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Diabetes
Diabetes is a common health problem which affects around 3-4% of the UK population. More than three-quarters of people with diabetes have type 2 diabetes (non-insulin dependent diabetes) and rely on diet and/or oral agents to control their blood glucose (blood ‘sugar’) levels. The majority of people with type 2 diabetes are overweight. Therefore, weight management is a crucial aspect in the prevention of type 2 diabetes and the management of diabetes in general.
Diabetes occurs when the pancreas - a gland situated behind the stomach - fails to produce enough of the hormone insulin to maintain control of blood glucose. In addition, many individuals are also insulin resistant, in which the body fails to respond adequately to its own insulin. The result is a rise in blood glucose level above the normal level.
There are two main types of diabetes:
Type 1 Diabetes
Develops when most or all of the cells in the pancreas that produce insulin are destroyed. It usually occurs in people under the age of 40, commonly during childhood, and is treated by regular insulin injections and a healthy diet.
Type 2 Diabetes
Develops when the pancreas still produces some insulin, but either in an inadequate amount or if its utilisation is less effective. It generally occurs in people over the age of 40 - occasionally in younger people - and is caused by a combination of factors, one being overweight. Type 2 diabetes can often be treated by a healthy diet alone, or by a combination of diet and medication or, in other cases, by diet and insulin injections.
Lifestyle recommendations for people with diabetes
The aim of nutritional management of diabetes is to optimise blood glucose control and reduce risk factors associated with heart and kidney disease. The diet for people with diabetes is no longer a special one, but merely follows the basic principles of healthy eating, ie a low-fat, high-carbohydrate diet. Research has shown that when people with type 2 diabetes consume higher carbohydrate intakes, the result is an increase in insulin and a reduction in free fatty acids, which could help slow down the progression of the disease.
The old idea that sugar causes diabetes was dismissed as long ago as 1989 by the UK Government’s COMA Committee (DoH 1989) . The FAO/WHO Expert Consultation on Carbohydrates in Human Nutrition reiterated in 1998 that sucrose, and other sugars, do not cause diabetes. The evidence available since these consultations does not merit any revision of that opinion (ADA 2008). Furthermore, despite diabetes being a condition of blood glucose regulation, specific restriction of sugars is not necessary, except to ensure a balanced diet.
Achieving and maintaining a healthy body weight through diet and physical activity is of the utmost importance. Foods high in fat, which might predispose to obesity, are not encouraged, even though they might appear to have an advantage in not raising the level of glucose in the blood rapidly. Overweight individuals with diabetes should be encouraged to reduce their energy intake, by decreasing their dietary fat intake, and increase their physical activity levels, as even a modest weight loss (5-10%) will improve blood glucose control and other metabolic abnormalities associated with the disease. Research has shown that a weight loss of 10kg can reduce the risk from diabetes-related deaths by about a third.
Diet composition
The most recent set of nutrition guidelines, from the American Diabetes Association (ADA), utilises all the latest research to provide a comprehensive, evidence-based set of recommendations (ADA 2008). The key dietary focus is to restrict the intake of saturated and polyunsaturated fats. Saturated fatty acids should provide less than 10% of total energy intake - some individuals may benefit from an even lower intake of around 7%. Polyunsaturated fatty acids should also not exceed 10% of total daily energy intake. Dietary cholesterol intake should not exceed 300 mg per day - some individuals may benefit from an even lower intake of 200 mg per day.
Protein intake should not exceed recommended levels (10-20% of total energy). People with Type 1 diabetes, particularly those with high blood pressure, should ensure dietary protein does not exceed 20% of total energy due to the increased risk of kidney disease in these individuals.
The remaining 60-70% of total daily energy intake should come from a combination of carbohydrates and monounsaturated fats, with the proportions being dependant on individual clinical circumstances. The current emphasis is more on the total energy intake rather than a fixed recommendation for the amount of calories from fat and carbohydrate.
