if you are following the weight-loss research you see that the intent during the plateau is really to help people maintain that weight that they have lost. Again, if we look to see how much weight people have lost, most of these individuals weigh around 100 kg, on average, and you can see they lost 8 kg, so about an 8% weight loss. Now, again, I always point out that this is a bell-shaped curve, isn't it? There are always some people at the end of the bell-shaped curve. They are the people we remember if they are in our clinical practice, aren’t they? They lose more. Or they are the people we read about in the magazines or we hear about on TV. Unfortunately, there are also people on the other end of the bell-shaped curve that we tend to forget about.

So what have we learned about why weight loss is difficult? Certainly we know there is a genetic factor. You have only to look at families to see. If your parents are tall and lean luckily you may be tall and lean as well, and if your parents are short and stocky you may be short and stocky as well. However, I think what is important to know is the research that is being done looking at how our weight is tightly regulated by neural, hormonal and metabolic factors. And what you see is that when individuals lose weight there’s a number of hormonal adaptations that occur and as a result of these changes a message is sent to the hypothalamus in the brain saying that the fat cells are emptying and the individual should eat. And what has been shown is that initially this research was very short-term. Now, studies have shown that many of these hormonal adaptations remain for a year after the initial weight reduction and that has been the longest studies done at this point. So we know that our changes in body hormones that cause the individual to be driven to eat. We also know that research has shown that with weight loss there is changes in adaptive thermogenesis. What that means is that about 80% of our caloric requirement is for basal energy needs, and what has been shown as people lose weight, there is a decrease in these needs for calories and, again, research has shown that this has been maintained for up to a year. So I think research is helping us to understand why the

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problems that occur with weight loss.

But what is important is, the message that needs to be given to the public, is that there are many benefits from modest weight loss because often individuals think they have to lose 50 pounds or more to have a health benefit and the health benefits are from starting at about a 5% loss. The first and foremost one is the prevention or delay of type 2 diabetes, an extremely important message to give to the public. We see improvements in blood pressure, circulatory, inflammatory, and potential beneficial effects on lipids. So even though often a 5% weight loss may not seem like a lot it has very important health benefits, and I think as educators and clinicians this is a very important message for us to give to the public.

Here we see the Diabetes Prevention Program, which I hope all of you are familiar with, and the red line, again, was the intensive lifestyle program and you can see they lost about 7 kg, just as I showed you in the previous slide. They had a plateau from 6 months to 1 year and a gradual regain, but it was this type of weight loss that reduced their risk of developing diabetes by 58%. So a modest weight loss, physical activity, is extremely important for the prevention or delay of type 2 diabetes.

But what happens when people develop diabetes, then? What is the role of weight loss? This is a summary of a systematic review that we recently published, and the studies were done in, weight-loss studies in people with type 2 diabetes. The studies needed to be 1 year in duration and have a 70% completion rate. And there were 11 studies and actually 5 of them lasted longer than 1 year and in these 11 studies 8 of them compared 2 different weight-loss interventions and 3 of them compared a weight-loss intervention to a control or usual care group. And then we looked at weight loss, A1C, lipids, and blood pressure outcomes. And what we basically see is that in the majority of the interventions, so in 11 studies that would be 22 study arms, and in 17 of the study arms what you see is the weight loss was between 2 to 5 kg. There were two study arms, one was the Mediterranean-style diet and one was the intensive lifestyle intervention, which was in the Look AHEAD trial, and they definitely had weight losses greater than 5 kg, or 5% of the starting weight. And then you can see one study, which was a low carbohydrate, thatcarbohydrate that had the lowest weight loss.

So here we have a figure looking at the weight-change outcomes and you can see that the two bottom lines, the bottom line is the Look AHEAD trial and the second line from the bottom is the Mediterranean-style diet. Now, I need to point out in these two studies, the intensive nutrition therapy was combined with physical activity and these individuals were either newly diagnosed or early in their diagnosis. Very important to note, and you can see their weight loss. Now, you can see the other studies, which were also a year in duration, and if you look you can see that the weight loss in them is less than 5 kg. Now, remember, in the graph I showed you earlier in people without diabetes where the

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average weight loss was 8 kg? It certainly seems that it might be harder for people with diabetes to lose weight, doesn’t it? Because these were research studies where people are getting a lot of support with the different interventions and still you can see at 6 months, at 12 months, the weight loss is less than 5 kg, less than about 5% of their starting weight.

