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Nutrition therapy has been recognized as a primary treatment strategy for diabetes since the condition was identified centuries ago. The recently published American Diabetes Association (ADA) Nutrition Recommendations and Interventions for Diabetes—2006 is sure to help guide you and your patients in the new millennium.1 As a clinician, you are in a great position to use these recommendations during routine contact with patients to address the challenges of leading a healthy life-style to prevent or manage diabetes.
"WE MUST BELIEVE [PATIENTS] CAN ACHIEVE HEALTH BEHAVIOR CHANGE."
CHANGE US, THEM, OR BOTH?
To help our patients apply nutrition recommendations, we must believe they can achieve health behavior change. And yet, as cultural anthropologist Margaret Mead said, "It is easier to change a man's religion than to change his diet."
In a survey of >2,000 adults with diabetes, the most frequently cited barrier to achieving self-management goals was adherence to diet and exercise.2 Although data from the Third National Health and Nutrition Examination Survey (NHANES III) confirm that individuals with diabetes are eating too much fat, not taking in enough fruits and vegetables, and leading inactive lifestyles,3 getting patients to take a pill or injection can be easier than convincing them to lose a few pounds, count carbohydrates, or start a physical activity program.
However, medical nutrition therapy (MNT) does make a
difference.4 In the
Diabetes Prevention Program, the incidence of diabetes was reduced 58% in the
lifestyle group compared with 31% in the metformin
group.5 Diabetes MNT
trials and outcome studies have demonstrated reductions in glycated hemoglobin
(A1C) of 
1% in type 1 diabetes and 1–2% in type 2 diabetes,
depending on the duration of the diabetes. These results are similar to A1C
reductions achieved with drug
treatment.1 MNT also
plays a role in lowering blood pressure and
lipids.1
As clinicians, we have the perfect opportunity to be the change agent that helps patients lead healthier lives. When a physician provides advice regarding weight loss, for example, patients are nearly three times as likely to act on that recommendation as patients who do not receive the advice.6 And patients are more satisfied with their interactions with us when they receive information, support, and resources, especially when our messages are positive, nonjudgmental, and understanding of the difficulties of changing health behavior.7
1-MINUTE LIFESTYLE MESSAGES
Research suggests that physicians spend <0.7 minutes on health promotion when averaged across all visits, and <1.35 minutes during the visits in which they give health promotion advice.8 Often, more time is spent on health education related to illness care (i.e., up to 1.98 minutes). Because clinicians are busy, the concept of 1-minute messages was developed.9 Using that approach, we have created some brief nutrition messages based on the three levels of diabetes-related prevention categories outlined in ADA's 2006 recommendations:
Primary Prevention
Insulin resistance (weight loss and/or regular physical activity)
Based on your fasting blood glucose level and your weight, you have insulin
resistance. You are at risk of developing type 2 diabetes.
Secondary Prevention
Meal planning
Tertiary Prevention
Cardiovascular disease risk
• To reduce your risk for heart disease, your food plan should include
several servings each day of fresh or frozen fruits and vegetables and whole
grains. You may include natural peanut butter and nuts in moderation, as they
are also healthful foods.
High blood pressure
Kidney disease
INCLUDE MNT PAYMENT RESOURCES
Achieving nutrition-related goals requires a coordinated team effort that includes the person with diabetes as well as a registered dietitian.1 Unfortunately, only 35% of people with diabetes are estimated to be receiving formal diabetes self-management education.11 Yet many health management organizations and private payers now include an MNT benefit, and most of the 50 states have mandates for coverage of diabetes self-management training and MNT. Flexible spending accounts also can be used to cover the cost of nutrition and/or diabetes education.
So if your diabetes patients are struggling to achieve the ADA recommendations, refer them to a registered dietitian or certified diabetes educator at your local hospital outpatient diabetes education program, a freestanding diabetes education center, or a professional in private practice. MNT is an effective treatment strategy for preventing and managing diabetes if you make the referral.
Footnotes
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References
2. Glasgow RE, Hampson SE, Strycker LA, et al.: Personal-model beliefs and social-environmental barriers related to diabetes self-management. Diabetes Care 20:556–561, 1997.[Abstract]
3. Nelson KM, Reiber G, Boyko EJ: Diet and exercise among adults with
type 2 diabetes: Findings from the Third National Health and Nutrition
Examination Survey (NHANES III). Diabetes Care 25: 1722–1728, 2002.
4. Pastors JG, Warshaw H, Daly A, et al.: The evidence for the
effectiveness of medical nutrition therapy in diabetes management.
Diabetes Care 25:608–613, 2002.
5. Knowler WC, Barrett-Connor E, Fowler SE, et al., for the Diabetes
Prevention Research Group: Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformin. N Engl J Med 346: 393–403, 2002.
6. Galuska DA, Will JC, Serdula MK, et al.: Are health care
professionals advising obese patients to lose weight?
JAMA 282:1576–1578, 1999.
7. Wadden TA, Anderson DA, Foster GD, et al.: Obese women's
perceptions of their physicians' weight management attitudes and practices.
Arch Fam Med 9:854–860, 2000.
8. Stange KC, Zyzanski SJ, Jaen CR, et al.: Illuminating the `black box': A description of 4,454 patient visits to 138 family physicians. J Fam Pract 46:377–389, 1998.[Medline]
9. Stange KC, Woolf SH, Gjeltema K: One minute for prevention: The power of leveraging to fulfill the promise of health behavior counseling. Am J Prev Med 22:320–323, 2002.[Medline]
10. American Diabetes Association: Standards of medical care in
diabetes—2006 (Position Statement). Diabetes
Care 29 (Suppl. 1):S4
–S42, 2006.
11. Coonrod BA, Betschart J, Harris MI: Frequency and determinants of diabetes patient education among adults in the U.S. population. Diabetes Care 17:852–858, 1994.[Abstract]
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