The implementation of nutritional advice for people with diabetes

Nutritional Strategies for the Management of Type 2 Diabetes Mellitus: A Narrative Review

BACKGROUND

Thinking about greater adherence to dietary planning, it is extremely important to be aware of all nutritional strategies and dietary prescriptions available in the literature, and of which of them is the most efficient for the management of T2DM.

METHODS

A search was carried out in 2023 for randomized clinical trials, systematic reviews, meta-analyses, and guidelines in the following databases: Pubmed, Scielo, Web of Science, CrossRef and Google Scholar. In total, 202 articles were collected and analyzed. The period of publications was 1983-2023.

RESULTS

There is still no consensus on what the best nutritional strategy or ideal dietary prescription is, and individuality is necessary. In any case, these references suggest that Mediterranean Diet may of greater interest for the management of T2DM, with the following recommended dietary prescription: 40-50% carbohydrates; 15-25% proteins; 25-35% fats (<7% saturated, 10% polyunsaturated, and 10% monounsaturated); at least 14 g of fiber for every 1000 kcal consumed; and <2300 mg sodium.

CONCLUSIONS

Individuality is the gold standard for dietary prescriptions, however, the Mediterranean diet with low levels of carbohydrates and fats seems to be the most promising strategy for the management of T2DM.

Adaptations in the transformation of cassava (Manihot esculenta Crantz; Euphorbiaceae) for consumption in the dietary management of diabetes: the case of Palikur, or Parikwene People, from French Guiana

Introduction

In the French overseas department of French Guiana, in South America, nutrition therapy for the management of diabetes is based on French guidelines. However, this region is demographically diverse and includes several populations of Indigenous Peoples, Parikwene among others, also called Palikur. Due to socio-economical, cultural, and geographical differences, along with distinctions in the local food system, dietary recommendations, which many consider in the context of post-colonial power dynamics, are not well suited to local populations. In the absence of suitable recommendations, it is hypothesized that local populations will adapt their dietary practices considering diabetes as an emerging health problem.

Methods

Seventy-five interviews were conducted with community members and Elders, as well as healthcare professionals and administrators providing services to the Parikwene population of Macouria and Saint-Georges de l'Oyapock communes. Data regarding the representation of cassava (Manihot esculenta Crantz) consumption and diabetes were collected via semi-structured interviews and participant observation (i.e., observation and participation in community activities), namely via participating in activities related to the transformation of cassava tubers at swidden and fallow fields.

Results and Discussion

Parikwene have adapted the transformation of cassava tubers for their consumption in the management of diabetes.The importance of cassava tubers as a staple and core food to the Parikwene food system was established by identifying it as a cultural keystone species. Narratives illustrated conflicting perceptions regarding the implication of cassava consumption in the development of diabetes. Adaptations to the operational sequence involved in the transformation of cassava tubers led to the production of distinct cassava roasted semolina (i.e., couac), based on organoleptic properties (i.e., sweet, and acidic couac). Preferences for the consumption of acidic couac were grounded in the Parikwene knowledge system, as well as attention to diabetes related symptoms and glucometer readings.

Conclusion

These results provide important insights related to knowledge, attitudes, and practices in developing locally and culturally adapted approaches to providing dietary recommendations in the treatment of diabetes.

The beneficial short-term effects of a high-protein/low-carbohydrate diet on glycaemic control assessed by continuous glucose monitoring in patients with type 1 diabetes

AIM

To compare the effects of three different but isocaloric dietary patterns, high-protein/low-carbohydrate (HPD) with 20% of calories as carbohydrates, Mediterranean/low glycaemic index (MED) with 40% carbohydrates, and a reference diet (REF) with 50% carbohydrates, in patients with type 1 diabetes (T1D).

MATERIALS AND METHODS

In a randomized crossover study, 15 patients with T1D were assigned to the three dietary patterns for three separate weeks, with 7-day washout periods in between. Continuous glucose monitoring was applied during the intervention periods. The primary outcome was glycaemic control, as measured by the percentage of time patients spent within the euglycaemic range (TIR_{70-140   mg/dl} ). Other key glycaemic metrics were also investigated as secondary outcomes.

RESULTS

TIR_70-140 was not statistically different between HPD, MED and REF (p = .105). Pairwise analysis revealed a statistically significant difference between HPD and REF at the .05 level, which was not retained after applying Bonferroni correction (54.87% ± 14.11% vs. 48.33% ± 13.72%; p = .018). During the HPD period, 11 out of 15 participants spent more time within TIR_70-140 compared with either the REF or MED. The HPD performed significantly better than the REF in terms of TIR_70-180 (74.33% ± 12.85% vs. 67.53% ± 12.73%; p = .012), glycaemic variability (coefficient of variation: 36.18% ± 9.30% vs. 41.48% ± 8.69%; p = .016) and time spent in the hypoglycaemic range (TBR_{70   mg/dl} ; median: 12, IQR: 16 vs. median: 14, IQR: 20; p = .007), whereas no statistically significant differences were observed between MED and HPD or REF.

CONCLUSIONS

Compared with REF and MED, an HPD plan may have a positive impact on glycaemic control in patients with T1D. During the HPD, patients spent a shorter time in hypoglycaemia and exhibited lower glycaemic variability.

Impact of Diet on Inflammatory Bowel Disease Symptoms: An Adolescent Viewpoint

Background

Dietary modification shows promise as therapy in inflammatory bowel disease (IBD); however, it is unknown whether adolescents are interested in a dietary approach.

Methods

Cross-sectional survey of adolescents with IBD ages 14-21 on disease knowledge, dietary habits, and perceptions of diet therapy.

