Evidence Based Nutrition Guidelines For The Prevention Of Diabetes

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This Book covers the following topics: Nutrition management, Prevention of Type 2 diabetes in high risk group, Nutrition recommendations for people with diabetes, Nutrition recommendations for managing diabetes and related complications, Micronutrients, Nutrition support, Cystic fibrosis,Disorders of the pancreas, Coeliac disease, Nutrition provided by external agencies, Fasting, supplements and functional foods.

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Evidence-Based Nutrition Guidelines For The Prevention And Management Of Diabetes

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2 Evidence-based nutrition guidelines for the prevention and management of diabetes

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Evidence-based nutrition guidelines for the prevention and management of diabetes 3 Diabetes UK Nutrition working group members Diabetes UK Nutrition Working Group members Dr Trudi Deakin Advanced Diabetes Practitioner Want to Cure Diabetes Click Here

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4 Evidence-based nutrition guidelines for the prevention and management of diabetes Alastair Duncan Principal Dietitian HIV Guy’s and St Thomas’ Hospital NHS Foundation Trust Dr Pamela Dyson Research Dietitian Oxford Centre for Diabetes Endocrinology and metabolism OCDEM Churchill Hospital Professor Gary Frost Head of Nutrition and Dietetic Research group Faculty of Medicine Imperial College Zoe Harrison Clinical Advisor and Dietitian Diabetes UK Tracy Kelly Clinical Team Manager and Dietitian Diabetes UK Editors: Tracy Kelly Pam Dyson Deepa Khatri Clinical Advisor and Dietitian Diabetes UK Denise Kunka Diabetes Specialist Dietitian Royal Free Hospital NHS Trust Paul McArdle Lead Clinical Dietitian Birmingham Community Healthcare NHS Trust Duane Mellor Senior Lecturer Nutrition and Dietetics Chester University Lindsay Oliver Consultant Dietitian Northumbria Healthcare Joy Worth Diabetes Specialist Dietitian Manchester Diabetes Centre We would like to thank the staff at Diabetes UK and the Publishing Digital Media Library and Information teams for supporting this project. We would also like to thank colleagues at BDA DMEG and Coeliac UK for their contribution. Contents Contents 1 Introduction 5 2 Aims and goals 6 3 Nutrition management and models of education 7 4 Prevention of Type 2 diabetes in high risk groups 9 To Cure Diabetes Click Here X-PERT Health

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Evidence-based nutrition guidelines for the prevention and management of diabetes 5 5 Nutrition recommendations for people with diabetes 12 5.1Glycaemic control for Type 1 diabetes 12 5.2 Glycaemic control of Type 2 diabetes 15 5.3 Weight management 17 5.4 Cardiovascular disease – blood lipids and blood pressure 19 6 Nutrition recommendations for managing diabetes-related complications 22 6.1 Short-term complications hypoglycaemia 22 6.2 Long-term complications 23 6.2.1 Macrovascular complications 23 6.2.1.1 Cardiovascular disease 23 6.2.2 Microvascular complications 23 6.2.2.1 Diabetic nephropathy 23 6.2.2.2 Lower limb ulcers and amputations 24 6.2.2.3 Gastroparesis 24 6.2.2.4 Retinopathy 24 7. Additional considerations 25 7.1 Nutrition support 25 7.2 Disorders of the pancreas 26 Contents 7.3 Older person 26 7.4 Cystic fibrosis – related diabetes mellitus CFRD 26 7.5 Coeliac disease 27 7.6 Pregnancy and lactation 29 7.7 HIV and insulin resistance 30 7.8 Nutrition provided by external agencies 30 7.9 Fasting 30

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6 Evidence-based nutrition guidelines for the prevention and management of diabetes 7.10 Eating disorders 30 8. Micronutrients supplements and functional foods 32 Appendix One : Grading scheme for recommendations Appendix Two: Overview of major nutrition recommendations 33 included in the guidance 34 Note about these guidelines: These guidelines represent the view of Diabetes UK which were arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not however override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and/or guardian or carer. Introduction

