The implementation of nutritional advice for people with diabetes

Comparable postprandial glucose reductions with viscous fiber blend enriched biscuits in healthy subjects and patients with diabetes mellitus: acute randomized controlled clinical trial

AIM

To compare the blood glucose-lowering effect of a highly viscous fiber blend (VFB) added to a starchy snack on postprandial glycemia between healthy participants and participants with diabetes mellitus.

METHODS

Ten healthy participants (4 men and 6 women, aged 28+/-2.6 years, body mass index [BMI], 24.3+/-0.8 kg/m(2)) and 9 participants with diabetes mellitus type 2 (3 men and 6 women, aged 68+/-3.8 years, BMI 28.8+/-1.2 kg/m(2)) on four separate occasions took either 50 g available carbohydrates as control biscuits, biscuits with 10 g of highly viscous fiber blend, white bread with 12 g of margarine, or white bread alone. Postprandial blood glucose response, glycemic index (GI), and palatability were determined.

RESULTS

Mean (95% confidence interval) GI values of the viscous fiber blend biscuits were 26 (16-36) and 37 (27-47) GI units for healthy participants and participants with diabetes mellitus, respectively. These values were significantly lower than those of white bread, white bread with 12 g of margarine, and control biscuits (P<0.001, paired t test) both in healthy participants (GI 100, 108 [57-159], and 101 [44-158], respectively) and participants with diabetes mellitus (GI 100, 103 [79-127], and 94 [78-110], respectively). Viscous fiber blend significantly reduced the glycemic index by 74% (7.4 GI units/g of fiber) in healthy participants and by 63% (6.3 GI units/g of fiber) in participants with diabetes. The GI did not differ between control meals in both healthy participants and participants with diabetes. There were no significant differences in palatability among the types of meals, although participants with diabetes found the viscous fiber blend biscuits more palatable (P=0.002, t test).

CONCLUSION

Viscous fiber blend is a very potent and palatable soluble fiber addition to a starchy snack, which is able to reduce the glycemic response to a similar extent in both healthy participants and individuals with diabetes mellitus. Biscuits with low GI, and possibly other viscous fiber blend fortified starchy foods, may potentially be a useful replacement of high GI snack foods in the diet.

Nutritional considerations for older adults with type 2 diabetes

As Western populations age, the burden of associated chronic diseases, including diabetes, cardiovascular disease (CVD), and cancer will increase dramatically. In the United States in the next 50 years, it is projected that the percentage of adults with type 2 diabetes will exceed 30%, with the vast majority older than 65 years. It is therefore important to determine the best possible dietary and lifestyle modifications to prevent and control this disease and its associated complications. Although few data are available regarding the optimal nutritional regimen for the elderly with type 2 diabetes, as a general rule, the use of nutrient-dense, low glycemic index, high-dietary fiber foods with possibly higher protein intake is recommended.

International tables of glycemic index and glycemic load values: 2008

OBJECTIVE

To systematically tabulate published and unpublished sources of reliable glycemic index (GI) values.

RESEARCH DESIGN AND METHODS

A literature search identified 205 articles published between 1981 and 2007. Unpublished data were also included where the data quality could be verified. The data were separated into two lists: the first representing more precise data derived from testing healthy subjects and the second primarily from individuals with impaired glucose metabolism.

RESULTS

The tables, which are available in the online-only appendix, list the GI of over 2,480 individual food items. Dairy products, legumes, and fruits were found to have a low GI. Breads, breakfast cereals, and rice, including whole grain, were available in both high and low GI versions. The correlation coefficient for 20 staple foods tested in both healthy and diabetic subjects was r = 0.94 (P < 0.001).

CONCLUSIONS

These tables improve the quality and quantity of GI data available for research and clinical practice.