Results

A total of 132 subjects (48.5% female), mean age of 17.8 years and median disease length of 5 years (range 0, 16), completed the survey. Diet was perceived as a symptom trigger by 59.8% of subjects, and 45.4% had tried using diet as a treatment for symptom resolution, often without physician supervision and with limited success. Subjects experiencing active disease symptoms as determined by Manitoba IBD Index were more likely to be currently modifying their diet compared to subjects without active disease symptoms (odds ratio = 4.11, confidence interval = 1.58, 10.73, P = 0.003).

Conclusions

Adolescents with IBD perceive a relationship between diet and disease symptoms and are interested in dietary modification as a symptom management option.

Diet and Healthy Lifestyle in the Management of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) among pregnant women increases the risk of both short-term and long-term complications, such as birth complications, babies large for gestational age (LGA), and type 2 diabetes in both mother and offspring. Lifestyle changes are essential in the management of GDM. In this review, we seek to provide an overview of the lifestyle changes which can be recommended in the management of GDM. The diet recommended for women with GDM should contain sufficient macronutrients and micronutrients to support the growth of the foetus and, at the same time, limit postprandial glucose excursions and encourage appropriate maternal gestational weight gain. Blood glucose excursions and hyperglycaemic episodes depend on carbohydrate-intake. Therefore, nutritional counselling should focus on the type, amount, and distribution of carbohydrates in the diet. Further, physical activity has beneficial effects on glucose and insulin levels and it can contribute to a better glycaemic control.

Glycemic index of millet based food mix and its effect on pre diabetic subjects

Diet plays an important role in management of diabetes and foods having low glycemic index are gaining more importance as they delay the release of glucose in the blood. It is essential to develop low glycemic food mix from regionally available ingredients for use in daily dietaries. Hence, the present study was undertaken to assess the glycemic index of the traditional recipes prepared from developed millet based food mix and their effect on pre diabetic subjects. The developed millet based food mix had appreciable amount of protein (19.41 g/100 g) and dietary fibre (21.11 g/100 g). The traditional recipes viz., roti, dosa and dumpling (mudde) prepared from developed mix exhibited higher acceptance with good sensory parameters and are comparable to regional preparations. The glycemic index was found to be 37, 48 and 53 for dosa, mudde and roti respectively with a glycemic load of 11.05, 18.43 and 18.09. However, all the three developed products showed the relatively lower glycemic index (< 55) and moderate glycemic load of < 20. Further, dietary intervention on pre diabetic subjects revealed that there was a significant reduction in FBS (120.50 ± 18.73 to 97.81 ± 20.00) and HbA1c (6.14 ± 0.30 to 5.67 ± 0.40) indicating their preferable option in the management of diabetes mellitus.

Effects of a Carob-Pod-Derived Sweetener on Glucose Metabolism

BACKGROUND

Patients with type 2 diabetes mellitus (T2DM) have a higher incidence of cardiovascular (CV) events. The ingestion of high-glycemic index (GI) diets, specially sweetened beverage consumption, has been associated with the development of T2DM and CV disease.

OBJECTIVE

We investigated the effects of the intake of a sweetened beverage, obtained from natural carbohydrates containing pinitol (PEB) compared to a sucrose-enriched beverage (SEB) in the context of impaired glucose tolerance (IGT) and diabetes.

METHODS

The study was divided in three different phases: (1) a discovery phase where the plasma proteomic profile was investigated by 2-DE (two-dimensional electrophoresis) followed by mass spectrometry (matrix-assisted laser desorption/ionization time-of-flight-MALDI-TOF/TOF) in healthy and IGT volunteers; (2) a verification phase where the potential mechanisms behind the observed protein changes were investigated in the discovery cohort and in an additional group of T2DM volunteers; and (3) the results were validated in a proof-of-concept interventional study in an animal model of diabetic rats with complementary methodologies.

RESULTS

Six weeks of pinitol-enriched beverage (PEB) intake induced a significant increase in two proteins involved in the insulin secretion pathway, insulin-like growth factor acid labile subunit (IGF1BP-ALS; 1.3-fold increase; P = 0.200) and complement C4A (1.83-fold increase; P = 0.007) in IGT subjects but not in healthy volunteers. Changes in C4A were also found in the serum samples of Zucker diabetic fatty (ZDF) rats after four weeks of PEB intake compared to basal levels (P = 0.042). In addition, an increased expression of the glucose transporter-2 (GLUT2) gene was observed in the jejunum (P = 0.003) of inositol-supplemented rats when compared to sucrose supplementation. This change was correlated with the observed change in C4A (P = 0.002).

CONCLUSIONS

Our results suggest that the substitution of a common sugar source, such as sucrose, by a naturally-based, pinitol-enriched beverage induces changes in the insulin secretion pathway that could help to reduce blood glucose levels by protecting β-cells and by stimulating the insulin secretion pathway. This mechanism of action could have a relevant role in the prevention of insulin resistance and diabetes progression.

Role of a registered dietitian in pediatric type 1 and type 2 diabetes

Type 1 and type 2 diabetes are complex, chronic diseases that are best managed by a multidisciplinary care team. Type 1 diabetes is most commonly diagnosed in the pediatric population, although the prevalence of type 2 diabetes in youth is increasing rapidly. A registered dietitian (RD) is a critical member of the diabetes team who provides focused nutrition education from diagnosis and throughout routine follow-up care. Specifically in the pediatric population, the RD also assesses growth and development, as well as eating behaviors, food choices and meal patterns. Based on a review of research, ongoing support from an RD improves glycemic control and delays onset of diabetes complications. In addition, dietitian-led nutrition education helps better manage lipid levels and aids in weight management. A sample model describing RD involvement in a pediatric diabetes care team is discussed in further detail.

