Historically, nutrition principles and recommendations for diabetes and related complications have been based on scientific evidence and diabetes knowledge when available and, when evidence was not available, on clinical experience and expert consensus. Often it has been difficult to discern the level of evidence used to construct the nutrition principles and recommendations. Furthermore, in clinical practice, many nutrition recommendations that have no scientific supporting evidence have been and are still being given to individuals with diabetes. To address these problems and to incorporate the research done in the past 8 years, this 2002 technical review provides principles and recommendations classified according to the level of evidence available. It reviews the evidence from randomized, controlled trials; cohort and case-controlled studies; and observational studies, which can also provide valuable evidence (1,2), and takes into account the number of studies that have provided consistent outcomes of support. In this review, nutrition principles are graded into four categories based on the available evidence: those with strong supporting evidence, those with some supporting evidence, those with limited supporting evidence and those based on expert consensus.

Evidence-based nutrition recommendations attempt to translate research data and clinically applicable evidence into nutrition care. However, the best available evidence must still be moderated by individual circumstances and preferences. The goal of evidence-based recommendations is to improve the quality of clinical judgments and facilitate cost-effective care by increasing the awareness of clinicians and patients with diabetes of the evidence supporting nutrition services and the strength of that evidence, both in quality and quantity.

Before 1994, the American Diabetes Association’s (ADA’s) nutrition principles and recommendations attempted to define an “ideal” nutrition prescription that would apply to everyone with diabetes (3,4,5). Although individualization was a major principle of all recommendations, it was usually done within defined …

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Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications

Background
It has been recognised that adoption of self-management skills by the person with diabetes is necessary in order to manage their diabetes. However, the most effective method for delivering education and teaching self-management skills is unclear.

Objectives
To assess the effects of group-based, patient-centred training on clinical, lifestyle and psychosocial outcomes in people with type 2 diabetes.

Search methods
Studies were obtained from computerised searches of multiple electronic bibliographic databases, supplemented by hand searches of reference lists of articles, conference proceedings and consultation with experts in the field.

Selection criteria
Randomised controlled and controlled clinical trials which evaluated group-based education programmes for adults with type 2 diabetes compared with routine treatment, waiting list control or no intervention. Studies were only included if the length of follow-up was six months or more and the intervention was at least one session with the minimum of six participants.

Data collection and analysis
Two reviewers independently extracted data and assessed study quality. A meta-analysis was performed if there were enough homogeneous studies reporting an outcome at either four to six months, 12-14 months, or two years, otherwise the studies were summarised in a descriptive manner.

Main results
Fourteen publications describing 11 studies were included involving 1532 participants. The results of the meta-analyses in favour of group-based diabetes education programmes were reduced glycated haemoglobin at four to six months (1.4%; 95% confidence interval (CI) 0.8 to 1.9; P < 0.00001), at 12-14 months (0.8%; 95% CI 0.7 to 1.0; P < 0.00001) and two years (1.0%; 95% CI 0.5 to 1.4; P < 0.00001); reduced fasting blood glucose levels at 12 months (1.2 mmol/L; 95% CI 0.7 to 1.6; P < 0.00001); reduced body weight at 12-14 months (1.6 Kg; 95% CI 0.3 to 3.0; P = 0.02); improved diabetes knowledge at 12-14 months (SMD 1.0; 95% CI 0.7 to 1.2; P < 0.00001) and reduced systolic blood pressure at four to six months (5 mmHg: 95% CI 1 to 10; P = 0.01). There was also a reduced need for diabetes medication (odds ratio 11.8, 95% CI 5.2 to 26.9; P < 0.00001; RD = 0.2; NNT = 5). Therefore, for every five patients attending a group-based education programme we could expect one patient to reduce diabetes medication.

Authors' conclusions
Group-based training for self-management strategies in people with type 2 diabetes is effective by improving fasting blood glucose levels, glycated haemoglobin and diabetes knowledge and reducing systolic blood pressure levels, body weight and the requirement for diabetes medication.