Acting on screening results: a guide to treating malnutrition in the community

Part 1 of this article described the Malnutrition Universal Screening Tool (MUST) and its implementation. Part 2 aims to provide basic practical guidance for treating malnutrition. Establishing the aim of treatment and undertaking a dietary assessment will provide the basis for your intervention. Addressing nutrition-related problems, such as drug induced gastrointestinal disturbances, will improve the efficacy of your treatment. A food-first approach should be adopted, paying attention to meal pattern, snacks, appropriate food choices, and food fortification. Over-the-counter supplements can be useful. Proprietary (prescribable) nutritional supplements or sip feeds should be used if dietary intervention does not sufficiently improve nutritional status. Consideration of patient preferences regarding flavour, style and presentation are necessary for compliance and particular care is required when selecting sip-feeds for patients with diabetes. Regular monitoring is essential and gradual discontinuation of supplements should commence if the aim of treatment is achieved. Assistance from dietetic services should be sought in developing a locally agreed policy for treating malnutrition.

Dietary advice for the prevention of type 2 diabetes mellitus in adults

BACKGROUND

Prevention of type 2 diabetes in adults is a far better option than treatment, to alleviate pressure on health care providers and resources. However, there is no current review of the evidence regarding the efficacy of a diet-only intervention for prevention.

OBJECTIVES

To assess the effects of type and frequency of dietary advice for the prevention of type 2 diabetes mellitus.

SEARCH STRATEGY

We carried out a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, bibliographies and contacted relevant experts.

SELECTION CRITERIA

All randomised controlled trials, of twelve months or longer, in which dietary advice for the prevention of type 2 diabetes was the only intervention in adults.

DATA COLLECTION AND ANALYSIS

The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other four investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. Change data are presented.

MAIN RESULTS

Two trials which randomised 358 people to dietary treatment and control groups were identified. Longest duration of follow-up was six years. In the 6-year Da Qing IGT & Diabetes study, the incidence of type 2 diabetes in the control group was 67.7% (95% confidence interval (CI) 59.8% to 75.2%) which was reduced to 43.8% (95% CI 35.5% to 54.7%) in the diet group. Overall, the dietary intervention group had a 33% reduction in the incidence of diabetes after six years (P < 0.03). The Oslo Diet & Exercise Study (ODES) found significant (P<0.05) reductions in insulin resistance, fasting insulin (pmol/L), fasting C-peptide (pmol/L), fasting proinsulin (pmol/L), fasting blood glucose (mmol/L), BMI (kg/m(2)), mBP (mmHg) and fasting triglycerides (mmol/L), and a significant increase in fasting HDL cholesterol (mmol/L) and PAI-1 (U/ml) after 12 months of dietary intervention. Data on mortality, morbidity, health-related quality of life, adverse effects, costs were not reported in either study.

AUTHORS' CONCLUSIONS

There are no high quality data on the efficacy of dietary intervention for the prevention of type 2 diabetes. More well-designed, long-term studies, providing well-reported, high-quality data are required before proper conclusions can be made into the best dietary advice for the prevention of diabetes mellitus in adults.

State of the Art Reviews: Glycemic Index, Obesity, and Chronic Disease

There is increasing evidence that both the amount and type of carbohydrate play an important role in weight management and risk of chronic disease. Classifying carbohydrates according to their post-prandial glycemic effect (ie, the glycemic index of foods) has yielded more useful insights than the historical distinctions of simple versus complex chemical structure. Diets based on carbohydrate foods that are more slowly digested and absorbed (ie, low glycemic index diets) have been independently linked to reduced risk of type 2 diabetes, cardiovascular disease, and some types of cancer. In individuals with diabetes, intervention studies have shown improvements in insulin sensitivity and glycated hemoglobin concentration with low glycemic index diets. Research also suggests that low glycemic index diets may assist with weight management through effects on satiety and fuel partitioning. Although ongoing research is needed, the current findings, together with the fact that there are no demonstrated negative effects of a low glycemic index diet, suggest that the glycemic index should be an important consideration in the dietary management and prevention of obesity and chronic disease.