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Evidence-based nutrition guidelines for the prevention and management of diabetes 7 To Cure Diabetes Naturally Click Here Introduction The purpose of this paper is to provide evidence-based recommendations for the practical implementation of nutrition advice in the UK. It is almost 10 years since Diabetes UK published dietary recommendations for people with diabetes. Since then the evidence base for nutritional recommendations has been extensively reviewed by the American Diabetes Association ADA and the American Dietetic Association. The Diabetes UK nutrition working group of Diabetes UK is in agreement with the conclusions reached in these technical reviews and with the recommendations based on those conclusions. The literature review for the ADA recommendations was completed in 2006/2007 and the nutrition working group proposed that the new guidelines should be drawn from the existing technical reviews together with a review of published evidenced from 2008 to august 2010. The nutrition guidelines are relevant to people at high risk of developing Type 2 diabetes and people with Type 1 and Type 2. Children are not included in the scope of these guidelines. The International Society of Paediatric and Adolescent Diabetes ISPAD clinical practice guidelines 2009 have been adopted by Diabetes UK. The criteria for the grading of recommendations in this document are based upon a paper by Petrie et on behalf of the Scottish Intercollegiate Guidelines Network. Appendix one Many studies rely on surrogate markers rather than hard end points eg studies reporting change in lipid levels rather than cardiac event rates and some of the recommendations made in this document are based upon this type of evidence. A criticism often made about new guidelines is that they fail to acknowledge previous or competing guidelines 1. These guidelines address this by adopting a system of signposting relevant current guidelines for each section and these are highlighted by the following symbol: 2. Aims and goals 2 . Aims and goals

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8 Evidence-based nutrition guidelines for the prevention and management of diabetes Nutrition management is fundamental for the prevention of Type 2 diabetes and the effective management of both Type 1 and Type 2 diabetes. The purpose of these guidelines is to provide information to healthcare professionals and people living with diabetes about nutritional interventions that will assist them in making appropriate food choices to reduce risk and improve glycaemic control and quality of life in relation to their diabetes. Advice needs to be based on scientific evidence and then tailored specifically for the individual taking into account their personal and cultural preferences beliefs lifestyle and the change that the individual is willing and able to make. An individual’s circumstances may change over time and all advice should be tailored accordingly. Achieving nutrition related goals requires a co- ordinated team approach with the person with diabetes at the centre of the decision making process. A registered dietitian with specialist knowledge should take the lead role in providing nutritional care. However it is important that all members of the multi-disciplinary team are knowledgeable about diabetes-related nutrition management and support its implementation. The beneficial effects of physical activity in the prevention and management of diabetes and the relationship between physical activity energy balance and body weight are an integral part of lifestyle counseling and have been discussed in this document. The aim of these Diabetes UK nutritional guidelines is to establish individualised evidence-based recommendations for people with diabetes and those at high risk of developing Type 2 diabetes which: • support self management to reduce the risk of Type 2 diabetes and its associated co-morbidities • promote quality of life and healthy lifestyles • provide flexibility and meet the needs of all individuals including those with co-morbidities such as Coeliac disease and Cystic fibrosis. Nutrition management and models of education 3. Nutrition management and models of education Recommendations • Nutrition management is effective in people with diabetes and those at high risk of developing Type 2 diabetes when it is an integrated component of education and clinical care. A • Everyone with diabetes should receive individual ongoing nutritional advice from a registered dietitian. A

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Evidence-based nutrition guidelines for the prevention and management of diabetes 9 • All people with diabetes and/or their carer should be offered structured education at the time of diagnosis with an annual follow-up. A • Education should involve a person-centred approach and a variety of learning styles. A Nutrition and lifestyle education programmes have been shown to be effective in delaying the onset of Type 2 diabetes 2 3 and in achieving treatment goals for intermediate risk factors such as glycaemia lipids and blood pressure 456. Structured education programmes are beneficial and clinical effective for individuals with Type 1 and Type 2 diabetes 7 8 9 10 1112 13 14 and should comply with criteria outlined in National Institute for Health and Clinical Effectiveness NICE guidance see signposts. Culturally appropriate health education is more effective than the usual health education for people from ethnic minority groups 15. Educational visual aids are effective tools to support diabetes self-management 8 and are useful when educating individuals whose first language is not English or for those with sub-optimal literacy skills 16. Telemedicine is an acceptable and feasible form of communication and is another tool that can be used for patient education. However there is little evidence related to its effect on health outcomes 1718. There is consensus that person-centred care and self-management support are essential evidence- based components of good diabetes care 19 resulting in better quality of life improved outcomes and fewer diabetes-related complications 20. Nutrition management has shifted from a prescriptive one-size fits all approach to a person- centred approach. A person-centred approach puts the person at the centre of their care and involves assessing the person’s willingness and readiness to change tailoring recommendations to their personal preferences and joint decision making 5. Training in patient-centeredness and cultural competence may improve communication and patient satisfaction however more research is needed to ascertain whether this training makes a difference to healthcare use or outcomes 2122.

