Diabetes UK has published its guidelines for 2018. Diabetes UK is a registered charity in the United Kingdom made up of 300,000 supporters, 5,000 volunteers and 6,000 healthcare professionals. They are a terrific resource for those diagnosed with all types of diabetes and provide information and support for these people.
Diabetes UK also assist healthcare professionals by providing many patient resources and best practice guidelines. They have now released their 2018 version of the guidelines titled evidence based nutrition guidelines for the prevention and management of diabetes. This draws upon the latest research and helps us to advise patients using tried and tested approaches.
1. Models of education
Whether type 1 or type 2 (type 3’s are usually treated as type 1), you are entitled to some form of group education. This is a cost effective method of care and allows patients to learn from one another as well as their healthcare professional.
If you have not had some form of group education I would recommend speaking with your GP regarding a referral for this.
Attending structured education shows an improvement in HbA1c of 8mmol/mol in type 1 diabetes and between 5-21mmol/mol in type 2 diabetes. If you don’t know what HbA1c is, I have written many times on this topic and you can find it here. For now, know this, these improvements are worth it, especially if more towards an improvement of 21mmol/mol. Group education has also been shown to be favourable in reducing other health risks and improve patients ability to cope with the condition.
2. Prevention of type 2 diabetes
You can reduce your risk of developing type 2 diabetes by 50% with lifestyle interventions i.e. diet and exercise. This can be achieved with as little as 5% weight loss. So for a 70kg individual this means a loss of only a 3.5kg weight loss (approx half a stone).
A loss of 10% weight loss can reduce your risk of developing type 2 diabetes by up to 80%. So about a stone in a 70kg person.
To achieve this they recommend reducing fat intake, increasing dietary fibre intake (wholegrain, fruit and vegetables) and increase physical activity. As a result, you reduce your calorie intake and/or increase your calorie expenditure.
Essentially, basing your diet around fruit, vegetables, wholegrain, fibre, good fats like fish oils and limiting saturated fat and sugar, should translate into positive outcomes.
If you’re reading this, it might be too late to prevent type 2 diabetes but embracing such recommendations will definitely help your condition. It may also be useful information for friends and family or those who are on the borderline of diabetes.
3. Weight management and remission of type 2 diabetes
90% of those with type 2 diabetes are overweight. Therefore, priority number one in most people with type 2 diabetes should be weight loss. Those who develop type 2 diabetes and are not overweight tend be more on the elderly side and are less likely to see long term complications. Obviously some individuals unfortunately just have a genetic predisposition for the disease in which case lifestyle approaches can still help and are outlined below.
Okay, back to weight loss. Generally speaking there is no major differences between the type of diet you follow to achieve this. High protein, low fat, high mono-unsaturated fat and low carbohydrate have all produced similar results.
Low carbohydrate diets have been shown to be safe and effective for weight loss in the short term (under 6 months) but long term effects are unknown. From experience, adherence to the diet can also be an issue. The less carbohydrate you have in the diet the harder it becomes to follow. Therefore, if choosing such a diet, I’d recommend aiming for around 100-150g of carbohydrate per day as this allows some flexibility.
The Mediterranean diet is also an approach which looks to be successful. This diet is based around wholegrains, fruit, vegetables, beans, pulses, lentils, good fats such as olive oil and oily fish and limits processed foods and sugar.
Ultimately, the most important factor with any weight loss is how well you can stick with the plan.
Very low calorie diets and total diet replacement
There is emerging evidence that when food is replaced by nutritionally complete fluids providing 800-1200kcal per day over 3 months can be effective in weight loss in type 2 diabetes.
A new study found 46% of people who did this followed by a food reintroduction phase managed to push their diabetes into remission if diagnosed within the previous 6 years.
The evidence shows us that total diet replacement plans induce more weight loss over the first 6 months. However, the long term application of such diets are usually unsustainable and often a more sustainable approach is more effective in the long term.
You need to exercise for at least 60 minutes per day in order to lose weight. This recommendation was based upon people who were already overweight or obese and so can only be applied to these people. High intensity exercise lead to greater weight loss than moderate and light intensity. This was without any changes to diet.
However, when exercise intensity was compared alongside dietary changes, there were no significant differences between intensity and weight loss. What we can take from this then, is if you have no intention of changing your diet, exercising outside your comfort zone is more effect for weight loss. If modifying your diet alongside exercise, the important thing is to keep active regardless of intensity.
From personal experience, as your exercise intensity increases your time spent exercising can come down and vice versa.
All types of exercise had positive effects on the participants health and blood glucose levels. One of the key messages from Diabetes UK was for patients to avoid being sedentary.
4. Glycaemic control and type 1 diabetes
The main consideration in type 1 diabetes is matching insulin to your carbohydrate intake – known as carbohydrate counting.
No evidence has yet demonstrated any additional benefits for people with type 1 diabetes following low carbohydrate or low glycaemic index diets.
People with type 1 diabetes should still endeavour to follow a healthy lifestyle.
A personal comment on this recommendation is my experience is those who eat healthy and are organised have the best glucose control. Those who demonstrate poor dietary habits and lack routine tend to have erratic glucose control. Sometimes, looking at your lifestyle before your insulin therapy is a good starting point to reduce glucose levels.