Measuring the glycemic index of foods: interlaboratory study

BACKGROUND

Many laboratories offer glycemic index (GI) services.

OBJECTIVE

We assessed the performance of the method used to measure GI.

DESIGN

The GI of cheese-puffs and fruit-leather (centrally provided) was measured in 28 laboratories (n=311 subjects) by using the FAO/WHO method. The laboratories reported the results of their calculations and sent the raw data for recalculation centrally.

RESULTS

Values for the incremental area under the curve (AUC) reported by 54% of the laboratories differed from central calculations. Because of this and other differences in data analysis, 19% of reported food GI values differed by >5 units from those calculated centrally. GI values in individual subjects were unrelated to age, sex, ethnicity, body mass index, or AUC but were negatively related to within-individual variation (P=0.033) expressed as the CV of the AUC for repeated reference food tests (refCV). The between-laboratory GI values (mean+/-SD) for cheese-puffs and fruit-leather were 74.3+/-10.5 and 33.2+/-7.2, respectively. The mean laboratory GI was related to refCV (P=0.003) and the type of restrictions on alcohol consumption before the test (P=0.006, r2=0.509 for model). The within-laboratory SD of GI was related to refCV (P<0.001), the glucose analysis method (P=0.010), whether glucose measures were duplicated (P=0.008), and restrictions on dinner the night before (P=0.013, r2=0.810 for model).

CONCLUSIONS

The between-laboratory SD of the GI values is approximately 9. Standardized data analysis and low within-subject variation (refCV<30%) are required for accuracy. The results suggest that common misconceptions exist about which factors do and do not need to be controlled to improve precision. Controlled studies and cost-benefit analyses are needed to optimize GI methodology. The trial was registered at clinicaltrials.gov as NCT00260858.

Protein restriction for diabetic renal disease

BACKGROUND

Diabetic renal disease (diabetic nephropathy) is a leading cause of end-stage renal failure. Once the process has started, it cannot be reversed by glycaemic control, but progression might be slowed by control of blood pressure and protein restriction.

OBJECTIVES

To assess the effects of dietary protein restriction on the progression of diabetic nephropathy in patients with diabetes.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, ISI Proceedings, Science Citation Index Expanded and bibliographies of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and before and after studies of the effects of a modified or restricted protein diet on diabetic renal function in people with type 1 or type 2 diabetes following diet for at least four months were considered.

DATA COLLECTION AND ANALYSIS

Two reviewers performed data extraction and evaluation of quality independently. Pooling of results was done by means of random-effects model.

MAIN RESULTS

Twelve studies were included, nine RCTs and three before and after studies. Only one study explored all-cause mortality and end-stage renal disease (ESRD) as endpoints. The relative risk (RR) of ESRD or death was 0.23 (95% confidence interval (CI) 0.07 to 0.72) for patients assigned to a low protein diet (LPD). Pooling of the seven RCTs in patients with type 1 diabetes resulted in a non-significant reduction in the decline of glomerular filtration rate (GFR) of 0.1 ml/min/month (95% CI -0.1 to 0.3) in the LPD group. For type 2 diabetes, one trial showed a small insignificant improvement in the rate of decline of GFR in the protein-restricted group and a second found a similar decline in both the intervention and control groups. Actual protein intake in the intervention groups ranged from 0.7 to 1.1 g/kg/day. One study noted malnutrition in the LPD group. We found no data on the effects of LPDs on health-related quality of life and costs.

AUTHORS' CONCLUSIONS

The results show that reducing protein intake appears to slightly slow progression to renal failure but not statistically significantly so. However, questions concerning the level of protein intake and compliance remain. Further longer-term research on large representative groups of patients with both type 1 and type 2 diabetes mellitus is necessary. Because of the variability amongst patients, there might perhaps be a six month therapeutic trial of protein restriction in all individuals, with continuation only in those who responded best. Trials are required of different types of protein.