Group based training for self‐management strategies in people with type 2 diabetes mellitus

ContextEpidemiologic data demonstrate that moderate alcohol intake is associated
with improved insulin sensitivity in nondiabetic individuals. No controlled-diet
studies have addressed the effects of daily moderate alcohol consumption on
fasting insulin and glucose concentrations and insulin sensitivity.ObjectiveTo determine whether daily consumption of low to moderate amounts of
alcohol influences fasting insulin and glucose concentrations and insulin
sensitivity in nondiabetic postmenopausal women.Design, Setting, and ParticipantsRandomized controlled crossover trial of 63 healthy postmenopausal women,
conducted at a clinical research center in Maryland between 1998 and 1999.InterventionsParticipants were randomly assigned to consume 0, 15, or 30 g/d of alcohol
for 8 weeks each as part of a controlled diet. All foods and beverages were
provided during the intervention. An isocaloric beverage was provided in the
0-g/d arm. Energy intake was adjusted to maintain constant body weight.Main Outcome MeasuresFasting insulin, triglyceride, and glucose concentrations, measured
at the end of each dietary period; insulin sensitivity, estimated with a published
index of glucose disposal rate corrected for fat-free mass based on fasting
insulin and fasting triglyceride concentrations, compared among treatments
with a mixed-model analysis of variance.ResultsA complete set of plasma samples was collected and analyzed for 51 women
who completed all diet treatments. Consumption of 30 g/d of alcohol compared
with 0 g/d reduced fasting insulin concentration by 19.2% (P = .004) and triglyceride concentration by 10.3% (P = .001), and increased insulin sensitivity by 7.2% (P = .002). Normal-weight, overweight, and obese individuals responded
similarly. Only fasting triglyceride concentration was significantly reduced
when comparing 0 and 15 g/d of alcohol (7.8%; P =
.03), and no difference was found between consumption of 15 and 30 g/d of
alcohol; however, there was a significant linear trend (P = .001). Fasting glucose concentrations were not different across
treatments.ConclusionsConsumption of 30 g/d of alcohol (2 drinks per day) has beneficial effects
on insulin and triglyceride concentrations and insulin sensitivity in nondiabetic
postmenopausal women.

https://jamanetwork.com/journals/jama/articlepdf/194914/jci20001.pdf

Effects of Moderate Alcohol Intake on Fasting Insulin and Glucose Concentrations and Insulin Sensitivity in Postmenopausal Women: A Randomized Controlled Trial

Nonalcoholic fatty liver disease (NAFLD) is emerging as a component of the metabolic syndrome, although it is not known whether markers of NAFLD, including elevated concentrations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALK), predict the development of metabolic syndrome. Our objective was to investigate the associations of elevated AST, ALT, and other liver markers, including C-reactive protein (CRP), with incident National Cholesterol Education Program-defined metabolic syndrome among 633 subjects in the Insulin Resistance Atherosclerosis Study who were free of metabolic syndrome at baseline. Insulin sensitivity (Si) and acute insulin response (AIR) were directly measured from the frequently sampled intravenous glucose tolerance test among African-American, Hispanic, and non-Hispanic white subjects aged 40-69 years. After 5.2 years, 127 individuals had developed metabolic syndrome. In separate logistic regression models adjusting for age, sex, ethnicity, clinic, and alcohol consumption, subjects in the upper quartiles of ALT, ALK, and CRP were at significantly increased risk of incident metabolic syndrome compared with those in the lowest quartile: ALT, odds ratio 2.50 (95% CI 1.38-4.51); ALK, 2.28 (1.24-4.20); and CRP, 1.33 (1.09-1.63). Subjects in the upper quartile of the AST-to-ALT ratio were at significantly reduced metabolic syndrome risk (0.40 [0.22-0.74]). After further adjustment for waist circumference, Si, AIR, and impaired glucose tolerance, the associations of ALT and the AST-to-ALT ratio with incident metabolic syndrome remained significant (ALT, 2.12 [1.10-4.09]; the AST-to-ALT ratio, 0.48 [0.25-0.95]). These associations were not modified by ethnicity or sex, and they remained significant after exclusion of former and heavy drinkers. In conclusion, NAFLD markers ALT and the AST-to-ALT ratio predict metabolic syndrome independently of potential confounding variables, including directly measured Si and AIR.

https://diabetes.diabetesjournals.org/content/diabetes/54/11/3140.full.pdf

Liver markers and development of the metabolic syndrome: the insulin resistance atherosclerosis study.