So if we look at what type of effect this weight loss has what we find is that in eight of the weight-loss interventions A1C did improve at one year. The biggest improvement in weight loss occurred with the Mediterranean-style diet and the Look AHEAD trial, but in 11 of the weight-loss interventions there was no improvement in A1C at 1 year, so in most of those studies, the majority of the studies, where individuals had less than a 5% weight loss, it did not improve their A1C levels. If we look, then, at changes in lipids the majority of the studies showed no significant change in lipids. The major change was improvement in HDL and then about half improved blood pressure and half did not.

It was interesting to note that there were five of these studies that compared different macronutrient percentages. One compared a high mono to a high carbohydrate. Two compared a low carbohydrate to a low fat, and one compared, or two compared high protein versus high carb. Weight loss was similar in all of them and in all of these five studies, four of them reported no improvements in A1C. One study, one of the studies, which used a high protein, high carb, compared the two, reported improvement in both study arms, a modest improvement. But it was clear that the macronutrient composition, you can see, resulted in similar weight-loss changes.

So why doesn’t weight loss always lead to improved glycemia? Well, perhaps, our usual weight-loss interventions are not adequate enough to lead to adequate weight loss. You saw that in the two studies where weight loss was greater than 5% we did see improvement in A1C. It was the studies in which weight loss was less than 5% where the A1C did not improve. Perhaps we are intervening too late. That the individuals are being asked to lose weight when they are now primarily insulin deficient and it is too late. Weight loss helps when people are insulin resistant before they develop diabetes or early in this course of the disease or, perhaps, our medications already make weight loss more difficult or actually contribute to weight gain. Or, perhaps, what really is important is how much people eat. That it is really a reduced energy intake which improves glycemia control. Reduced energy intake improves glycemia control, and that it is not the weight loss so much but it is what people are eating, how much people are eating. That is what really is important.

So let’s look for a minute at macronutrients. And so the ADA review said very clearly that there is no ideal percentage of calories from carbohydrates, protein and fat, and I do think it is important to just remind ourselves that all three nutrients require insulin to become, be metabolized. I think often we focus so much on the carbohydrate that we forget protein and fat also require insulin and, again, really it is how much people eat that

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seems to be important. And then they have also said monitoring carbohydrate is important.

So I just want to remind you, because our time is going by, that people with diabetes do not eat a high or a low carbohydrate diet. They eat a moderate amount of carbohydrate.

And I just want to emphasize because I still hear this. The glycemic index does not measure how rapidly blood glucose levels increase. This was a study done by Jennie Brand-Miller where she compared different glycemic index foods to glucose. And in the first panel you see the green line is glucose, 50 g of glucose, and the next three lines are high-, medium-, or low-glycemic-index breads. And you see the shape of the curve is identical and people are often led to believe that a high-glycemic-index food causes a sharp increase rise in blood glucose and the role of glycemic-index food can contribute to a low, more gradual increase. And again, in the second panel we see the green line, which is glucose, and fruits and fruit juice with equal amount of carbohydrate, the lines are parallel. And Jennie Brand-Miller concluded there is no statistical difference in the glucose response curve from different foods. Low-glycemic foods do not produce a slower rise in blood glucose nor do they produce an extended glucose response.

And so there have been two studies done showing that at a year, short-term studies have shown benefit from low-GI trials, low-GI diets, two 1-year trials did not and the ADA macro review also concluded that there was minimal benefit from a low-GI diet, and the benefit is often compounded by high fiber intake.

So what is important? What the ADA has said is that all carbohydrate foods can be eaten for good health. We obviously encourage vegetables, fruits, whole grains, legumes, and dairy products over foods with added fat, sugars, or sodium. The ADA, for the first time, made a strong recommendation on limiting or avoiding intake of sugar-sweetened beverages to reduce risk of weight gain and worsening of cardiovascular risk factors, and it is important to individualize macronutrients.