Predictors of treatment adherence in young children with type 1 diabetes

AIM

This paper reports a study to investigate whether diabetes-specific, demographic and psychosocial variables predict adherence in young children with type 1 diabetes.

BACKGROUND

Paediatric diabetes rates are increasing worldwide; however, young children are neglected in treatment adherence research, despite the importance of adherence for health. Greater understanding of adherence in this group could enhance nurses' ability to provide care tailored to families' needs.

METHOD

A cross-sectional study was carried out between 2001 and 2003 with 65 children aged 2-8 years and their mothers in Britain. Mothers were interviewed about children's diabetes care, nutritional analyses were conducted and mothers completed assessments of diabetes knowledge, parenting stress, family functioning and child psychological adjustment. Demographic and medical information was collected from patient records.

FINDINGS

Consistent with older populations, blood glucose monitoring and dietary regimens showed greater adherence variability than injection frequency and injection time consistency. Better maternal diabetes knowledge correlated with less injection time variability, more frequent blood glucose monitoring, lower percentage energy intake from extrinsic sugars, lower glycosylated haemoglobin levels and fewer relationship difficulties. Longer diabetes duration, greater injection time variability and higher percentage energy intake from extrinsic sugars predicted less frequent blood glucose monitoring. More relationship difficulties and less frequent blood glucose monitoring predicted higher percentage energy intake from extrinsic sugars.

CONCLUSIONS

Nurses can facilitate treatment adherence through provision of educational, practical and socio-emotional support. Nursing interventions should target blood glucose monitoring and dietary regimens in particular, and nurses should be sensitive to the various caretaking challenges presented to parents by different components of the diabetes regimen.

Challenges and strategies: weight management in type 2 diabetes

This article examines the link between obesity and type 2 diabetes and discusses some of the challenges health-care professionals face in helping people with diabetes achieve and maintain a healthy weight. Increasing numbers of people in both developed and developing countries are being classified as overweight or obese, which is resulting in growing numbers of people being diagnosed with type 2 diabetes. Worryingly this includes large numbers of children developing type 2 diabetes as the younger age groups are becoming overweight or obese. The health-care practitioner's role is explored and strategies to promote and achieve a healthy lifestyle for people with type 2 diabetes are offered. Such strategies are linked to obesity management through, diet, exercise and behavioural therapy.

Prevalence of obesity in type 2 diabetes in secondary care: association with cardiovascular risk factors

AIMS

To determine the prevalence of overweight and obesity among patients with type 1 and type 2 diabetes mellitus attending a secondary care diabetes clinic in the United Kingdom, and to assess the impact of overweight and obesity on glycaemic control and cardiovascular risk factors in patients with type 2 diabetes.

METHODS

3637 patients with diabetes were identified from the hospital electronic diabetes register, 916 with type 1 diabetes (mean (SD) age 40.4 (15.1) years, 496 male) and 2721 with type 2 diabetes (mean (SD) age 62.5 (11.8) years, 1436 male). Data on body mass index (BMI), glycaemic control, lipid profiles, and blood pressure were extracted.

RESULTS

Of patients with type 1 diabetes, 55.3% were overweight (BMI >or=25 kg/m(2)), 16.6% were obese (BMI >or=30 kg/m(2)), and 0.4% had morbid obesity (BMI >or=40 kg/m(2)). In contrast, 86% of patients with type 2 diabetes were overweight or obese, 52% were obese, and 8.1% had morbid obesity. Obese patients with type 2 diabetes were younger, had poorer glycaemic control, higher blood pressures, worse lipid profiles, and were more likely to be receiving antihypertensive and lipid lowering drugs compared with patients with BMI <30 kg/m(2).

CONCLUSIONS

Obesity is the rule among patients attending this hospital diabetes clinic, with 86% of those with type 2 diabetes overweight or obese. Obesity is associated with significantly worse cardiovascular risk factors in this patient group, suggesting that more active interventions to control weight gain would be appropriate.