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Diabetes Health Disparities: A Systematic Review of Health Care Interventions

OBJECTIVE: Light-to-moderate alcohol consumption has been associated with reduced cardiovascular disease (CVD) mortality, which may be explained by increased insulin sensitivity (SI) and an improved lipoprotein and blood pressure profile. Prior research has shown improved SI with light-to-moderate alcohol intake even though somewhat imprecise measures of SI were used. RESEARCH DESIGN AND METHODS: Relationships between alcohol use and SI and CVD risk factors were assessed in a cross-sectional analysis of 1,196 white, African-American, and Hispanic men and women from the Insulin Resistance and Atherosclerosis Study (IRAS). Five categories of previous-year alcohol use (never, or =3 drinks/day) and log SI + 1 (frequently sampled intravenous glucose tolerance test with Bergman minimal model analysis), log fasting insulin, log triglycerides, HDL cholesterol, and systolic/diastolic blood pressure were examined using analysis of variance. RESULTS: Univariate analysis showed an inverse U-shaped relationship between SI and alcohol intake, with a peak at the 0.5-0.99 drinks/day category. A U-shaped relationship was observed between fasting insulin and the lipid and blood pressure measures. After adjustment for demographic (clinic, sex, ethnicity, age), lifestyle (smoking, dietary energy/fat intake, physical activity), and physical (BMI, waist circumference) variables, the alcohol/insulin association was attenuated, but the association with lipids and blood pressure remained for high-intake categories. CONCLUSIONS: These data suggest that the enhanced SI associated with light-to-moderate alcohol consumption may be a function solely of a BMI and central adiposity profile more favorable to higher SI.

https://care.diabetesjournals.org/content/diacare/23/11/1630.full.pdf

Associations between alcohol consumption and insulin sensitivity and cardiovascular disease risk factors: the Insulin Resistance and Atherosclerosis Study.

This pilot test effort focused on weight management strategies for individuals with type 2 diabetes living in rural, medically under-served communities. Randomly selected patients from the diabetes registry of a federally funded primary care practice in a rural community were randomized to one of two 8-week interventions: intensive lifestyle (reduced fat and calorie intake and increased activity) or intensive lifestyle plus ongoing formal evaluation for continuous quality improvement. Mean weight loss was 1.15 +/- 1.90 kg (96.4% African American, n = 23, p < 0.01) with no difference between groups. Among the 78% who lost weight, mean loss was 2.00 kg. Mean difference in pre- vs. postintervention fasting blood glucose was -24.23 mg/dL (n = 23, p < 0.05). In this rural, medically under-served community, the interventions were moderately successful in facilitating weight loss and improving fasting glucose concentration. For purposes of state-of-the-art weight management interventions with diabetics, the addition of formal evaluation did not result in improved outcomes.

Pilot study of strategies for effective weight management in type 2 diabetes: Pounds off with empowerment (POWER)

Associations Between Alcohol Consumption and Insulin Sensitivity and Cardiovascular Disease Risk Factors

Importance
Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes.


Objective
To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality.


Design, Setting, and Participants
This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021.


Interventions
Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group.


Main Outcomes and Measures
There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery.


Results
Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups.


Conclusions and Relevance
In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes.


Trial Registration
ClinicalTrials.gov Identifier: NCT03360539.

Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial.

Abstract Objective To assess the impact of COVID‐19 on trends in postpartum mental health diagnoses and utilization of psychotherapy and prescription drug treatment. Data Sources Data were obtained from a large, national health insurance claims database that tracks individuals longitudinally. Study Design We used interrupted time series models to examine changes in trends of postpartum mental health diagnoses before and during the COVID‐19 pandemic and t‐tests to examine differences in treatment. Data Extraction Methods We used billing codes to identify individuals who received mental health‐related diagnoses and treatment in the first 90 days after a birth hospitalization. We excluded individuals diagnosed with schizophrenia or bipolar disorder and those with an unknown payer at delivery. Principal Findings Compared to the pre‐pandemic period, the trend in new postpartum mental health diagnoses increased significantly in the post‐COVID‐19 period (0.06 percentage points [95%CI 0.01, 0.11]). Over 12 months, the percentage of new diagnoses was 5.0% greater relative to what would be expected in absence of COVID‐19. The percentage of diagnosed individuals who did not receive treatment increased from 50.4% to 52.7% (p = 0.003). Conclusions Findings point to an urgent need to improve screening and treatment pathways for perinatal individuals in the wake of COVID‐19.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/1475-6773.14051

Michelle A. Martin

Papers

Associations between alcohol consumption and insulin sensitivity and cardiovascular disease risk factors: the Insulin Resistance and Atherosclerosis Study.

Pilot study of strategies for effective weight management in type 2 diabetes: Pounds off with empowerment (POWER)

Associations Between Alcohol Consumption and Insulin Sensitivity and Cardiovascular Disease Risk Factors

Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial.

Trends in postpartum mental health care before and during COVID‐19