EAL

Recommendations Summary

PDM: Assessment in High-Risk Groups 2014

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

Recommendation(s)
PDM: Assessment in High-Risk Groups
- The registered dietitian nutritionist (RDN) should assess the following, but not limited to, for individuals who are at high risk for type 2 diabetes:
  - Glycemia (fasting blood glucose, two-hour post-prandial blood glucose and A1C)
  - Anthropometrics (weight, BMI, waist circumference, waist-to-hip ratio)
  - CVD risk factors (lipid profile and blood pressure)
  - Physical activity
  - Medications and supplements
  - Dietary factors
  - History of depression
  - Obesigenic/diabetogenic environment
  - Socio-economic status (SES).
- These factors allow the RDN to determine the appropriate interventions to prevent type 2 diabetes.
Rating: Consensus
Imperative
- Risks/Harms of Implementing This Recommendation
  None.
- Conditions of Application
  Data on these factors may not be available.
- Potential Costs Associated with Application
  The costs of medical nutrition therapy (MNT).
- Recommendation Narrative
  From Prevention/Delay of Type 2 Diabetes Recommendations from the American Diabetes Association Standards of Medical Care, 2014
  - Patients with IGT (A), IFG (E), or an A1C of 5.7% to 6.4% (E) should be referred to an effective ongoing support program targeting weight loss of 7% of body weight and increasing physical activity to at least 150 minutes per week of moderate activity such as walking
  - Follow-up counseling appears to be important for success (B)
  - Based on the cost-effectiveness of diabetes prevention, such programs should be covered by third-party payers (B)
  - Metformin therapy for prevention of type 2 diabetes may be considered in those with IGT (A), IFG (E), or an A1C of 5.7% to 6.4% (E), especially for those with BMI more than 35kg/m², aged less than 60 years and women with prior GDM (A)
  - At least annual monitoring for the development of diabetes in those with prediabetes is suggested (E)
  - Screening for and treatment of modifiable risk factors for CVD is suggested. (B)
  From Project IMAGE European Evidence-Based Guideline for the Prevention of Type 2 Diabetes, 2010
  - Overweight and obesity:
    
    Reversal of obesity also decreases the risk for T2D (A) and improves glycemic control in patients with established diabetes (A)
    
    A strong curvilinear relationship between BMI and the risk for T2DM was found in women in the Nurses' Health Study (B)
    
    However, studies trying to discern the relative importance of waist circumference (or waist-to-hip ratio) compared to BMI regarding risk for T2D development have not shown a major advantage of one over the other. (A)
  - Physical inactivity: The benefit of physical activity in preventing diabetes has been demonstrated in several studies (A)
  - Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT):
    
    The prevalence of IFG and IGT varies considerably among different ethnic groups and increases with age (B)
    
    The reported estimates of diabetes development in IFG and IGT individuals vary widely, depending on the ethnicity of the population studied, with a higher incidence of T2D noted in non-Caucasian populations (B)
    
    Two recent meta-analyses found no evidence of a difference in T2D risk among people with either IGT, IFG, i-IGT or i-IFG, but both concluded that individuals with IFG + IGT have a substantially increased risk of T2D compared to all other groups (B)
    
    However, studies of shorter duration have shown that during a period of three to five years about 25% of individuals progress to diabetes, 25% return to a normal glucose tolerance status and 50% remain in the prediabetic state. (B)
  - Dietary factors, such as low fiber intake, low unsaturated:saturated fat ratio and other nutrients:
    
    It has been shown that a dietary pattern promoting weight loss reduces the risk of T2D (A)
    
    Individuals with low intake of dietary fiber, particularly of insoluble cereal fiber, have been found to be at increased risk for T2D in several epidemiologic studies (B)
    
    Nevertheless, a recent meta-analysis of 37 prospective cohort studies showed, in fully adjusted models, that both high glycemic load and high glycemic index diets are associated with increased risk for T2D (B)
    
    Shifting from a diet based on animal fat to a diet rich in vegetable fat might reduce the risk for T2D (B)
    
    An increased intake of monounsaturated fat appears to be of particular benefit (C)
    
    The consumption of trans fatty acids has consistently been found to be associated with increased risk for T2D and CVD (A)
    
