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John P. Bantle, MD
Optimal treatment of diabetes mellitus requires nutrition therapy, an exercise program, and, for most patients, medication(s). When patients fail to achieve diabetes treatment goals, it is usually because one or more of these fundamental treatment modalities has not been effectively implemented. For many patients, the most challenging part of the treatment program (and thus the part of the program that often is not done well) is nutrition therapy. Patients often have difficulty understanding nutrition therapy. Moreover, many have difficulty putting their plan into action.
There are at least five reasons why understanding and adhering to nutrition therapy is difficult. First, nutrition recommendations have changed over time, with new recommendations sometimes contradicting previous recommendations. The contradictions have usually resulted from recommendations made in the absence of scientific evidence. The recommendations must then be modified or even abandoned when evidence becomes available. This creates confusion and erodes confidence in the recommendations. Second, many physicians do not themselves understand the principles of nutrition therapy and do not emphasize the importance of strategies to achieve food and nutrition goals. Thus, patients often do not recognize the importance of nutrition therapy. A third reason that nutrition therapy is difficult is that adhering to any eating pattern is challenging if that eating pattern differs from the usual eating pattern followed by family, friends, and cultural group. Even the most motivated of patients is likely to develop a sense of deprivation if asked to avoid foods that others are eating and enjoying. Any recommendation to depart from usual eating habits should be made only if there is compelling scientific evidence of potential benefit. Fourth, in our society, food has many purposes in addition to meeting biological needs. Food is often the focus of social activities and is frequently used as a reward, as a means of expressing affection, and as a way to help cope with stress. We are constantly exposed to appealing advertisements for food that exploit these factors. Even the most motivated of patients can be expected to occasionally succumb to these influences. Fifth, and very importantly, it is now clear that energy intake, energy expenditure, and body weight are regulated in the central nervous system. Thus, when we ask overweight or obese patients with diabetes to reduce energy intake and lose weight, we are asking them to override a powerful biological control system. Most of us have great difficulty making this change.
Although nutrition therapy is difficult and there are barriers to overcome, we should still do everything we can to implement it effectively. Healthy eating patterns are a key element in establishing good control of glycemia and lipemia and thereby preventing the complications of diabetes and its companion atherosclerosis. Without a strong nutrition component, most treatment plans will fall short. However, we must keep in mind that only a limited number of dietary strategies have documented efficacy. Marion Franz and Alison Evert and their chapter authors have done an outstanding job of describing these strategies in the American Diabetes Association Guide to Nutrition Therapy for Diabetes. They also carefully point out gaps in our knowledge, allowing us to avoid making unsubstantiated recommendations. I believe this volume belongs in the bookshelf of every health care provider who deals with patients who have diabetes mellitus.
John P. Bantle is Professor of Medicine and Director, Division of Endocrinology and Diabetes, University of Minnesota, Minneapolis, MN.
Chapter 1 Effectiveness of Medical Nutrition Therapy in Diabetes
Joyce Green Pastors, MS, RD, CDE, and Marion J. Franz, MS, RD, CDE
Background on Diabetes Nutrition Therapy
Evidence for the Clinical Effectiveness of MNT in Diabetes
Highlights Effectiveness of Medical Nutrition Therapy in Diabetes
• Medical nutrition therapy (MNT) for the treatment of diabetes is effective, with the greatest impact at the initial onset of diabetes. Randomized control and observational studies have shown that within the first 6 months of diagnosis, A1C can be reduced up to ~3% point reductions (range 0.23–2.6%), depending on the type and duration of