Macronutrient Composition and Management of Non-Insulin-Dependent Diabetes Mellitus (NIDDM): A New Paradigm for Individualized Nutritional Therapy in Diabetes Patients

Medical nutrition therapy constitutes an important lifestyle intervention in diabetes management. Several nutrition patterns have been effective in improving diabetes control, but there has been a debate about the optimal macronutrient composition in diabetes meal planning. For many years, the recommended diets for persons with and without diabetes were similar, i.e. heart-healthy and low in fat. For almost three decades, carbohydrates have been lauded, lipids demonized, and proteins considered of little importance. However, in the past few years, this concept has been questioned and reassessed. Modern nutritional recommendations for people with diabetes are headed towards individualization, but lack specific guidelines. Nutritional algorithms may help nutritionists in diabetes meal planning. This review aims to discuss: 1) the effects of the three major macronutrients (carbohydrates, proteins, and lipids) on glucose levels, 2) current recommendations for macronutrient intake for people with diabetes, and 3) specific parameters that need to be taken into consideration when determining the macronutrient composition for a person with diabetes, for example body mass index, degree of insulin resistance, HbA1c value, and lipid profile (especially triglycerides and HDL cholesterol). These aspects are analyzed in the context of the results of recent studies, especially randomized controlled trials (RCTs). Finally, we introduce an individualized nutritional concept that proposes carbohydrate over lipid restriction, substitution of SFAs with MUFAs and PUFAs, and adequate intake of dietary fiber, which are key factors in optimizing diabetes management.

A 6-month follow-up study of the randomized controlled Ma-Pi macrobiotic dietary intervention (MADIAB trial) in type 2 diabetes

BACKGROUND

In the MADIAB trial (a 21-day randomized, controlled trial in patients with type 2 diabetes (T2D)), intervention with the Ma-Pi 2 macrobiotic diet resulted in significantly greater improvements in metabolic control compared with a standard recommended diet for patients with T2D. We report on a 6-month follow-up study, which investigated, whether these benefits extended beyond the 21-day intensive dietary intervention, in real-world conditions.

SUBJECTS

At the end of the MADIAB trial (baseline of this follow-up study), all participants continued their assigned diet (Ma-Pi or control) for 6 months. The Ma-Pi 2 group followed the Ma-Pi 4 diet during this follow-up study. Forty of the original 51 subjects (78.4%) participated in the follow-up (body mass index, 27-45 kg m(-2); age, 40-75 years). Primary outcome was percentage change from baseline in HbA1c; secondary outcomes were anthropometric data and lipid panel.

RESULTS

A significantly greater median percentage reduction was observed for HbA1c in the Ma-Pi group (-11.27% (95% confidence interval (CI): -10.17; -12.36)) compared with the control group (-5.88% (95% CI: -3.79; -7.98)) (P < 0.001). Total and low-density lipoprotein (LDL) cholesterol increased in both groups with no differences between groups (P=0.331 and P=0.082, respectively). After correcting for age and gender, the Ma-Pi diet was associated with a higher percentage reduction in HbA1c (95% CI: 2.56; 7.61) and body weight (95% CI: 0.40; 3.99), and a higher percentage increase in LDL cholesterol (95% CI: -1.52; -33.16). However, all participants' total and LDL cholesterol levels remained within recommended ranges (<200 mg dl(-1) and <100 mg dl(-1), respectively). The Ma-Pi diet group achieved the target median HbA1c value (<5.7% (39 mmol mol(-1))) at 6 months.

CONCLUSIONS

Both the Ma-Pi and control diets maintained their benefits beyond the 21-day intensive monitored intervention over a 6-month follow-up in real-world conditions. The Ma-Pi diet resulted in greater improvement in glycemic control.

Dietary Glycemic Load and Macronutrient Intake in Healthy Italian Children

The objective is of this study is to examine the relationship of dietary glycemic load (GL) and overall glycemic index (OGI) with macronutrients intake, body mass index (BMI) and insulin sensitivity in healthy children. The subjects comprised of 105 healthy non-obese eight -years old children, 60 boys and 45 girls. A Food Frequency Questionnaire (FFQ) evaluating dietary habits, GL and OGI. Insulin sensitivity was evaluated by the homeostatic model assessment (HOMA). GL was positively associated with dietary total (correlation coefficient, r=0.57) and starch (r=0.67) carbohydrates, daily consumption of pasta and white bread, cooked potatoes, bakery products and cookies, and negatively with dietary fats (r=-0.52). OGI was positively associated with daily consumption of white bread and cookies, and negatively associated with soluble carbohydrates (r=-0.35), and consumption of fibres, proteins, fruit, legumes and carrots. No significant association was found of GL or OGI with BMI or insulin sensitivity. In healthy children, GL and OGI may represent a useful indicator of quality of diet. Asia Pac J Public Health 2005; 17(2): 88-92.

Glycemic index and glycemic load of commercial Italian foods

BACKGROUND AND AIM

The glycemic index (GI) and glycemic load (GL) are useful parameters in the nutritional classification of carbohydrate foods. Diets characterized by a low GI and/or a low GL have been repeatedly and independently associated with decreased risk of diabetes and other chronic diseases. The aim of this study is to report the GI and GL value of carbohydrate-rich foods available on the Italian market and mostly consumed in Italy.

METHODS AND RESULTS

GI values were determined according to FAO/WHO (1997) and ISO (2010). Overall, the 141 commercial foods that were analyzed represent food categories that are the source of >80% carbohydrate intake in Italy. The food items chosen were based mainly on the market share of the brand within each food category and grouped into 13 food categories: 1) beverages: fermented milk drink, juice, smoothie, soft drink; 2) biscuits; 3) breads; 4) bread substitutes; 5) breakfast cereals; 6) cakes and snacks; 7) candy and confectionery; 8) cereals; 9) desserts and ice-creams; 10) marmalade and jam; 11) pasta; 12) pizza; 13) sugar and sweetener.

CONCLUSION

This database of commercial Italian foods partly overcomes the lack of information on GI and GL of local foods, contributing to a better understanding of the association between GI/GL and health and providing a more informed choice to Italian consumers and health practitioners.