The glycemic and insulinemic index of plain sweet biscuits: relationships to in vitro starch digestibility

BACKGROUND

Among the various classes of processed starchy foods, wheat-based cereal products exhibit a wide range in glycemic and insulinemic responses. Understanding starch behavior during cooking and processing may help identify strategies that lower postprandial glycemia and insulinemia.

OBJECTIVE

To determine the relationship between the in vivo glycemic index (GI)/insulinemic index (II) and in vitro digestibility and composition characteristics (rapidly available glucose and slowly available glucose, RAG and SAG respectively) of 24 plain sweet biscuits (cookies).

METHODS

The products were commercially available and selected on the basis of their high starch content. In vivo responses (GI and II) were measured by standardised methods over 7 studies, with 12 subjects in each study (30 males, 42 females). In vitro digestibility characteristics were measured by the Englyst procedure.

RESULTS

The observed GI ranged from 38 to 60 (low to moderate) with the majority between 40 and 50, and correlated strongly with the observed insulinemic index (r = 0.76, P < 0.0001). The digestibility profile of carbohydrates was significantly correlated to in vivo responses (SAG and GI: r = -0.41; p = 0.04; SAG and II: r = -0.52; p < 0.01; RAG and GI: r = 0.5; p = 0.01; RAG and II: r = 0.34; p = 0.1) and explained in vivo responses better than fat, protein and fiber content amongst this selection of plain sweet biscuits.

CONCLUSION

The findings indicate that plain sweet biscuits have a low GI and a moderate II and that these characteristics are correlated to in vitro starch digestibility and are dependent on the type of processing.

The evolution of the nutritional management of diabetes

Diet and lifestyle advice for individuals with diabetes has changed dramatically. The changes in nutritional recommendations have largely been in response to advances in the knowledge of the biochemical and physiological mechanisms of impaired glucose metabolism and the micro- and macrovascular complications of diabetes. The most recent guidelines for the nutritional management of diabetes were set out by Diabetes UK in 2003. This consensus-based advice paper builds on the previous evidence-based review papers of the European Association for the Study of Diabetes in 2000 and the American Diabetes Association in 2002. The changes from previous recommendations include a more liberal use of sucrose, in line with healthy eating recommendations for the general population, and allow for greater flexibility in energy derived from carbohydrate and monounsaturated fat. In addition, monounsaturated fats are promoted as the fat of choice and active promotion of carbohydrate foods with a low glycaemic index is encouraged. These guidelines emphasise the practical application of nutritional management of diabetes and the need to provide education and support in a structured way that will facilitate change in diet and lifestyle behaviour. Structured educational programmes have been shown to be effective in reducing the progression to diabetes and also in slowing the onset and progression of the complications of diabetes. These programmes require ongoing intensive input to maintain behavioural change in diet and lifestyle. Considerable energy and resources are required to set up and maintain these educational programmes, but the cost per individual is small compared with the costs of treating the complications of diabetes.

Glycaemic control in type II diabetic tube-fed patients with a new enteral formula low in carbohydrates and high in monounsaturated fatty acids: a randomised controlled trial

OBJECTIVES

To investigate the effects of long-term treatment with a new enteral formula low in carbohydrates and high in monounsaturated fatty acids (MUFAs), in comparison with a standard formula, on glycaemic control in tube-fed type II diabetic patients.

DESIGN

Randomised, double-blind, controlled, multi-centre trial.

SETTING

Early rehabilitation centres, primary care and nursing facilities.

SUBJECTS

A total of 78 patients with insulin-treated type II diabetes with HbA(1C) > or =7.0% and/or fasting blood glucose >6.66 mmol/l, who required enteral tube feeding due to neurological dysphagia.