A couple minutes on protein. What we have learned about protein is that although protein undergoes gluconeogenesis, the glucose does not enter into the general circulation. It is thought that the glucose from the gluconeogenesis is stored in the liver as glycogen but proteins stimulate as much insulin as does carbohydrate and so that is why individuals with type 2 diabetes, if you are treating them for hypoglycemia you should not add protein. Protein is a stimulant of insulin, and if protein does not, if the glucose from protein does not enter into the general circulation it is not going to be helpful in the treatment of hypoglycemia nor is it going to prevent future hypoglycemia. The ADA has said a normal amount is fine and then another change that I think is important is that in persons with diabetic kidney disease with either micro or macroalbuminuria, they made the statement that reducing protein is not recommended as this doesn’t alter the course of the glomerular filtration decline. Earlier studies show that when you reduce protein you

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reduce albuminuria but, as you know, what we are concerned about today is glomerular filtration rate and reducing protein does not change the decline in glomerular filtration rate so it is not necessarily beneficial.

So there is no need to add protein to snacks or meals. It doesn’t slow or change carbohydrate absorption, not helpful in the prevention of treatment of hypoglycemia, and not necessary for people with diabetic kidney disease.

I just want to make one comment about, because I hope you are aware that what we are looking at is the quality of fat. That monos or polys or the omega-3s, obviously, can be substituted for saturated or trans fats. I think what we will pay more attention to in the future is that studies have shown that when people eat a higher-fat diet, particularly a high-saturated-fat diet that it contributes to insulin resistance and this is something I think we will see more research on in the future.

So what is important is individualization. I have said that the ADA also reviewed eating patterns and found many were satisfactory and that there are no ideal macronutrient percentages and so our recommendations have to be based on the individual’s personal and cultural preferences but most importantly on the changes an individual is willing and able to make.

So if you said to me what is the best nutrition therapy intervention for diabetes?

I would say in the ideal world people with type 2 diabetes would all lose 5% to 10% of their baseline weight, they would all eat a nutrient-dense eating pattern in appropriate portion sizes, they would all participate in the 150 minutes of regular physical activity, people with type 2 diabetes would all cut carbohydrate, they would use insulin to carbohydrate ratios and correction factors.

Unfortunately, we work and live in the real world and we interact with people with diabetes in the real world and what then becomes important is to facilitate behavior change that the individual with diabetes is willing and able to make and I think it is extremely important that the suggestions we give to people are based on evidence that they are effective. And clearly we see that there are a variety of nutrition therapy interventions and patterns that can be implemented, but I hope I have also convinced you that lifestyle interventions for diabetes are effective and are essential. Thank you.

MS. GALLIVAN: Yes, Marion, thank you very much. That was really informative and got rid of a lot of the myths that I had about diabetes and eating so I really appreciate that and I do want to leave some time for questions but I am going to really quickly go through some of the resources that both NDEP and NIDDK have that address eating and diabetes.

The first resource that we have is Diabetes Health Sense. This is our online compendium

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of resources where you have access to more than 160 resources from 80 organizations that provide information that supports people with diabetes, people at risk, and the people who care for them to help them make and sustain some of the lifestyle changes that Marion talked about.

What you see now is the home page for Diabetes Health Sense. You can navigate the different resources by going on the left-hand column underneath where it says Help Me and you can really customize your search for resources based on things like key behaviors, diabetes status, age, format and language. So you can also access what we call our Make a Plan Just One Step Behavior Change Tool that can help your patients set goals for managing their diabetes. We also have a section for healthcare professionals where you can access resources and some of the research articles on behavior change.

The Diabetes Health Sense also has a number of different videos, behavioral videos that you are welcome to download and use. The one that you are seeing here features Robin Edelman. She is an RD CDE. She is talking about healthy eating. The videos contain people with diabetes and people with prediabetes talking about some of the challenges that they face as they are working to make changes in their lifestyle, as well as some of the experts, such as Robin, covering various topics.

Again, this is how you can go to Diabetes Health Sense and customize your search by going under the left-hand bar. I am not going to take the time to do it right now but after this webinar we hope you go to Diabetes Health Sense and play around with it and see all the different resources that are available to you based upon how you customize your search.

This is another great resource, the bilingual tasty recipes for people with diabetes and families. It is a cookbook that has some delicious diabetes-friendly meals. It also includes nutrition facts, along with messages around managing your diabetes. We also have recipe card sets that you can order. You can order this from the CDC website and you can see the URL and the phone number on the slide.