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

Review status was set to withdrawn. The review is out of date and does not meet current Cochrane standards. It will be superseded by a new expanding Cochrane review on 'Diet, physical activity or both for the prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk'.

The editorial group responsible for this previously published document have withdrawn it from publication.

Glycemic index and microstructure analysis of a newly developed fiber enriched cookie

A diet with a high glycemic index (GI) is associated with an elevated risk for obesity or type 2 diabetes.

The effect of the macrobiotic Ma-Pi 2 diet vs. the recommended diet in the management of type 2 diabetes: the randomized controlled MADIAB trial

Background

Diet is an important component of type 2 diabetes therapy. Low adherence to current therapeutic diets points out to the need for alternative dietary approaches. This study evaluated the effect of a different dietary approach, the macrobiotic Ma-Pi 2 diet, and compared it with standard diets recommended for patients with type 2 diabetes.

Methods

A randomized, controlled, open-label, 21-day trial was undertaken in patients with type 2 diabetes comparing the Ma-Pi 2 diet with standard (control) diet recommended by professional societies for treatment of type 2 diabetes. Changes in fasting blood glucose (FBG) and post-prandial blood glucose (PPBG) were primary outcomes. HbA_1c, insulin resistance (IR), lipid panel and anthropometrics were secondary outcomes.

Results

After correcting for age, gender, BMI at baseline, and physical activity, there was a significantly greater reduction in the primary outcomes FBG (95% CI: 1.79; 13.46) and PPBG (95% CI: 5.39; 31.44) in those patients receiving the Ma-Pi 2 diet compared with those receiving the control diet. Statistically significantly greater reductions in the secondary outcomes, HbA_1c (95% CI: 1.28; 5.46), insulin resistance, total cholesterol, LDL cholesterol and LDL/HDL ratio, BMI, body weight, waist and hip circumference were also found in the Ma-Pi 2 diet group compared with the control diet group. The latter group had a significantly greater reduction of triglycerides compared with the Ma-Pi 2 diet group.

Conclusions

Intervention with a short-term Ma-Pi 2 diet resulted in significantly greater improvements in metabolic control in patients with type 2 diabetes compared with intervention with standard diets recommended for these patients.

Trial registration

Current Controlled Trials ISRCTN10467793.

Dietary changes and associations with metabolic improvements in adults with type 2 diabetes during a patient-centred dietary intervention: an exploratory analysis

OBJECTIVES

Describe dietary intake of participants enrolled in a non-prescriptive dietary intervention and dietary changes at 6 months and explore whether these changes had a role in observed improvements in glycated haemoglobin (HbA1c), weight, lipids and blood pressure.

DESIGN

Secondary analysis of data from the Early ACTivity in Diabetes randomised controlled trial.

PARTICIPANTS

262 patients with newly diagnosed type 2 diabetes randomised to the dietary intervention.

OUTCOMES AND ANALYSIS

Changes in energy intake, macronutrients, fibre and alcohol and in weight, waist circumference, lipids, HbA1c and blood pressure at baseline and 6 months. Multivariate models were used to examine associations between dietary changes and metabolic variables.

RESULTS

Men reported reducing mean energy intake from 1903±462 kcal to 1685 kcal±439 kcal (p<0.001), increasing carbohydrate intake from 42.4±6.6% to 43.8±6.6% (p=0.002) and reducing median alcohol intake from 13 (0-27) g to 5 (0-18) g (p<0.001). Women reported reducing mean energy intake from 1582±379 kcal to 1459±326 kcal (p<0.001) with no change to macronutrient distribution and alcohol. Fibre intake was maintained. In men (n=148), weak and clinically insignificant associations were found between increased carbohydrates and reduction in HbA1c (β=-0.003 (-0.006, -0.001); p=0.009), increased fibre and reduction in total cholesterol (β=-0.023 (-0.044, -0.002); p=0.033), decreased total fat and reduction in low-density lipoprotein (LDL)-cholesterol (β=0.024 (0.006, 0.001); p=0.011), and decreased alcohol and reduction in diastolic blood pressure (β=0.276 (0.055, 0.497); p=0.015). In women (n=75), associations were found between a decrease in transfats and reductions in waist circumference (β=-0.029 (0.006, 0.052); p=0.015), total cholesterol (β=0.399 (0.028, 0.770); p=0.036) and LDL cholesterol (β=0.365 (0.042, 0.668); p=0.028).

CONCLUSIONS

Clinically important metabolic improvements observed in a patient-centred dietary intervention were not explained by changes in macronutrients. However, a non-prescriptive approach may promote a reduction in total energy intake while maintaining fibre consumption.

TRIAL REGISTRATION NUMBER

The Early ACTID trial number ISRCTN92162869.

Ma-Pi 2 macrobiotic diet and type 2 diabetes mellitus: pooled analysis of short-term intervention studies

The macrobiotic, Ma-Pi 2 diet (12% protein, 18% fat and 70% carbohydrate), has shown benefit in adults with type 2 diabetes mellitus (T2DM). This pooled analysis aims to confirm results from four, 21-day intervention studies with the Ma-Pi 2 diet, carried out in Cuba, China, Ghana and Italy. Baseline and end of study biochemical, body composition and blood pressure data, were compared using multivariate statistical methods and assessment of the Cohen effect size (d). Results showed that all measured indicators demonstrated significant changes (p < 0.001); most of them with a very high (d ≥ 1.30), or high (d = 0.80-1.29) effect size. The global effect size of the diet was Italy (1.96), China (1.79), Cuba (1.38) and Ghana (0.98). The magnitude of the individual effect on each variable by country, and the global effect by country, was independent of the sample size (p > 0.05). Similarly, glycemia and glycemic profiles in all four studies were independent of the sample size (p = 0.237). The Ma-Pi diet 2 significantly reduced glycemia, serum lipids, uremia and cardiovascular risk in adults with T2DM. These results suggest that the Ma-Pi 2 diet could be a valid alternative treatment for patients with T2DM and point to the need for further clinical studies. Mechanisms related to its benefits as a functional diet are discussed.

