Nutrition is one of the most significant factors in a patient’s diabetes management, but there is no universal approach to diet for people living with this disease. Researchers and clinicians may find they have conflicting opinions about what an optimal diet for patients with diabetes looks like compared to their colleagues based on the nutritional research they have been exposed to. 

A symposium at the 83rd Scientific Sessions discussed the evidence behind food as medicine, expedited dietary education, binge-eating disorder, and weight stigma. Hot Topics in Nutrition—What’s the Evidence? can be viewed by registered meeting participants at ADA2023.org. If you haven’t registered for the 83rd Scientific Sessions, register today to access the valuable meeting content through August 28.

Food Is Medicine

Food Is Medicine is a subset of interventions that provide food and nutrition resources to improve health in connection with the health care system, explained Seth A. Berkowitz, MD, MPH, Associate Professor of Medicine, University of North Carolina at Chapel Hill.

These interventions are designed to address food insecurity for patients with inadequate access to the food required for an active, healthy lifestyle.

“I think it really exemplifies the way that big-picture distributive institutions lead to individual effects,” Dr. Berkowitz said.

Food Is Medicine programs generally take one of two forms: cash or near-cash benefits like the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), produce prescriptions and food subsidies or in-kind distribution from food pantries, medically tailored groceries, and medically tailored meal delivery.

“Using the healthy eating index of diet quality, we found there’s a really large effect of receiving medically tailored meals on improving diet quality,” Dr. Berkowitz said. “So, going from a diet quality when not receiving meals that was about one standard deviation below the national average, people went up to about two standard deviations above the national average.”

Food insecurity is a key pathway that creates health disparities and can often impact multiple aspects of a person’s overall health. According to Dr. Berkowitz, food insecurity is associated with worse management of A1C, blood pressure, and low-density lipoprotein (LDL) cholesterol for patients with type 2 diabetes, while also leading to more microvascular and macrovascular complications. Food insecurity can also cause negative compensatory and psychological effects.

Diabetes nutritional education in five minutes or less

Throughout a shift, clinicians are often pressed for time. Ka Hei Karen Lau, MS, RDN, LDN, CDCES, Registered Dietician and Certified Diabetes Instructor for the Joslin Diabetes Center, shared strategies for providers to use to inform new type 2 diabetes patients about diabetes nutrition in five minutes or less.

The four goals of nutrition therapy for diabetes are to promote and support healthy eating patterns to improve overall health, address individualized nutrition needs, maintain the pleasure of eating for the patient, and provide practical tools for day-to-day meal planning, she noted.

Ms. Lau also emphasized that identifying personal and cultural preferences is an important piece of designing a plan that will work for a patient with type 2 diabetes. It’s important to discuss the foods they eat regularly rather than generalizing about eating more vegetables or fewer carbs. These discussions should include an assessment of typical dietary intake.

Providers should also assess barriers in language, literacy, numeracy, and finances that exist for a patient to ensure they’re providing realistic recommendations.

“You might think, ‘There are so many questions to ask, and we only have five minutes. How are we going to ask all those questions?’ But most of the time, clinically, it happens more organically,” Ms. Lau explained.

She said that dietary management options must be tailored to the individual and that a variety of eating patterns are acceptable as long as they emphasize non-starchy vegetables, minimize added sugars or refined grains, and choose whole foods over highly processed foods as often as possible.

To help patients with portion control, she recommended the plate method or the hand method. The plate method is a visual diagram of a dinner plate that reflects the proportions of each food group people should prioritize in each meal. Half of the plate should be filled with vegetables, one-quarter with carbs (preferably whole grain), and the other quarter with proteins. Patients can then also have a serving of fruit or dairy products along with a small allocation of healthy fats. 

The hand method is a way to standardize the plate method to account for different sizes of plates, bowls, or other dishes. Ms. Lau recommends two fists of vegetables, one fist of carbs, a palmful of protein, and a thumb-sized portion of oils for cooking.

She clarified that nutritional therapy is an art as much as a science and that the process often requires incremental progress instead of definitive breakthroughs.

“Remember, any improvement is an improvement for our patients,” she said. “As long as we’re moving the needle in the right direction, they are seeing change.”

Binge-eating disorder and weight stigma

Binge-eating disorder was first recognized as a stand-alone diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, in 2013 and is prevalent among type 2 diabetes patients. According to Research Coordinator Meg Salvia, MS, RDN, CDCES, Boston University, approximately 12%-15% of people with binge-eating disorders have type 2 diabetes.

Common patterns for clinicians to investigate with their patients include skipping meals to compensate for a binge, elevated blood glucose levels without explanation, anomalies in patients’ diabetes logs, and unsustainable habits like eating meals that are too small. 

To address binge-eating disorders, providers should adopt a collaborative approach that aims to reduce the frequency and severity of binge behaviors in the short term while adequately meeting nutritional needs, improving glycemic control, and potentially incorporating care to address mental health. Long-term goals should aim to foster curiosity and experimentation in patients about nutrition and their bodies, build trust, and provide supportive counseling and education.

Ms. Salvia also talked at a higher level about weight stigma, a pervasive form of social stigma based on the typically unproven assumption that body weight is derived primarily from a lack of self-discipline and responsibility.

Weight stigma and weight discrimination can lead to serious physical and mental health effects, including social isolation, depression, anxiety, low self-esteem, unhealthy eating, and weight-control behaviors. Especially concerning for providers, patients who experience weight stigma also report less health care education, poorer treatment outcomes, changes in self-care behavior, and even health care avoidance.

She said the diabetes community has done commendable work in adopting person-focused care and person-first language models. She also recommended the integration of strengths-based and harm-reduction language to bolster patients’ comfort. A wider lens to solve weight stigma and discrimination may also be necessary to account for social and environmental determinants of health. Ms. Salvia stressed that sensitivity is vital during patient interactions.

“Stigma, shame, and blame aren’t super motivating,” she said.