Type 2 diabetes (T2DM) is a growing health issue globally, which, until recently, was considered to be both chronic and progressive. Although having lifestyle and dietary changes as core components, treatments have focused on optimising glycaemic control using pharmaceutical agents. With data from bariatric surgery and, more recently, total diet replacement (TDR) studies that have set out to achieve remission, remission of T2DM has emerged as a treatment goal. A group of specialist dietitians and medical practitioners was convened, supported by the British Dietetic Association and Diabetes UK, to discuss dietary approaches to T2DM and consequently undertook a review of the available clinical trial and practice audit data regarding dietary approaches to remission of T2DM. Current available evidence suggests that a range of dietary approaches, including low energy diets (mostly using TDR) and low carbohydrate diets, can be used to support the achievement of euglycaemia and potentially remission. The most significant predictor of remission is weight loss and, although euglycaemia may occur on a low carbohydrate diet without weight loss, which does not meet some definitions of remission, it may rather constitute a ‘state of mitigation’ of T2DM. This technical point may not be considered as important for people living with T2DM, aside from that it may only last as long as the carbohydrate restriction is maintained. The possibility of actively treating T2DM along with the possibility of achieving remission should be discussed by healthcare professionals with people living with T2DM, along with a range of different dietary approaches that can help to achieve this.
The role of carbohydrate in the diet of people living with diabetes is an area of much debate. This relates to both type and quantity of carbohydrate consumed, with low carbohydrate diets increasing in popularity. However, it is important to take a whole diet approach and not just in terms of single nutrients. This review considers what carbohydrates are and how recommendations for people with diabetes might differ from those for the general population. There are no obligate requirements for dietary carbohydrate. UK recommendations suggest 50% of total energy should come from carbohydrate for the general population; however, evidence does not support an optimal carbohydrate intake for people living with diabetes. Equally, there is no evidence to support a change in other macronutrient intakes including fat; thereby challenging the perspective of low carbohydrate diet advocates, which may encourage higher saturated fat intakes. Carbohydrate quality is important in terms of glycaemic index and fibre, and may have other health benefits; however, the quantity of carbohydrate is a more important predictor of glycaemic response. People with type 1 diabetes can improve the accuracy of insulin dosing with carbohydrate counting and technology may also have a role to play in this, with the introduction of bolus advisor meters. There is no universal recommendation for the amount of carbohydrate for people living with diabetes. Recommendations should therefore be based on personal preference, individual glycaemic response and other health targets, ideally with the support of a registered dietitian specialising in diabetes. Copyright © 2016 John Wiley & Sons.
It is recommended that a structured group education programme such as DAFNE (Dose Adjustment For Normal Eating) is offered to all adults with type 1 diabetes. Such programmes teach the skills of carbohydrate counting and insulin dose adjustment with the aim of improving glycaemic control (HbA1c) without increasing the risk of hypoglycaemia. South West Essex Community Services adult diabetes service was finding that individuals were not accessing the DAFNE programme for various reasons. A diabetes specialist dietitian and nurse decided to pilot the delivery of two 3‐hour group sessions to teach some of the basic carbohydrate counting and insulin dose adjustment skills. Changes in HbA1c pre‐ and post‐intervention were reported for 68 subjects. The four different intervention arms compared were: those who attended just the carbohydrate counting session (n=14), those who attended both sessions (n=24), those who had attended one or both sessions and then went on to attend DAFNE (n=10), and those who had received no carbohydrate counting education (n=20). Those who had attended one or both of the 3‐hour sessions had a mean and absolute reduction in HbA1c compared with the group that had not received any education, although this was not statistically significant. The group that had attended one or both of the 3‐hour sessions and DAFNE did achieve a statistically significant reduction in HbA1c compared with the group that had not received any education. Despite several identified limitations to the pilot, it was felt that the delivery of the two 3‐hour carbohydrate counting and insulin dose adjustment sessions demonstrated some clinically (if not statistically) significant improvement in HbA1c. Copyright © 2013 John Wiley & Sons.
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