Self-care practices of Chinese individuals with diabetes

The aim of this study was to investigate the self-care practices of Chinese individuals with diabetes. Data were collected from 163 Chinese individuals with diabetes using a one-to-one interview approach. The Chinese version of the Summary of Diabetes Self-Care Activities (SDSCA) was used to assess diabetes-related knowledge and self-care practices. The majority of participants were aware of the importance of self-care in managing diabetes. However, only 70 participants (43%) scored >50% in the diabetes-related questionnaires. Mean fasting blood glucose (FBG) levels were higher (P<0.04) for participants who had extra meals per day (46%). The majority of participants took oral hypoglycemic agents (OHAs; 60.1%) and some were also treated with OHA-insulin combination therapy (17.8%). Participants with medication adherence (52%) tended to have lower FBG levels. Only 13% of participants practiced self-monitoring of blood glucose (SMBG). The predictors of a knowledge deficit or poor self-care were a low level of education (P<0.01) or old age (older than 53 years old; P=0.002). Deficits in diabetes-related knowledge and self-care practices existed among the majority of patients with suboptimal blood glucose control. The understanding of the importance of self-care practices requires improvement in individuals with diabetes. The development of effective education strategies to improve the awareness of self-care practices by Chinese individuals with diabetes is necessary.

Contribuição de cesta básica na segurança alimentar de idosos diabéticos de programa assistencial em uma cidade do sul do Brasil

A garantia de acesso em quantidade, qualidade e regularidade aos alimentos é direito constitucional e humano. Em função disso, os programas públicos de segurança alimentar procuram focar suas ações nas populações de maior vulnerabilidade social. Este trabalho teve como objetivo investigar a contribuição energética e de macronutrientes da composição da cesta básica diet, oferecida pelo Programa Cidadania Alimentar (PCA) da cidade de Canoas-RS, ao estado nutricional dos idosos diabéticos. Para tanto, foi realizado estudo descritivo incluindo os 163 idosos diabéticos, de ambos os sexos, cadastrados no PCA que receberam o benefício da cesta básica diet. Constatou-se que 76,1% dos inscritos são do sexo feminino e 68,1% apresentaram classificação do índice de massa corporal (IMC) >27kg/m², indicando excesso de peso. A composição da cesta básica diet fornecida pelo PCA contemplou a média de 924,4 kcal/dia, distribuída em 54,2% de carboidratos, 13,4% de proteínas e 32,5% de gorduras. Os resultados mostraram boa adequação energética da cesta básica diet quando considerada a necessidade energética estimada (NEE) recomendada para os idosos. No entanto, sugere-se uma reavaliação do programa para que ele possa atuar em ações promotoras de saúde frente aos resultados do IMC encontrados nessa população.

A prospective assessment of dietary patterns in Muslim subjects with type 2 diabetes who undertake fasting during Ramadan

AIMS

The aim was to assess the dietary pattern during Ramadan season among type 2 diabetic Muslim subjects who underwent fasting and intensive dietary counseling.

MATERIALS AND METHODS

The study was conducted among 70 Muslim subjects with type 2 diabetes mellitus who undertook fasting during Ramadan and was part of a randomized control trial using pioglitazone published previously. All subjects were subjected to a dietary assessment and counseling at three stages, i.e., initiation of the study, mid-Ramadan and post-Ramadan, by a trained dietician. Dietary assessment was done by the 24-hour dietary recall method and the food frequency questionnaire. Diabetic diet sheets were dispensed to subjects based on their body mass index (BMI), daily activity, and needs.

RESULTS

The mean caloric intake between pre-Ramadan (before fasting) and mid-Ramadan (15 days after fasting) were 1506.80 kcal and 1614.29 (P = 0.001) respectively. The distribution of active components pre and during Ramadan were: carbohydrates (g) 260.76 and 265.35 g (P = 0.001), proteins (g) 43.64 and 46.19 (P = 0.001) and fat (g) was 32.88 and 44.16 (P = 0.0001) respectively. The percentage of energy from dietary carbohydrate prior to fasting (64.11 ± 6.73) and during fasting (68.41 ± 4.41) remained almost unchanged but statistically significant when compared at different intervals before and during fasting. Fat intake increased significantly during fasting (P = < 0.001).

CONCLUSIONS

The dietary composition in a type 2 diabetic Muslim population who undertook fasting during Ramadan showed a mean increase in consumption of all components of diet during the period of fasting. Nutritional compliance during such a time seems to be difficult and warrants repeated counseling and regular follow-up to achieve targets.

The diet of diabetic patients in Spain in 2008-2010: accordance with the main dietary recommendations--a cross-sectional study

BACKGROUND

No previous study has assessed the diet of the diabetic patients in the general population of an entire country in Europe. This study evaluates accordance of the diet of diabetic adults in Spain with nutritional recommendations of the European Association for the Study of Diabetes (EASD), American Diabetes Association (ADA), and the Mediterranean diet (MD).

METHODS AND FINDINGS

Cross-sectional study conducted in 2008-2010 among 12,948 persons representative of the population aged ≥18 years in Spain. Usual food consumption was assessed with a dietary history. EASD accordance was defined as ≥6 points on a score of 12 nutritional goals, ADA accordance as ≥3 points on a score of 6 goals, and MD accordance as ≥7 points on the Mediterranean Diet Adherence Screener. In the 609 diagnosed diabetic individuals, the diet was rich in saturated fat (11.2% of total energy), but trans fat intake was relatively low (1.1% energy) and monounsaturated fat intake was high (16.1% energy). Carbohydrate intake was relatively low (41.1% energy), but sugar intake was high (16.9% energy). Intake of cholesterol (322 mg/day) and sodium (3.1 g/day) was also high, while fiber intake was insufficient (23.8 g/day). EASD accordance was observed in 48.7% diabetic patients, ADA accordance in 46.3%, and MD accordance in 57.4%. The frequency of EASD, ADA and MD accordance was not statistically different between diagnosed and undiagnosed diabetic individuals.

