Dietary Therapies for the management of Diabetes Position Statement

Low Carbohydrate Diets

The cornerstone of diabetes management is undoubtedly diet and lifestyle. More recently emerging evidence, as well as increased media coverage, on low carbohydrate and high fat diets has sparked a wave of interest by patients and health professionals.

Gloucestershire Diabetes Teams have reviewed their local position regarding these diets to ensure consistent and clear messages are delivered by all professionals supporting the management of individuals with diabetes.

Two national bodies (The British Dietetic Association and Diabetes UK) have issued statements regarding Low Carbohydrate and High Fat diets for the management of Type 2 Diabetes.

A Low carbohydrate diet is a collective term used to describe any form of carbohydrate restriction. This includes significant variation and the evidence and strength of studies vary. The following definitions apply (Accurson et al 2008)

Moderate carbohydrate : 130g – 225g/day

Low 130g/day

Very Low 30g/day

Type 1 Diabetes

The evidence to support the use of low-carbohydrate diets in people with Type 1 diabetes is limited. The Diabetes Control and Complication Trial showed that lower carbohydrate, and higher saturated, monounsaturated and total fat intake were associated with higher HbA1c levels (Delahanty et al, 2009).There is a lack of robust, good quality and long term evidence to support the universal use of low carbohydrate diets as a standard approach (<50g/day) for all individuals with diabetes.

In Individuals with Type 1 diabetes we are unable to universally advise low carbohydrate diets as a standard approach. Should an individual choose to follow a carbohydrate restricted plan (of varying amounts)they should access specialist diabetes care and seek advice from the specialist care team before commencing restricted carbohydrate plans and during the time they apply this restriction.

The local policy for the management of Type 1 diabetes is within the Secondary care Specialist Diabetes Team where they have access to a multidisciplinary team including a specialist dietitian.

Type 2 Diabetes

In Individuals with Type 2 diabetes we are unable to universally advise low carbohydrate diets as a standard approach, carbohydrate sources, intake and amounts are discussed in the County’s diabetes education programme which is available to all patients in Gloucestershire with a diagnosis of Type 2 diabetes. For patients who attend either the community or secondary care diabetes services, assessment by a registered dietitian is a key component of care, where carbohydrate intake and possibilities for reduction is assessed on an individual basis.

As with many prescriptive diets, there is a lack of evidence relating to the long term benefits and risks of following this diet for individuals with Type 2 Diabetes. There is a behavioural element to consider with all levels of prescriptive advice and plans.

There are a range of options that would enable people to achieve an improvement in HbA1c and weight. It is therefore an essential component of considering carbohydrate restriction is that each individual is assessed and advised by an appropriately trained health care professional, preferably a Registered Dietitian.

When considering low carbohydrate diets it is essential to ensure nutritional adequacy from a range of nutrient dense foods. This is particularly vital when our Type 2 population includes women of child bearing age and children. Special consideration needs to be given where Type 2 diabetes co-exists with other co-morbidities where there are specific dietary guidelines for their management. Examples include chronic kidney disease, Coeliac Disease and Cardiovascular Disease.

At present, given the current evidence base and the individualised nature of Type 2 Diabetes, we are not currently in a position to routinely promote the use of a Low Carbohydrate/High Fat diet for the management of Type 2 Diabetes.

Cautions/special considerations

Apply extreme caution for patients on insulin who should not restrict diet without formal advice

Pancreatic insufficiency

Uncertainty regarding Type of diabetes diagnosis

Co-existing endocrine disease

Gestational group or those planning pregnancy

Consideration for supporting an individual who wishes to restrict carbohydrate should include the following as stated by Diabetes UK;

  • A range of approaches to weight loss should be considered with the overall aim of energy intake being less than energy expenditure; and that the most appropriate method to achieve this is identified between the person with diabetes and their dietitian.
  • When considering a low-carbohydrate diet as an option for weight loss, people with diabetes should be made aware of possible side effects such as the risk of hypoglycaemia, head-aches, lack of concentration and constipation.
  • Diabetes control should be considered and blood glucose levels need to be closely monitored with adjustments to medications as required.
  • Nutritional adequacy should be considered ensuring that optimal amounts of vitamins, minerals and fibre are supplied by the diet.
  • The amount of carbohydrate to be restricted should be agreed between the person with diabetes and their dietitian.

How to access support for someone with Diabetes where it is clinically indicated that weight loss and/or HbA1c requires reduction.

Structured education

Diabetes and You

Diabetes Food and You

Diabetes, Insulin and You

This team includes registered dietitians who are also available for individual consultations (subject to referral criteria)

Secondary Care Diabetes Team:

This team includes Consultants, Specialist Nurses and Specialist Dietitians offering individualised assessment.

Tier 3 Specialist Weight Management Service

For those with a BMI greater than 40kg/m² and Type 2 Diabetes

This includes non-surgical specialist management of weight and is a pre-requisite for those considering surgical management of their weight.

This service includes Specialist Dietitians, Psychologists and Nurses available for individualised assessments and treatments.

Tier 2 Slimming World

12 weeks free on referral

Useful websites

Caution: this is a forum for people with Diabetes. It is not moderated by health professionals and the advice posted does not always reflect current evidence and guidance.

This document has been jointly produced by Diabetes Specialist Teams in Gloucestershire. July 2016

References

Accurso A, Bernstein R, Dahlqvist A, Drazini B, Finman R, Fine E, Gleed A, Jacobs D, Larson G, Lustig R, Manninen A, Mcfarlane S, Morrison K, Nielsen J, Ravnskov U, Roth K, Silvestre R, Sowers J, Sundberg R, Volvek J, Westman E, Wood R, Wortman J and Vernon M (2008). Dietary carbohydrate restriction in type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal. Nutrition and Metabolism 5; 9

Delahanty L, Nathan D, Lachin; Hu B; Cleary P; Ziegler G; Wylie-Rosett J; Wexler D (2009). Association of diet and glycated hemoglobin during intensive treatment for type 1 diabetes in the Diabetes Control and Complications Trial. American Journal of Clinical Nutrition 89; 518–524

Dyson,P (2015). Low Carbohydrate Diets and Type 2 Diabetes: What is the Latest Evidence? Diabetes Therapy 6; 411-424. accessed 10.04.17

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