INTERVENTIONS

Patients received 113 kJ (27 kcal)/kg of body weight of either test feed or an isoenergetic, isonitrogenous enteral formula (control) for 12 weeks. Glycaemic control (total daily insulin dosage (IU), fasting blood glucose, and HbA(1C)) and gastrointestinal tolerance were monitored daily.

RESULTS

After 12 weeks, median values for changes from baseline were as follows (test group vs control group, 'data as available' analysis): total daily IUs -6.0 vs 0.0 (P=0.0024), fasting blood glucose (mmol/l) -1.59 vs -0.08 (P=0.0068); HbA(1C) (%) -0.8 vs 0.0 (P=0.0016). Both formulas were tolerated comparably.

CONCLUSIONS

This study indicates that in tube-fed insulin-treated type II diabetic patients, the new low-carbohydrate, high MUFA formula results in a more effective glycaemic control than the standard diet, while being comparable in safety.

Nutrition in patients with Type 2 diabetes: are low-carbohydrate diets effective, safe or desirable?

Low-carbohydrate diets have been around for over 100 years. They have become very popular recently but the scientific basis for their use remains to be fully established. This article reviews the recent trials that have been published and also what is known about the effects of low-carbohydrate, high-protein diets on energy expenditure and body composition. Although many controversies remain, there is now mounting evidence that these diets can lead to effective weight loss and may thus be a useful intervention for patients who have, or are at risk of, diabetes. The practical aspects of using these diets as a short- to medium-term intervention are discussed.

Glycemic index and load-dynamic dietary guidelines in the context of diseases

The concepts of glycemic index (GI) and glycemic load (GL) are among a new generation of so-called dynamic dietary guidelines. In contrast to classical static guidelines, these new guidelines do not primarily consider the absolute amount of energy or nutrient to be ingested within 24 h, but rather are focused on the postprandial response. It is claimed that low-GI and -GL diets favorably affect many noncommunicable diseases that are prevalent in developed countries, including type II diabetes, insulin resistance, obesity, cardiovascular disease (CVD), and cancer. During the past 20 years, considerable evidence has accumulated suggesting that low-GI or -GL diets indeed positively influence some but not all diseases. Because virtually no deleterious effects of low-GI and -GL diets have been documented thus far or are to be expected, the promotion of these diets should be considered in the management of noncommunicable diseases.

Review of dietary recommendations for diabetes mellitus

Previous nutritional guidelines for people with diabetes focused on carbohydrate-based meal planning. Updated guidelines from Europe and North America reflect a more flexible approach to nutritional intervention. New aspects of these most recent recommendations include: (1) increased emphasis on the role of trained dietitians for educating people with diabetes; (2) greater individualization of dietary choices based on cultural, regional and personal preferences; (3) more flexibility for choosing between carbohydrate and monounsaturated fat consumption, but with limitations on intake of polyunsaturated fats (<10% of total energy); (4) broadened allowance of sucrose in the diet (up to 10% of total energy); and (5) greater recognition of physical activity as an important means to control weight and enhance general health. Expert guidelines vary regarding preferential intake of carbohydrates with lower glycemic indices.

Managing obesity and glycemic control in insulin-using patients: clinical relevance and practice recommendations

In a number of large-scale studies, intensive therapy regimens have improved glycemic control while reducing the microvascular complications of type 2 diabetes. However, insulin use has been associated with weight gain, thereby hampering patient compliance with intensive insulin therapy. As the prevalence of type 2 diabetes and obesity continues to increase worldwide, health care providers must incorporate the management of weight gain in therapeutic strategies that promote glycemic control. The central component in any such strategy is a tailored program of medical nutrition therapy (MNT), which includes a healthy diet, physical activity, and education. This article reviews several dietary options within a MNT program, including the uses of liquid meal replacements, low-glycemic index carbohydrates, and foods rich in monounsaturated fatty acids. It also provides several practice recommendations to encourage compliance in patients with type 2 diabetes who wish to manage their weight while receiving insulin therapy.