CONCLUSIONS

Only about half of diabetic patients in Spain have a diet that is consistent with the major dietary recommendations. The lack of dietary differences between diagnosed and undiagnosed diabetic individuals reflects deficiencies in diabetes management.

Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes

This article summarizes the Diabetes UK evidence-based guidelines for the prevention of Type 2 diabetes and nutritional management of diabetes. It describes the development of the recommendations and highlights the key changes from previous guidelines. The nutrition guidelines include a series of recommendations for the prevention of Type 2 diabetes, nutritional management of Type 1 and Type 2 diabetes, weight management, management of microvascular and macrovascular disease, hypoglycaemia management, and additional considerations such as nutrition support, end-of-life care, disorders of the pancreas, care of the older person with diabetes, nutrition provided by external agencies and fasting. The evidence-based recommendations were graded using the Scottish Intercollegiate Guidelines Network methodology and, in a small number of topic areas, where strong evidence was lacking, the recommendations were reached by consensus. The Diabetes UK 2011 guidelines place an emphasis on carbohydrate management and a more flexible approach to weight loss, unlike previous guidelines which were expressed in terms of recommendations for individual nutrient intakes. Additionally, the guidelines for alcohol have been aligned to national recommendations. The full evidence-based nutrition guidelines for the prevention and management of diabetes are available from: http://www.diabetes.org.uk/nutrition-guidelines.

Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial

BACKGROUND

Lifestyle changes soon after diagnosis might improve outcomes in patients with type 2 diabetes mellitus, but no large trials have compared interventions. We investigated the effects of diet and physical activity on blood pressure and glucose concentrations.

METHODS

We did a randomised, controlled trial in southwest England in adults aged 30-80 years in whom type 2 diabetes had been diagnosed 5-8 months previously. Participants were assigned usual care (initial dietary consultation and follow-up every 6 months; control group), an intensive diet intervention (dietary consultation every 3 months with monthly nurse support), or the latter plus a pedometer-based activity programme, in a 2:5:5 ratio. The primary endpoint was improvement in glycated haemoglobin A(1c)(HbA(1c)) concentration and blood pressure at 6 months. Analysis was done by intention to treat. This study is registered, number ISRCTN92162869.

FINDINGS

Of 593 eligible individuals, 99 were assigned usual care, 248 the diet regimen, and 246 diet plus activity. Outcome data were available for 587 (99%) and 579 (98%) participants at 6 and 12 months, respectively. At 6 months, glycaemic control had worsened in the control group (mean baseline HbA(1c) percentage 6·72, SD 1·02, and at 6 months 6·86, 1·02) but improved in the diet group (baseline-adjusted difference in percentage of HbA(1c) -0·28%, 95% CI -0·46 to -0·10; p=0·005) and diet plus activity group (-0·33%, -0·51 to -0·14; p<0·001). These differences persisted to 12 months, despite less use of diabetes drugs. Improvements were also seen in bodyweight and insulin resistance between the intervention and control groups. Blood pressure was similar in all groups.

INTERPRETATION

An intensive diet intervention soon after diagnosis can improve glycaemic control. The addition of an activity intervention conferred no additional benefit.

FUNDING

Diabetes UK and the UK Department of Health.

Maternal communication style, problem-solving and dietary adherence in young children with type 1 diabetes

The incidence of type 1 diabetes (T1D) in young children is increasing markedly however young children have been overlooked in paediatric adherence research despite the unique challenges their care presents. We investigated the relation between maternal communication style and adherence to the dietary regimen in 40 children with T1D, aged 2-8 years, and their mothers. Mothers completed measures of children's sugar consumption, parent-child communication quality, and child psychological functioning. Mothers and children engaged in a videotaped problem-solving task related to the dietary regimen, with maternal utterances analysed for behavioural control style (e.g., commands versus suggestions) and cognitive complexity (e.g., provision of labels versus questions). Maternal communications which engaged children, behaviourally and cognitively, in the task were associated with better adherence, medical, communication quality, and child adjustment outcomes. We conclude that adherence and health (medical and psychological) are optimized when young children are given opportunities to participate in their care.

Food intake and dietary glycaemic index in free-living adults with and without type 2 diabetes mellitus

A recent Cochrane review concluded that low glycaemic index (GI) diets are beneficial in glycaemic control for patients with type 2 diabetes mellitus (T2DM). There are limited UK data regarding the dietary GI in free-living adults with and without T2DM. We measured the energy and macronutrient intake and the dietary GI in a group (n = 19) of individuals with diet controlled T2DM and a group (n = 19) without diabetes, matched for age, BMI and gender. Subjects completed a three-day weighed dietary record. Patients with T2DM consumed more daily portions of wholegrains (2.3 vs. 1.1, P = 0.003), more dietary fibre (32.1 vs. 20.9 g, P < 0.001) and had a lower diet GI (53.5 vs. 57.7, P = 0.009) than subjects without T2DM. Both groups had elevated fat and salt intake and low fruit and vegetable intake, relative to current UK recommendations.

CONCLUSIONS

Patients with T2DM may already consume a lower GI diet than the general population but further efforts are needed to reduce dietary GI and achieve other nutrient targets.