The latest recommendations from the ADA puts a greater emphasis on the total amount of carbohydrate from meals and snacks rather than the source or type. A consistent intake of carbohydrates is recommended for individuals on fixed daily insulin regimens. Foods containing carbohydrate from whole grains, fruits and vegetables are recommended, as they form an important component of a healthy balanced diet. Dietary fibre should also be encouraged, but is no longer felt to be of particular importance for people with diabetes other than the beneficial effect it may have on gut health and satiety (feeling of fullness).
One of the prominent changes of the recent guidelines from Europe and the USA is the relaxation on dietary restriction of sugar and high-sugar content foods, providing blood glucose levels are kept in control. This is because sucrose (table sugar) does not increase blood glucose to a greater extent than similar amounts of starchy foods like bread, potatoes or rice. Fructose, sugar alcohols and other nutritive sweeteners, which are all energy sources, do not have substantial advantages over sucrose for people with diabetes and so should not be encouraged. However, non-nutritive sweeteners can be safely consumed within the recommended acceptable daily intake levels.
Physical activity and diabetes
People with diabetes should aim to participate in moderate-intensity physical activity for at least 20-30 minutes on most, and preferably all, days of the week. In addition, regular exercise is associated with a reduced risk of developing Type 2 diabetes, even in individuals who are overweight. Physical activity has been shown to improve insulin sensitivity, to acutely lower blood glucose, to favourably influence blood fat profiles, and to help weight control.
Key References
- American Diabetes Association. 2008. Nutrition recommendations and interventions for diabetes: a position statement of the ADA. Diabetes Care, 31suppl, pp61-78.
- Black RN et al 2006. Effect of eucaloric high and low-sucrose diets with identical macronutrient profile on insulin resistance and vascular risk: a randomised controlled trial. Diabetes; 55: 3566-3572.
- Department of Health. 1989. Dietary Sugars and Human Disease. Committee on Medical Aspects of Food Policy. Report on Health and Social Subjects No 37. HMSO, London.
- Diabetes and Nutrition Study Group of the EASD. 2000. Recommendations for the nutritional management of patients with diabetes mellitus. European Journal of Clinical Nutrition, 54, pp353-355.
- Diabetes Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD). 2004. Evidence-based nutritional approaches to the treatment and prevention of diabetes mellitus. Nutrition, Metabolism and Cardiovascular Disease, 14(6), pp373-94.
- Food and Agriculture Organisation of the United Nations & World Health Organisation. 1998. Carbohydrates in Human Nutrition. Report of a Joint FAO/WHO Expert Consultation. FAO Food & Nutrition Paper 66.
- Franz M.J. et al. 2002. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care, 25(1), pp148-199.
- Knowler W.C., Hamman R.F., Lachin J.M., Walker E.A. et al. 2002. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346, pp393-403.
- Lindstrom J., Louheranta A., Mannelin M., Rastas M., Salminen V., Eriksson J. 2003. The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care, 26, pp3230-3236.
- Moy et al. 1993. Insulin-dependent diabetes mellitus, physical activity, and death. American Journal of Epidemiology, 137, pp74-81.
- Myers J., Prakash M., Froelicher V., Do D., Parrington S. and Atwood J.E. 2002. Exercise capacity and mortality among men referred for exercise testing. New England Journal of Medicine, 346(11), pp793-801.
- Roman et al. 2008. Impact of 3-year lifestyle intervention on post-prandial glucose metabolism: the SLIM Study. Diabetic Medicine, DOI:10.1111/j.1464-5491.2008.02417x
- Tsilhlias E.B., Gibbs A.L., McBurney M.I. and Wolever T.M.S. 2000. Comparison of high- and low-glycemic-index breakfast cereals with monounsaturated fat in the long-term dietary management of type 2 diabetes. American Journal of Clinical Nutrition, 72(2), pp439-449.
- Tuomilehto et al. 2001. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine, 344, pp1343-1350.
- Wei et al. 1999. The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in men. Annals of Internal Medicine, 130, pp89-96.