5. Glycaemic control and type 2 diabetes
Like above, weight management is the primary treatment option with type 2 diabetes. Therefore, people should aim for a minimum of 5% weight loss of their total body weight. They should aim for a balanced diet following the Mediterranean diet or similar. This means basing your diet around wholegrains, vegetables, fruit, healthy fats like nuts, seeds and fish and lean sources of protein.
This needs to be sustainable and kept off for the long term. Therefore, choosing a dietary approach which you can stick to is the best approach.
They should also aim for a minimum 150 minutes of moderate intensity physical activity per week.
6. Cardiovascular Disease
With diabetes your risk of developing cardiovascular disease is increased twofold. This is because higher than normal glucose levels can damage the blood vessels.
Therefore, advice around reducing the effects or risk of cardiovascular disease can be as important as the diabetes itself.
There are two main dietary strategies for reducing the complications of cardiovascular disease. The Dietary Approaches to Stop Hypertension diet (The DASH diet) revolves around eating plenty of fruit and vegetables, limiting salt intake, choosing wholegrain courses of carbohydrate, reducing saturated fat, sugar and limiting alcohol.
The second approach is the Mediterranean style diet as mentioned above. Both are similar in principle.
Diabetes UK recommend following either/a combination of both the DASH diet or the Mediterranean style diet.
More specifically they recommend limiting your salt intake to <6g of salt per day (1tsp added salt).
Eating two portions of oily fish per week.
Eat plenty of vegetables, wholegrains, beans, pulses (legumes), nuts and fruit.
Try to limit the amount of processed meat, refined sugar and trans fats (artificial fats) you eat.
Limit your alcohol intake to <14 units per week.
You should try to meet the minimum physical activity activity guidelines of 150 minutes per week of moderate intensity activity.
Aim for a minimum of 5% weight loss.
You can also try 2g of plant sterols or stanols to help lower your cholesterol levels.
Preventing Gestational Diabetes
Developing gestational diabetes can change the enjoyment of pregnancy as well as the birth plan. Therefore, preventing gestational diabetes is something worth thinking about if you are high risk.
The main risk factors for developing gestational diabetes are if you are >35years old, overweight, have a family history of diabetes or you gain excessive weight gain in pregnancy.
Once again increasing physical activity and making dietary changes can help to reduce this risk. If you are overweight, losing weight prior to conception can also help reduce your risk.
Managing Gestational Diabetes
No good evidence exists for the best dietary approach. However, the recommendations are similar to all other types of diabetes. Choose lower glycaemic index carbohydrates and watch your total carbohydrate intake. Increase your fibre intake if low when starting (5 portions fruit and vegetables per day). Meet the recommendations for 150 minutes of physical activity per week as a minimum. Avoid excessive weight gain in pregnancy. Reduce the amount of processed foods in your diet with particular emphasis on high sugar foods.
The main recommendation from Diabetes Uk is to work alongside your dietitian to help optimise your glucose levels. They can work with you to help individualise the advice to your specific circumstances.
Micronutrients, food supplements and functional foods
There is some interesting links between certain micronutrients and diabetes. The problem is no concrete evidence exists that addresses these questions in sufficient detail.
People with type 2 diabetes have been shown to have lower levels of several B vitamins and vitamins C, D and E. This is likely due to the fact type 2 diabetes is usually bought about because of poor lifestyle or dietary choices and therefore such diets can lack nutrients. However, this cause is not confirmed and is my own opinion.
Less is known about people with type 1 diabetes but low levels of vitamin D have been reported.
Some evidence does exist demonstrating an association between lower levels of vitamin D and an increased risk of type 2 diabetes. Furthermore, higher intakes of vitamin D did show a lower incidence of type 2 diabetes.
These studies were far from conclusive and did not use the most robust study design. It is interesting though and perhaps in future we will have further recommendations regarding supplementation and diet.
Studies have focused on several minerals and their association with type 2 diabetes. Zinc, magnesium, chromium, copper, manganese and selenium have been looked at. Results at this stage are inconsistent.
There is some evidence those with type 2 diabetes have lower levels of zinc and supplementation can help this. It has been shown higher intakes of dietary magnesium lower the number of type 2 diabetes cases. Supplementation of magnesium has also shown to improve glycaemic control and reduce the risk of cardiovascular risk in those diagnosed with diabetes.
Other recent studies also suggest a positive effect of chromium picolinate supplementation on glycaemic control.
No formal recommendations are yet made to offer these routinely to patients due to a lack of evidence.
No food supplements have shown to improve diabetes control. This is despite several available products claiming to have this effect.
Formal products labelled as diabetic foods have not been recommended for over 30 years and this has not changed. Labelling food as diabetic implies a health benefit but none has been proven. Such products tend to be high in calories and stimulate a laxative effect.
Non Nutritive sweeteners such as acesulfame – K, aspartame, cyclamate, saccharine, stevia and sucralose are preferred in place of sugar. However, like everything, these should be taken in moderation.
The paper also advises on several specialist topics which I have decided not to go into today. Conditions such as cystic fibrosis, coeliac disease, pregnancy, diabetic ketoacidosis etc require specialist input. If you have any of these diseases you will hopefully be seeing a local specialist and therefore I feel writing about these may do the specialists an injustice.