Diet and nutrition
The dietary management of diabetes is the corner stone of its management. The exact nature of the approach recommended to people with diabetes has changes dramatically over the last 100 years and remains an area of much debate and controversy.
History of diet and nutrition in the management of diabetes
Historically, before the discovery of insulin, for type 1 diabetes, the only option was palliative management using a very low carbohydrate diet. With the discovery of insulin this allowed for the inclusion of limited amounts of carbohydrate. For many years nutritional advice for people with diabetes was defined by restriction and carbohydrate counting. Firstly by counting lines (black lines for carbohydrate and red lines for fat) and then by carbohydrate exchange, although no longer used, many patients may still follow these systems. During the 1980s and 1990s, there was a move away from carbohydrate counting and restriction with the rise in popularity low fat diets following the development of the’ fat – heart health’ hypothesis. This led to the dietary approach that was advocated being the same as the healthy eating messaged used for the wider population.
Reintroduction of counting carbohydrate
In many parts of Europe however, for type 1 diabetes carbohydrate counting remained the key nutritional management strategy. This developed as part of Therapeutic Patient Education (TPE) which has been translated into programmes such as DAFNE (Dose Adjustment for Normal Eating) in the UK. This has takes the approach that the key management principle is being able to match insulin to blood glucose. As the dietary carbohydrate is the primary determinant of blood glucose in type 1 diabetes. Being able to estimate carbohydrate intake and give a corresponding appropriate dose of insulin has become the nutritional management of choice in this group.
Type 2 diabetes is different
At this time, there also was a challenge to the view that the nutritional management of type 2 diabetes should be the same as for type 1 diabetes. Around 80% of individuals with type 2 diabetes are overweight or obese, and therefore weight management has become the primary approach. It is known that weight management can both improve the hyperglycaemia, reduce blood pressure and overall cardiovascular risk. The exact dietary approach to losing weight is less clear, as long as the nutritional approach is adequate (except for energy intake), the exact balance of macronutrients (protein, carbohydrate and fat) can vary according to individual patient preferences. Whichever approach is chosen, the key to the intervention must be the long term sustainability of any dietary and lifestyle changes.
This section looks at the nutritional management of diabetes across a range of situations, including in relation to sport and exercise, the effect of other concomitant illnesses on diabetes (including bowel preparation) and the dietary management of type 1 and type 2 diabetes.