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10 Evidence-based nutrition guidelines for the prevention and management of diabetes Nutrition management and models of education A registered dietitian with expertise in diabetes care should be providing nutrition advice to all people with diabetes or at high risk of developing diabetes. When commissioning specialist diabetes services it is recommended that there are four whole time equivalent WTE diabetes specialist dietitians per 250000 of the total population see signposts . Nutrition and weight management an area of concern for people with diabetes with many requesting better access to a registered dietitian 23. Relevant dietetic and nursing competencies for the treatment and management of diabetes including the facilitation of diabetes self management have been developed 2425. Nutrition interventions and self management group education have been shown to be cost effective 26 27 28 in high risk groups 29 and people with Type 1 30 and Type 2 31 diabetes and are associated with fewer visits to physician and health services with reductions of 23.5 per cent and 9.5 per cent respectively 32. NICE 2011 Diabetes in adults quality standards. National Institute of Health and Clinical excellence NICE 2003 Diabetes Types 1 and 2 – patient education models. Technology Appraisal TA60. National Institute of Clinical Excellence London For diabetes information in different languages visit the Diabetes UK language centre: www.diabetes.org.uk/languages Diabetes UK Task and finish group group report 2010. Commissioning specialist services for adults with diabetes. www.diabetes.org.uk/SpecialistServices

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Evidence-based nutrition guidelines for the prevention and management of diabetes 11 Prevention of Type 2 diabetes in high risk groups To Cure Diabetes in 21 Days Click Here 4. Prevention of Type 2 diabetes in high risk groups Recommendations • Weight loss is the most important predictor of risk reduction for Type 2 diabetes. Weight loss of at least 5 to 7 per cent is effective for Type 2 diabetes prevention. A • Lifestyle interventions that incorporate energy restriction low fat diets and increased physical activity can effectively reduce the risk of Type 2 diabetes in high risk groups. A • There is no evidence for the most effective dietary approach over another to achieve weight loss and prevent Type 2 diabetes. D • Interventions promoting diet alone increased physical activity alone or a combination of the two is equally effective in reducing risk. A • Dietary patterns characterised by low intakes of saturated fat and higher intakes of unsaturated fat are protective. B • Diets of low glycaemic index/load and higher in dietary fibre and wholegrains are protective. B • Some specific foods low fat dairy foods green leafy vegetables coffee and moderate intakes of alcohol are associated with reduced risk of Type 2 diabetes. B • Other foods red meats processed meat products and fried potatoes are associated with increased risk of Type 2 diabetes. B There is now strong evidence from randomised controlled trials that lifestyle interventions incorporating diet and physical activity can prevent Type 2 diabetes in high risk individuals from different ethnic backgrounds 33 34 35 and that intensive lifestyle interventions are rated as very cost-effective 36. The risk of Type 2 diabetes is reduced by 28 to 59 per cent after implementation of lifestyle change 37 and there is some evidence of a legacy effect with three trials reporting lower incidences of Type 2 diabetes at 7 to 20 years follow-up beyond the planned intervention period 33 38 39. The main components of these lifestyle interventions included weight loss reduction in fat intake and increased physical activity. The most dominant predictor for Type 2 diabetes

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12 Evidence-based nutrition guidelines for the prevention and management of diabetes prevention is weight loss every kilogram lost is associated with a 16 per cent reduction in risk 40. However there is little evidence supporting the best approach for weight reduction in people at risk of Type 2 diabetes. The four major randomised trials used largely similar dietary approaches which were characterised by modest energy reduction and reductions in total and saturated fat intake. This strategy for weight loss is promoted by all major diabetes organisations 4142 but evidence is emerging that alternative dietary methods may be as effective including the Prevention of Type 2 diabetes in high risk groups Mediterranean diet 43 low carbohydrate diets 44 and meal replacements 45. Further research is needed in this area to identify the optimal diet for weight loss and Type 2 diabetes prevention and there may be opportunities to increase flexibility in dietary approaches for people at risk of Type 2 diabetes 37. Most trials of lifestyle interventions to prevent Type 2 diabetes use a combination of diet and physical activity and do not distinguish the individual contributions of each component. One trial has reported that there were no differences in progression to Type 2 diabetes in high risk individuals randomly allocated either diet alone physical activity alone or a combination of the two 33. A recent review also states that there is no significant difference between approaches incorporating diet physical activity or both 46 although there is evidence that in the absence of weight loss increased physical activity can reduce the incidence of Type 2 diabetes by 44 per cent 40. Epidemiological evidence from large studies has shown that there are components of the diet that may protect against Type 2 diabetes and these are summarised in the table opposite. There are also specific vitamins and minerals that have been associated with a lower incidence of Type 2 diabetes although these are usually taken as supplements rather than obtained from food. Epidemiological evidence suggests that high intakes of Vitamin D and calcium 59 and magnesium 60 may reduce risk but the effect of chromium remains uncertain 61. One of the most challenging aspects of Type 2 diabetes prevention remains the general application of positive results from clinical trials. There are on-going studies investigating different strategies in the community 62 63 64 but at present there is little evidence in translation of the success of randomised controlled trials to public health.