Glycemic index and glycemic load of carbohydrates in the diabetes diet

Medical nutrition therapy is the first line of treatment for the prevention and management of type 2 diabetes and plays an essential part in the management of type 1 diabetes. Although traditionally advice was focused on carbohydrate quantification, it is now clear that both the amount and type of carbohydrate are important in predicting an individual's glycemic response to a meal. Diets based on carbohydrate foods that are more slowly digested, absorbed, and metabolized (i.e., low glycemic index [GI] diets) have been associated with a reduced risk of type 2 diabetes and cardiovascular disease, whereas intervention studies have shown improvements in insulin sensitivity and glycated hemoglobin concentrations in people with diabetes following a low GI diet. Research also suggests that low GI diets may assist with weight management through effects on satiety and fuel partitioning. These findings, together with the fact that there are no demonstrated negative effects of a low GI diet, suggest that the GI should be an important consideration in the dietary management and prevention of diabetes.

The effect of high-protein, low-carbohydrate diets in the treatment of type 2 diabetes: a 12 month randomised controlled trial

AIMS/HYPOTHESIS

Short-term dietary studies suggest that high-protein diets can enhance weight loss and improve glycaemic control in people with type 2 diabetes. However, the long-term effects of such diets are unknown. The aim of this study was to determine whether high-protein diets are superior to high-carbohydrate diets for improving glycaemic control in individuals with type 2 diabetes.

METHODS

Overweight/obese individuals (BMI 27-40 kg/m(2)) with type 2 diabetes (HbA(1c) 6.5-10%) were recruited for a 12 month, parallel design, dietary intervention trial conducted at a diabetes specialist clinic (Melbourne, VIC, Australia). Of the 108 initially randomised, 99 received advice to follow low-fat (30% total energy) diets that were either high in protein (30% total energy, n = 53) or high in carbohydrate (55% total energy, n = 46). Dietary assignment was done by a third party using computer-generated random numbers. The primary endpoint was change in HbA(1c). Secondary endpoints included changes in weight, lipids, blood pressure, renal function and calcium loss. Study endpoints were assessed blinded to the diet group, but the statistical analysis was performed unblinded. This study used an intention-to-treat model for all participants who received dietary advice. Follow-up visits were encouraged regardless of dietary adherence and last measurements were carried forward for study non-completers.

RESULTS

Ninety-nine individuals were included in the analysis (53 in high protein group, 46 in high carbohydrate group). HbA(1c) decreased in both groups over time, with no significant difference between groups (mean difference of the change at 12 months; 0.04 [95% CI -0.37, 0.46]; p = 0.44). Both groups also demonstrated decreases over time in weight, serum triacylglycerol and total cholesterol, and increases in HDL-cholesterol. No differences in blood pressure, renal function or calcium loss were seen.

CONCLUSIONS/INTERPRETATION

These results suggest that there is no superior long-term metabolic benefit of a high-protein diet over a high-carbohydrate in the management of type 2 diabetes.

TRIAL REGISTRATION

ACTRN12605000063617 ( www.anzctr.org.au ).

FUNDING

This study was funded by a nutritional research grant from Meat and Livestock Australia (MLA). J.E. Shaw is supported by NHMRC Fellowship 586623.

Nutrition in an ethnically diverse society: what are some of the key challenges?

The role of nutrition is especially important in certain ‘lifestyle’ diseases that impact disproportionately on ethnic minority populations. The aim of this paper is to review the evidence of risk, health outcomes and interventions for certain diseases that affect the UK's largest ethnic minority group (South Asians) in order to help professionals better address the needs of this diverse population. Research evidence is presented on factors influencing access to services by ethnic minority populations and the changing UK policy background for public health and preventive care. The available research base on obesity, diabetes and CVD is discussed. Conditions such as type 2 diabetes, which are more prevalent among the South Asian population, are associated with poorer health outcomes and appear to exhibit links to diet and nutrition that start in childhood or even before birth; all making preventive care important. Obesity is a major risk factor and it appears that BMI thresholds may need to be lower for South Asians. Targeted interventions to improve diet and outcomes in the South Asian population also appear promising. Recent moves to promote access to evidence of ethnicity and health and to improve the cultural competence of organisations are discussed. Health professionals will increasingly need to promote lifestyle changes in a manner that meets the needs of a diverse population in order to address future public health challenges. Nutritionists and other professionals will need to ensure that interventions are culturally appropriate and involve engagement with extended family members and communities.

Insulin resistance and management of the menopause: a clinical hypothesis in practice

Insulin resistance (IR) is associated with a number of metabolic abnormalities including glucose intolerance, dyslipidemia and central obesity (the metabolic syndrome), which predispose to cardiovascular disease, diabetes mellitus and some cancers. The incidence of many of these conditions increases after the menopause, a time when IR also increases. Medical intervention to help alleviate menopausal symptoms, frequently vasomotor in origin, usually involves hormone replacement therapy (HRT), but some women may only experience partial symptom relief. We have hypothesized that this may be due to concurrent IR. Our approach is therefore to manage menopausal symptoms in conjunction with the treatment of any concurrent IR, achieved through a combination of hormone replacement, dietary intervention and, if necessary, an insulin sensitizer. We suggest that this approach may not only improve symptom relief but may also reduce the risk of developing more serious health complaints in the future.

Practical management of diet and lifestyle interventions for people with diabetes or cardiovascular disease

Increased collaboration between the vascular specialities is clearly leading to increased understanding of the interrelationships between the different disease states and how each impacts and influences the other. This advantage will be reflected in improved patient care if the practical outputs of this growing knowledge are carefully implemented at service level. This article outlines how the aspects of diet and lifestyle associated with vascular-related disease complement, contrast and in some cases contradict each other. It gives information and guidelines as to how the expertise of dietitians working in the different specialist areas might usefully be shared to be of maximum advantage to all patients.

An assessment of lifestyle video education for people newly diagnosed with type 2 diabetes

BACKGROUND

Education plays a key role in the development of self-management skills for people with type 2 diabetes, although there is limited evidence for the use of video education.

AIMS

To develop a video-based lifestyle education programme for people newly diagnosed with type 2 diabetes and to evaluate changes in knowledge, biomedical indices and quality of life.