    A less consistent but still significant body of evidence suggests that the risk for T2D is lowered by regular consumption of moderate amounts of alcohol (B), fruits and vegetables (B), nuts (B) and coffee (B).
  - Depression: Depression has been considered as a risk factor for T2D and its complications and an increased risk for developing T2D in adults with depression has been demonstrated in a meta-analysis of nine longitudinal studies (B)
  - Obesigenic/diabetogenic environment: The recent increase in T2D seems to be strongly linked to unfavorable changes in the environment (B)
  - Low socio-economic status (SES):
    
    There is also an inverse association between SES and T2D, with a higher prevalence among less-advantaged groups. This appears to be consistent across several developed countries and across different ethnic groups. (B)
    
    An inverse graded association between diabetes prevalence, metabolic disorders and different measures of SES such as education, occupation, income, poverty income ratio and measures of material deprivation and poverty has been found (B).
- Recommendation Strength Rationale
  From Prevention/Delay of Type 2 Diabetes Recommendations from the American Diabetes Association Standards of Medical Care, 2014
  - The Academy of Nutrition and Dietetics Prevention of Type 2 Diabetes Work Group concurs with the references cited
  - Evidence in support of the recommendation was grades A, B and E.
  From Project IMAGE European Evidence-Based Guideline for the Prevention of Type 2 Diabetes, 2010
  - The Academy of Nutrition and Dietetics Prevention of Type 2 Diabetes Work Group concurs with the references cited
  - Evidence in support of the recommendation was grades A, B and C.
- Minority Opinions
  Consensus reached.

Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
- References
- References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
  American Diabetes Association. Standards of medical care in diabetes: 2014. Diabetes Care. 2014; 37 Suppl 1: S14-S80.
  
  Lindström J, Neumann A, Sheppard KE, Gilis-Januszewska A, Greaves CJ, Handke U, Pajunen P, Puhl S, Pölönen A, Rissanen A, Roden M, Stemper T, Telle-Hjellset V, Tuomilehto J, Velickiene D, Schwarz PE, Acosta T, Adler M, AlKerwi A, Barengo N, Barengo R, Boavida JM, Charlesworth K, Christov V, Claussen B, Cos X, Cosson E, Deceukelier S, Dimitrijevic-Sreckovic V, Djordjevic P, Evans P, Felton AM, Fischer M, Gabriel-Sanchez R, Gilis-Januszewska A, Goldfracht M, Gomez JL, Greaves CJ, Hall M, Handke U, Hauner H, Herbst J, Hermanns N, Herrebrugh L, Huber C, Hühmer U, Huttunen J, Jotic A, Kamenov Z, Karadeniz S, Katsilambros N, Khalangot M, Kissimova-Skarbek K, Köhler D, Kopp V, Kronsbein P, Kulzer B, Kyne-Grzebalski D, Lalic K, Lalic N, Landgraf R, Lee-Barkey YH, Liatis S, Lindström J, Makrilakis K, McIntosh C, McKee M, Mesquita AC, Misina D, Muylle F, Neumann A, Paiva AC, Pajunen P, Paulweber B, Peltonen M, Perrenoud L, Pfeiffer A, Pölönen A, Puhl S, Raposo F, Reinehr T, Rissanen A, Robinson C, Roden M, Rothe U, Saaristo T, Scholl J, Schwarz PE, Sheppard KE, Spiers S, Stemper T, Stratmann B, Szendroedi J, Szybinski Z, Tankova T, Telle-Hjellset V, Terry G, Tolks D, Toti F, Tuomilehto J, Undeutsch A, Valadas C, Valensi P, Velickiene D, Vermunt P, Weiss R, Wens J, Yilmaz T. Take action to prevent diabetes: The IMAGE toolkit for the prevention of type 2 diabetes in Europe. Horm Metab Res. 2010 Apr; 42 Suppl 1: S37-S55.
  
