A healthful eating pattern, regular physical activity, and often pharmacotherapy are key components of diabetes management. For many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat. It is the position of the American Diabetes Association (ADA) that there is not a “one-size-fits-all” eating pattern for individuals with diabetes. The ADA also recognizes the integral role of nutrition therapy in overall diabetes management and has historically recommended that each person with diabetes be actively engaged in self-management, education, and treatment planning with his or her health care provider, which includes the collaborative development of an individualized eating plan (1,2). Therefore, it is important that all members of the health care team be knowledgeable about diabetes nutrition therapy and support its implementation.

This position statement on nutrition therapy for individuals living with diabetes replaces previous position statements, the last of which was published in 2008 (3). Unless otherwise noted, research reviewed was limited to those studies conducted in adults diagnosed with type 1 or type 2 diabetes. Nutrition therapy for the prevention of type 2 diabetes and for the management of diabetes complications and gestational diabetes mellitus is not addressed in this review.

A grading system, developed by the ADA and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations (1) (Table 1). The level of evidence that supports each recommendation is listed after the recommendation using the letters A, B, C, or E. A table linking recommendations to evidence can be reviewed at http://professional.diabetes.org/nutrition. Members of the Nutrition Recommendations Writing Group Committee disclosed all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the position statement development process. Members of this committee, their employers, …

https://care.diabetesjournals.org/content/diacare/37/Supplement_1/S120.full.pdf

Nutrition Therapy Recommendations for the Management of Adults With Diabetes

Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults

Changing diet and physical activity behaviour is one of the cornerstones of type 2 diabetes treatment, but changing behaviour is challenging. The objective of this study was to identify behaviour change techniques (BCTs) and intervention features of dietary and physical activity interventions for patients with type 2 diabetes that are associated with changes in HbA1c and body weight. We performed a systematic review of papers published between 1975–2015 describing randomised controlled trials (RCTs) that focused exclusively on both diet and physical activity. The constituent BCTs, intervention features and methodological rigour of these interventions were evaluated. Changes in HbA1c and body weight were meta-analysed and examined in relation to use of BCTs. Thirteen RCTs were identified. Meta-analyses revealed reductions in HbA1c at 3, 6, 12 and 24 months of -1.11 % (12 mmol/mol), -0.67 % (7 mmol/mol), -0.28 % (3 mmol/mol) and -0.26 % (2 mmol/mol) with an overall reduction of -0.53 % (6 mmol/mol [95 % CI -0.74 to -0.32, P  0.3 % reduction in HbA1c: ‘instruction on how to perform a behaviour’, ‘behavioural practice/rehearsal’, ‘demonstration of the behaviour’ and ‘action planning’, as were intervention features ‘supervised physical activity’, ‘group sessions’, ‘contact with an exercise physiologist’, ‘contact with an exercise physiologist and a dietitian’, ‘baseline HbA1c >8 %’ and interventions of greater frequency and intensity. Diet and physical activity interventions achieved clinically significant reductions in HbA1c at three and six months, but not at 12 and 24 months. Specific BCTs and intervention features identified may inform more effective structured lifestyle intervention treatment strategies for type 2 diabetes.

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Behaviour change techniques targeting both diet and physical activity in type 2 diabetes: A systematic review and meta-analysis.

Social Position, Psychological Stress, and Obesity: A Systematic Review

Obesity is a growing global health concern, with a rapid increase being observed in morbid obesity. Obesity is associated with an increased cardiovascular risk and earlier onset of cardiovascular morbidity. The growing obesity epidemic is a major source of unsustainable health costs and morbidity and mortality because of hypertension, type 2 diabetes mellitus, dyslipidemia, certain cancers and major cardiovascular diseases. Similar to obesity, hypertension is a key unfavorable health metric that has disastrous health implications: currently, hypertension is the leading contributor to global disease burden, and the direct and indirect costs of treating hypertension are exponentially higher. Poor lifestyle characteristics and health metrics often cluster together to create complex and difficult-to-treat phenotypes: excess body mass is such an example, facilitating a cascade of pathophysiological sequelae that create such as a direct obesity-hypertension link, which consequently increases cardiovascular risk. Although some significant issues regarding assessment/management of obesity remain to be addressed and the underlying mechanisms governing these disparate effects of obesity on cardiovascular disease are complex and not completely understood, a variety of factors could have a critical role. Consequently, a comprehensive and exhaustive investigation of this relationship should analyze the pathogenetic factors and pathophysiological mechanisms linking obesity to hypertension as they provide the basis for a rational therapeutic strategy in the aim to fully describe and understand the obesity-hypertension link and discuss strategies to address the potential negative consequences from the perspective of both primordial prevention and treatment for those already impacted by this condition.

The relationship between obesity and hypertension: an updated comprehensive overview on vicious twins.

Behavior change theories and models, validated within the field of dietetics, offer systematic explanations for nutrition-related behavior change. They are integral to the nutrition care process, guiding nutrition assessment, intervention, and outcome evaluation. The American Dietetic Association Evidence Analysis Library Nutrition Counseling Workgroup conducted a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Two hundred fourteen articles were reviewed between July 2007 and March 2008, and 87 studies met the inclusion criteria. The workgroup systematically evaluated these articles and formulated conclusion statements and grades based upon the available evidence. Strong evidence exists to support the use of a combination of behavioral theory and cognitive behavioral theory, the foundation for cognitive behavioral therapy (CBT), in facilitating modification of targeted dietary habits, weight, and cardiovascular and diabetes risk factors. Evidence is particularly strong in patients with type 2 diabetes receiving intensive, intermediate-duration (6 to 12 months) CBT, and long-term (>12 months duration) CBT targeting prevention or delay in onset of type 2 diabetes and hypertension. Few studies have assessed the application of the transtheoretical model on nutrition-related behavior change. Little research was available documenting the effectiveness of nutrition counseling utilizing social cognitive theory. Motivational interviewing was shown to be a highly effective counseling strategy, particularly when combined with CBT. Strong evidence substantiates the effectiveness of self-monitoring and meal replacements and/or structured meal plans. Compelling evidence exists to demonstrate that financial reward strategies are not effective. Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations. Routine documentation and evaluation of the effectiveness of behavior change theories and models applied to nutrition care interventions are recommended.

State of the Evidence Regarding Behavior Change Theories and Strategies in Nutrition Counseling to Facilitate Health and Food Behavior Change

This randomized clinical trial investigates the effect of grocery gift cards and fruit and vegetable boxes provided to caregivers on healthfulness of diets among their children.

Nicole A. Clark

Papers

State of the Evidence Regarding Behavior Change Theories and Strategies in Nutrition Counseling to Facilitate Health and Food Behavior Change

Effect of Brief Produce Exposure and Unconstrained Grocery Gift Cards on Caregiver Influence on Diet of Elementary Age Children