Some of the other resources that we have include resources to help children and teens with diabetes. I hope some of you are familiar with our school guide, which offers a set of practices to help school personnel ensure a safe and learning environment for students with diabetes. There are topics in the school guide that address eating, such as planning meals for type 1 and type 2 diabetes, carb counting, and adjusting insulin for changing the carb intake. We also have our series of Tips for Teens with Diabetes that has information on healthy eating. Again, these are bilingual to help teens make better food choices and then our Tips for Kids with Diabetes that cover how to manage your diabetes. All of these can be downloaded from the NDEP website.

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The Clearinghouse, the National Diabetes Information Clearinghouse, has two publications on eating, What I Need to Know about Carbohydrate Counting and What I Need to Know about Eating, and, again, those are available through the NDIC clearinghouse.

We also have the National Kidney Disease Education Program that has materials for people with diabetes and kidney disease to raise the importance about the importance of eating healthy and managing diabetes and high blood pressure to protect your kidneys. The website features a variety of resources for all of you, including training modules on nutrition therapy for chronic disease management, materials to support educators in teaching students or parents to become registered dieticians, about nutritional interventions for kidney disease patients, and then educational materials that you can use with your patients.

In addition, the kidney education program has a variety of fact sheets to help the public make the connection between diabetes and healthy eating for kidney health and, again, you can go to the National Kidney Disease Education Program and use all these resources.

And lastly I want to talk about just briefly, you can go to the Weight-Control Information Network, which is another information service from NIDDK, which has information on obesity, weight control, physical activity, and other nutrition-related issues.

I just do want to say that we have a wonderful partnership with the Academy of Nutrition and Dietetic Diabetes Care and Education Practice Group. We are happy to celebrate and promote National Nutrition Month every March to bring attention to the importance of making informed food choices and how to develop sound physical activity and eating habits. And the DCE practice group co-brands a variety of NDEP patient education resources and you can find them on the patient education handout webinar page of DCE, and in addition we are going to be partnering with DCE in May to co-host a webinar focused on diabetes and kidney disease that will feature Dr. Andrew Narva, who is Director of the National Kidney Disease Education Program at NIDDK, on May 20th. More information will be sent to all of you about this particular webinar.

So now we will move to the questions and answers and Candice, I will turn this over to you.

CANDICE: Okay. So we have quite a few questions so we are going to open up with a question from Mary Perry and the question begins, Marion, once again you have nailed it and have always been the voice of wisdom in the diabetes nutrition community. I get the individualization but as educators who may not be as comfortable with individualizing, what kind of meal planning tools should be used?

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MS. FRANZ: Well, thank you for your kind comment. Well, I think, again, as we look at some of the resources that have just been shared with you from, by Joanne, some of those may be helpful. Sometimes people with diabetes just need some very simple guidelines, some general, what should I eat for breakfast, what should I eat for lunch? Just some really concise, simple menu ideas and in general we would probably start by saying, well, what do you usually eat and then what is it reasonable for you to think about cutting back on? What are the changes that you think you are willing and able to make in your current eating habits? Because they are the ones that have to do it.

CANDICE: The next question comes from Debbie Zimmerman. The slide supporting diabetes’s progressive nature was telling. Where can we find additional information on this?

MS. FRANZ: Well, the slide in the progression of diabetes is a slide from the International Diabetes Center in Minneapolis. It is in quite a few publications and Joanne probably, I know it is in our book that we edited, American Diabetes Association Nutrition Guide for, Nutrition Therapy Guide, but that is the source of it.

CANDICE: We have a question from Julie Shapiro. Is there still any reason to suggest certain carb-counting levels for type 2 based on specific calorie goals?

MS. FRANZ: I think carb counting is very helpful for people with type 2 diabetes. I don’t know that it necessarily has to be based on a calorie level, but oftentimes what we find is that for people with type 2 diabetes many times we recommend that they start for women having three to four carbohydrate choices at a meal or men having four to five carbohydrate choices at a meal, and then that they try to implement this and do blood glucose monitoring along with it. At that point we can have some feedback and see if they are reasonable recommendations. We can see that the effect of this amount of carbohydrate has had on their blood glucose levels and we can go from there. So I do think that carbohydrate counting is still very important for people with both type 1 and type 2 diabetes. I don’t mean to imply it isn't important for people with type 2 diabetes. I think it helps them know what and how much to eat but it is still, people can overeat on healthy foods is kind of my point, as well as they can overeat on unhealthy foods, and that is why I think total energy, we have to pay attention to total energy intake.