  Pajunen P, Landgraf R, Muylle F, Neumann A, Lindström J, Schwarz PE, Peltonen M, Acosta T, Adler M, AlKerwi A, Barengo N, Barengo R, Boavida JM, Charlesworth K, Christov V, Claussen B, Cos X, Cosson E, Deceukelier S, Dimitrijevic-Sreckovic V, Djordjevic P, Evans P, Felton AM, Fischer M, Gabriel-Sanchez R, Gilis-Januszewska A, Goldfracht M, Gomez JL, Greaves CJ, Hall M, Handke U, Hauner H, Herbst J, Hermanns N, Herrebrugh L, Huber C, Hühmer U, Huttunen J, Jotic A, Kamenov Z, Karadeniz S, Katsilambros N, Khalangot M, Kissimova-Skarbek K, Köhler D, Kopp V, Kronsbein P, Kulzer B, Kyne-Grzebalski D, Lalic K, Lalic N, Landgraf R, Lee-Barkey YH, Liatis S, Lindström J, Makrilakis K, McIntosh C, McKee M, Mesquita AC, Misina D, Muylle F, Neumann A, Paiva AC, Pajunen P, Paulweber B, Peltonen M, Perrenoud L, Pfeiffer A, Pölönen A, Puhl S, Raposo F, Reinehr T, Rissanen A, Robinson C, Roden M, Rothe U, Saaristo T, Scholl J, Schwarz PE, Sheppard KE, Spiers S, Stemper T, Stratmann B, Szendroedi J, Szybinski Z, Tankova T, Telle-Hjellset V, Terry G, Tolks D, Toti F, Tuomilehto J, Undeutsch A, Valadas C, Valensi P, Velickiene D, Vermunt P, Weiss R, Wens J, Yilmaz T. Quality indicators for the prevention of type 2 diabetes in Europe: IMAGE. Horm Metab Res. 2010 Apr; 42 Suppl 1: S56-S63.
  
  Paulweber B, Valensi P, Lindström J, Lalic NM, Greaves CJ, McKee M, Kissimova-Skarbek K, Liatis S, Cosson E, Szendroedi J, Sheppard KE, Charlesworth K, Felton AM, Hall M, Rissannen A, Tuomilehto J, Schwarz PE, Roden M, for the Writing Group: Paulweber M, Stadlmayr A, Kedenko L, Katsilambros N, Makrilakis K, Kamenov Z, Evans P, Gilis-Januszewska A, Lalic K, Jotic A, Djordevic P, Dimitrijevic-Sreckovic V, Hühmer U, Kulzer B, Puhl S, Lee-Barkey YH, AlKerwi A, Abraham C, Hardeman W, on behalf of the IMAGE Study Group: Acosta T, Adler M, AlKerwi A, Barengo N, Barengo R, Boavida JM, Charlesworth K, Christov V, Claussen B, Cos X, Cosson E, Deceukelier S, Dimitrijevic-Sreckovic V, Djordjevic P, Evans P, Felton AM, Fischer M, Gabriel-Sanchez R, Gilis-Januszewska A, Goldfracht M, Gomez JL, Greaves CJ, Hall M, Handke U, Hauner H, Herbst J, Hermanns N, Herrebrugh L, Huber C, Hühmer U, Huttunen J, Jotic A, Kamenov Z, Karadeniz S, Katsilambros N, Khalangot M, Kissimova-Skarbek K, Köhler D, Kopp V, Kronsbein P, Kulzer B, Kyne-Grzebalski D, Lalic K, Lalic N, Landgraf R, Lee-Barkey YH, Liatis S, Lindström J, Makrilakis K, McIntosh C, McKee M, Mesquita AC, Misina D, Muylle F, Neumann A, Paiva AC, Pajunen P, Paulweber B, Peltonen B, Perrenoud L, Pfeiffer A, Pölönen A, Puhl S, Raposo F, Reinehr T, Rissanen A, Robinson C, Roden M, Rothe U, Saaristo T, Scholl J, Schwarz PE, Sheppard KE, Spiers S, Stemper T, Stratmann B, Szendroedi J, Szybinski Z, Tankova T, Telle-Hjellset V, Terry G, Tolks D, Toti F, Tuomilehto J, Undeutsch A, Valadas C, Valensi P, Velickiene D, Vermunt P, Weiss R, Wens J, Yilmaz T. A European evidence-based guideline for the prevention of type 2 diabetes. Horm Metab Res. 2010 Apr; 42 Suppl 1: S3-S36.