Part 2 of 2

After 20 years of impressive clinical results, the Center for Medicare and Medicaid Services (CMS) has determined that the Diabetes Prevention Program (DPP) has yielded sufficient data to support reimbursement from Medicare for healthcare providers who deliver DPP to patients who are at risk of developing diabetes. The DPP will now consist of “16 sessions delivered by lifestyle coaches approximately weekly followed by six sessions delivered approximately monthly that promote healthy lifestyle changes and weight loss.” The memorandum from the CMS Office of the Actuary adds: “maintenance sessions would be offered after the first year of the program to aid participants in maintaining their healthy lifestyle and weight loss.”

The evidence supporting the DPP is very strong, and is especially noteworthy when an intensive lifestyle intervention is compared to the commonly used diabetes drug metformin. In a clinical trial published in the New England Journal of Medicine, the incidence of diabetes was 39 percent lower in the lifestyle-intervention group than in the metformin group, and only 14.4 percent of the participants in the lifestyle intervention group developed diabetes within three years, compared to 28.9 percent of the participants in the placebo group and 21.7 percent of the participants in the metformin group. The incidence of diabetes in the three groups is illustrated in Figure 2, from the New England Journal of Medicine paper.

DPP2_table

While meal replacements and nutrition bars are sometimes controversial among nutrition scientists and experts in weight loss and healthy lifestyle, a paper based on data from the National Weight Control Registry published in Diabetes Spectrum in 2013 found that meal replacement shakes and nutrition bars “have grown in popularity and variety … and have proven to be a viable option to support weight loss.” Meal replacements provide a pre-measured amount of nutrients that are listed on an ingredient label to enable easier nutrient tracking, are easy to transport and prepare, and reduce the need to plan and prepare meals, especially when individuals are on the go. Since under-reporting caloric intake is a common difficulty among obese patients when they begin tracking meals, meal replacements eliminate the guesswork involved in keeping a food diary.

The study also found that replacing two meals with meal replacements and replacing snacks with nutrition bars led to greater weight loss than consuming conventional foods. Indeed, at three months, the meal replacement group had lost 7.8 percent of their initial body weight while the conventional foods group had lost 1.5 percent of their initial body weight. For the next four years, both groups used one meal replacement per day and one nutrition bar snack per day. At four years of follow up, the meal replacement group had lost and maintained an average of 8.4 percent of their initial body weight, while the conventional foods group had lost and maintained an average of 3.2 percent of their initial body weight. The paper also provides tips on counseling patients on using meal replacements and on selecting meal replacement shakes and nutrition bars (see below, Meal Plans).

Beyond the clinical trials and meta-analyses referenced in the Diabetes Spectrum publication, many DPP-style programs advocate the use of meal replacements, especially to get participants on track to practice healthy eating behaviors. In particular, the PENN POWER-UP Program managed by the Perelman School of Medicine at the University of Pennsylvania starts participants off for four months with meal replacements for lunch and dinner and one nutrition bar for a snack.

The Joslin Diabetes Center’s Nutrition Guidelines also indicate that meal replacements can be used to initiate and maintain weight loss and should be used under the supervision of a Registered Dietitian. The Joslin guidelines draw particular attention to the optimal macronutrient ratios in the diet, encouraging everyone (particularly people who are at risk of developing diabetes) to adopt a dietary pattern with 40 percent of calories from carbohydrates, 30 percent of calories from fats, and 30 percent of calories from protein. Adopting a dietary pattern with these macronutrient ratios can be challenging, and meal replacements or medical foods formulated with this macronutrient ratio can be helpful for initiating major changes to eating and lifestyle behaviors.

A key element of the DPP is the collaboration between the supervising healthcare provider and the lifestyle educator who implements the program with patients. Healthcare providers and lifestyle educators also play an important role in guiding patients to appropriate meal planning so they may achieve their best results for weight loss and diabetes prevention. We have formulated meal plans of 1200, 1500, and 1800 calories per day that follow the Joslin Diabetes Center Guidelines macronutrient ratio of 40:30:30 and include meal replacements (nutritional beverages) in the MHICN meal plans. We encourage you to start with these meal plans for patients who are at elevated risk for developing diabetes. Continue reading below for additional tips on choosing appropriate meal replacements and working with patients who would like to use meal replacements, adapted from Diabetes Spectrum. Meal Plans PDF

References:

Craig, J. Meal Replacement Shakes and Nutrition Bars: Do They Help Individuals with Diabetes Lose Weight? Diabetes Spectrum. Vol. 26, No. 3. Nov 2013. 179-182. Source: New England Journal of Medicine

Knowler WC, Diabetes Prevention Program Research Group. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. New England Journal of Medicine, Vol. 346, No. 6. Feb 2002. 393-403.

Meal Plan for Diabetes Prevention/Treatment

The current environment of increased calorie intake and decreased physical activity has fueled an obesity epidemic which subsequently increased the prevalence of diabetes.  Several studies have demonstrated the reduction in the development of diabetes with moderate weight loss that is sustained over a long period of time.

Structured, intensive lifestyle programs that include individualized patient education on diet, physical activity and behavior modification have been proven to produce long-term weight loss and chronic disease prevention.  Additionally, use of meal replacements (one or two meals) as part of a structured meal plan can also result in significant weight loss and improvements in blood glucose levels, blood pressure, and blood cholesterol management.

Joslin’s clinical diabetes guidelines are based on evidence to support clinical practice and influence clinical behavior and outcomes.  These guidelines follow the Mediterranean diet practices and recommend a balanced macronutrient ratio of 40% carbohydrates, 30% protein, and 30% fat.   This style of eating pattern mainly focuses on nutrient-dense foods such as fresh, seasonably available fruits, vegetables, whole grains, legumes, nuts, omega-3 fatty acids, and healthy oils such as olive oil.

Healthy Eating Tips on Preventing Diabetes

  1. Choose slow-release, low glycemic index, fiber rich whole grains such as brown or wild rice, whole-grain breads, and cereals.
  2. Eat plenty of fresh fruits and vegetables instead of choosing canned fruits/vegetables that have added sugar and sodium.
  3. Include fiber rich foods such as dried beans, peas, and lentils. (associated with improved insulin sensitivity)
  4. Limit intake of food high in saturated fats: Replace saturated fats with healthier unsaturated fats (mono and polyunsaturated) and not with refined carbohydrates.
  5. Include omega-3 fatty acids in your diet such as salmon, mackerel, halibut, walnuts, chia seeds, flaxseeds, etc.
  6. Drink plenty of water and limit high sugar containing beverages such as fruit juices, sports drinks, sweetened teas, etc.
  7. Read labels carefully and check for added and hidden sugars. Look in the ingredients list for words such as high fructose corn syrup, rice syrup, dextrose, maltose, barley malt, etc and avoid these.

meal plan table

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