CANDICE: We have a question from Cathy Rucker. Are there any differences in nutrition therapy and outcomes based on provision from nurses or RDs?

MS. FRANZ: Well, that’s an excellent question and I don’t know that anyone has done that research. In most of the studies we were doing this, obviously, for the Academy and so we did look at studies in which the dieticians were doing the implementation. I will say, though, too, and I want to make this point, as well, that it is very important that we work together as a team, and we certainly have evidence from looking at diabetes

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education and support programs, again, showing that both nurses and dieticians that are involved in these education programs that it does lead to positive outcomes. So yes, I think there is definitely a very important role for nurses, as well as for dieticians, as we look at nutrition therapy and thank you for asking that question.

CANDICE: I have one question from Betsy Rodriguez. Can you please explain one more time why total calories are more important than carbohydrates in diabetes control? Is it because of the weight gain?

MS. FRANZ: Because partly, yes, the question was, why total calories? Because when we looked at the studies we could not find any ideal amount of carbohydrate, protein, or fat, so there are different percentages of carbohydrate, protein, and fat, now, that are clearly acceptable but it is quite clear that when people overeat that we do often find blood glucose levels increase and there probably are several reasons for that. One is the increased carbohydrate. They often increase fat, too, as I sort of alluded to the relationship of fat and the insulin resistance is not completely clear, so we have to look at the total amount of food that people are eating and what is important is that they really do try to eat a healthy eating pattern in appropriate portion sizes and that the total amount of food eaten is very important, and I do think that carbohydrate counting, as I said, is also important because I do think it often helps people eat less.

CANDICE: We have a question from Paola Rondon. Have you seen a growing trend in patient educators doing diabetes education with training from programs like DEEP and no RD or CDE training?

MS. FRANZ: Joanne probably could answer that. I have not.

MS. GALLIVAN: I have not, either.

CANDICE: We have another question from Jessica Miller. So many of my doctors are pushing protein these days. Many are telling their patients to do Atkins. How can I let them know carbs aren’t the enemy?

MS. FRANZ: I don’t know how you can win that battle. You know, it just is a thought that is out there. It is so pervasive. You could present research, it doesn’t seem to matter, you know, so if we are talking about what is important it really is healthy eating, and healthy eating of foods that contain carbohydrates are healthy foods and we hear so much about the benefits of protein, certainly protein is essential, but the other point you should make, too, is that what is interesting is that what has been shown is when people change eating habits what varies is carb and fat. Short-term, people can often change protein but long-term it is very difficult for people to change protein intake very much long-term. If you look at research studies where they have tried to do that they haven’t been able to

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long-term change protein intake. Short-term, yes, but not long-term. What tends to vary are carb and fat, those two go together, and what often happens, unfortunately, is as people cut back on carb, they eat more fat.

CANDICE: Just one question from Martha Biersner [phonetic]. Ms. Biersner is asking are you not recommending any protein with snacks now to decrease the rate of glucose absorption?

MS. FRANZ: Absolutely. She is correct. There are studies to have shown that if you give people 50 g of carbohydrate and 50 g of protein, if you give the carbohydrate separately you will get a peak, if you give the protein, the protein does not affect the blood glucose levels. If you combine them the peak is the same and at the same time. There is absolutely no evidence that adding protein to a snack slows the absorption of carbohydrate and what it usually does is, if people desire it, it is okay but what it usually does is, it adds unnecessary and often unwanted calories.

MS. GALLIVAN: Marion, thank you very much. This has really, really been informative, and as Marion said if you have any additional questions that you did not get to ask you can email me. My email is Joanne, J-O-A-N-N-E, underscore, Gallivan, G-A-L-L-I-V-A-N at N-I-H dot G-O-V and we will collect your questions and get back to you. Marion, again, thank you very, very much for a very informative webinar. We really appreciate the time that you have given to everybody and thank you, everybody, for joining us today. We hope you have a good afternoon.

MS. FRANZ: Thank you, Joanne.

MS. GALLIVAN: Thank you, Marion. Bye-bye.

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Nutrition Therapy Recommendations for People … · Web viewNational Diabetes Education ProgramNutrition Therapy Recommendations for People with Diabetes Webinar Transcript Thursday,