METHODS

Forty-two newly diagnosed type 2 diabetic subjects were recruited and randomly allocated to either a video education or control group. Data were collected at baseline and 6 months after the intervention. Subjects (43% male) had a mean (SD) age of 60.8 (9.6) years, weight 89.5 (15.5) kg, BMI 31.3 (5.1) kg m(2), glycated haemoglobin (A1c) 7.4 (1.7)%, total cholesterol 4.7 (1.2) mmol L(-1), high-density lipoprotein cholesterol 1.15 (0.34) mmol L(-1), triglycerides 1.8 (1.0) mmol L(-1), low-density lipoprotein cholesterol 2.8 (1.0) mmol L(-1), pedometer reading 5721 (3446) steps per day. There were 63.7% correct answers given to the ADKnowl questionnaire and the WHO-5 Well-Being score was 65.8%.

RESULTS

At 6 months, the intervention group showed increased knowledge compared to controls (74.3% versus 56.4% correct answers, P < or = 0.0001). Although there were no significant differences in changes over 6 months between the two groups, the intervention group showed improvements in A1c (-0.7%, P = 0.024), total cholesterol (-0.5 mmol L(-1), P = 0.017), low-density lipoprotein cholesterol (-0.5, P = 0.018) and increased physical activity measured by pedometer (1266 steps per day, P = 0.043) from baseline, with no significant changes in the control group.

CONCLUSIONS

A brief video intervention increased diabetes knowledge amongst those newly diagnosed with type 2 diabetes and may comprise an effective way of directing education to such individuals.

Dietary strategies for patients with type 2 diabetes in the era of multi-approaches; review and results from the Dietary Intervention Randomized Controlled Trial (DIRECT)

Dietary intervention is recognized as a key component in prevention and management of type 2 diabetes (T2DM) and the debate persists: which dietary strategy is most effective. In the Dietary Intervention Randomized Controlled Trial (DIRECT) 322 moderately obese participants were randomized for 2 years to one of three diet groups: low-fat, Mediterranean and low-carbohydrate. Differential effects were observed in the sub-group of patients with T2DM at 24 months: participants randomized to the Mediterranean diet, which had the highest intake of dietary fibers and unsaturated to saturated fat ratio, achieved greater significant improvements in fasting plasma glucose and insulin levels. Patients who were randomized to the low-carbohydrate diet, which had the minimal intake of carbohydrates, achieved a significant reduction of hemoglobin A1C. Although improvements were observed in all groups, the low-fat diet was likely to be less beneficial in terms of glycemic control and lipid metabolism. Interpretation of results from different studies on dietary strategies may be complex since there is often no consistency in diet compositions, calorie restriction, intensity of intervention, dietary assessment or extent of adherence in the trial. Nevertheless, it seems that low fat restricted calorie diets are effective for weight loss and are associated with some metabolic benefits; however, some recent trials have shown that low carbohydrate diets are as efficient in inducing weight loss and in some metabolic measures such as serum triglycerides and HDL-cholesterol may be even superior to low fat diets. When addressing the issue of diet quality rather than quantity applying the glycemic index may have some added benefits. Furthermore special features of the Mediterranean diet have apparent additional favorable effects for patients with T2DM.

Use of low-glycaemic index bread to reduce 24-h blood glucose: implications for dietary advice to non-diabetic and diabetic subjects

The present study investigated the effect of a simple dietary change on 24-h blood glucose. In a randomized cross-over design, 10 healthy subjects were prescribed a low-glycaemic-index (LGI) diet and a high-glycaemic-index (HGI) diet. The diets were identical with the exception of the type of bread consumed (LGI or HGI). Glucose concentrations over 24 h were measured using a continuous glucose monitoring system. The LGI diet resulted in a lower mean glucose response compared with the HGI diet over 24 h (P=0.135), during the day (P=0.171) and at night (P=0.100). Similarly, the 24-h, daytime and overnight incremental area under the curve for glucose following the LGI diet was consistently lower than following the HGI diet (P=0.093, P=0.132 and P=0.061, respectively). The results demonstrate how a very simple dietary change can favourably alter overall blood glucose concentrations. Such small modifications to the diet, if adopted in the long term, could improve glucose control and consequently reduce the risk of chronic disease in both diabetic and non-diabetic individuals.

Dietary education tools for South Asians with diabetes

PURPOSE

South Asian immigrants to Canada are at high risk for developing diabetes, and culturally relevant diet counselling tools are needed. We examined perceived needs and preferences for diet counselling resources based on the newly revised Canadian Diabetes Association meal planning guide.

METHODS

Five focus groups of individuals from different regions of South Asia (n=53) discussed portion size estimating methods, cultural values and holidays, food group classifications, and common South Asian foods. A focus panel with dietitians (n=8) provided insight on current diabetes education methods and resources for teaching South Asian clients.

RESULTS

The dietitian panel members reported a need for resources targeted at differing client skill levels. They also noted preferences for individual counselling, and common barriers to education including finances, access, South Asian diets, and cultural views on health. Community focus groups reported larger portions but fewer daily meals in Canada. Ingredients and portions were not measured. Fasting was an important value, and sweets were a crucial component of holidays. Resources in South Asian languages, inclusion of pictures, and separate legumes, sweets, and snacks food groups were preferred.

CONCLUSIONS

Findings can be used when developing new counselling tools for the South Asian community.

Gestational diabetes mellitus: developments in diagnosis and treatment

After many years of uncertainty regarding the true pathological nature of mild gestational diabetes and the possible benefits of treatment, the situation appears to have been resolved by the publication of the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS). It is now appropriate for obstetric units to review their treatment and screening programs for gestational diabetes mellitus. Furthermore, with the publication of the Metformin in Gestational Diabetes (MiG) trial, consideration should be given as to whether metformin should be the first choice when diet fails to maintain glycemic control.