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Evidence-based nutrition guidelines for the prevention and management of diabetes 13 Prevention of Type 2 diabetes in high risk groups Dietary component Specific foods: Factors related to reduced risk Factors related to increased risk Nutrients Carbohydrate: Glycaemic index Fat: Total and saturated fat Protein: Red meat High GI diets increase risk by 40. Highest quintile mean GI 83.1 associated with 59 increased risk 47 Relative risk increased by 26 for each serving increase of red meat 50. Processed meat increases risk. Highest quintile ≥ servings / week associated 5 with 46 increased risk 51. Relative risk increased by 19 for each serving increase of processed meat 52. Wholegrains Dairy products 4 or more cups/ day decrease risk by 47 51 58 risk reduction associated with 15 – 29.9 g/ day 1.5 – 3 UK units 57 2 weekly servings of fried potatoes increases risk by 16 58 Fruit and vegetables Coffee Alcohol Potatoes and fried potatoes Processed meat Wholegrains have a protective effect. Highest quintile mean 3.2 servings/day associated with risk reduction of 31 48 Dairy products are protective. Each serving/ day increase is associated with a risk reduction of 9 in men and 4 in women 5354 Green leafy vegetables reduce risk an increase of 1.15 servings/day associated with 14 decrease in incidence 55 highest quintile median 1.42 servings/ day associated with risk reduction of 30 56 Replacing saturated fat with unsaturated fat has a beneficial effect on insulin sensitivity 49

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Nutrition recommendations for people with diabetes 14 Evidence-based nutrition guidelines for the prevention and management of diabetes To Cure Diabetes Permanently Click Here 5 . Nutrition recommendations for people with diabetes 5.1 Glycaemic control and Type 1 diabetes Recommendations • Carbohydrate is the main nutritional consideration for glycaemic control in individuals with Type 1 diabetes A • People using multiple daily injections MDI and continuous subcutaneous insulin infusion CSII benefit from adjusting insulin to carbohydrate intake and should be offered education to support this A • Consistent quantities of carbohydrates on a day-to-day basis are beneficial for those people on fixed insulin regimens C • Increased physical activity offers general health benefits although there is no evidence of benefit in glycaemic control A Carbohydrate – amount and type Carbohydrate is the main nutritional consideration for people with Type 1 diabetes in terms of glycaemic control and both the amount and type have an effect on post-prandial blood glucose levels. Amount of carbohydrate There is no evidence for a recommended ideal amount of carbohydrate for maintaining long term glycaemic control in people with Type 1 diabetes. Intervention studies have failed to show any significant effect on glycaemic control of manipulating carbohydrate 65 666768. On a meal-by-meal basis matching insulin to the amount of carbohydrate consumed carbohydrate counting and insulin dose adjustment is an effective strategy in improving glycaemic control. Randomised controlled trials have shown carbohydrate counting can improve glycaemic control quality of life and general well-being 69707172 without increases in severe hypoglycaemic events body weight or blood lipids 73 74. Carbohydrate counting and insulin adjustment have proven to be efficacious and cost effective in the long term 75. These strategies can only be utilised by individuals treated by MDI or CSII where prandial insulin doses can be manipulated according to carbohydrate intake. For individuals on fixed or biphasic insulin regimens consistency in the quantity of carbohydrate glycaemic index

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Evidence-based nutrition guidelines for the prevention and management of diabetes 15 GI and starch on a day-to-day basis are all beneficial and have been positively associated with improved HbA1c levels 76. Type of carbohydrate The amount of carbohydrate ingested is the primary determinant of post-prandial blood Nutrition recommendations for people with diabetes glucose response but the type of carbohydrate also affects this response. Studies have investigated the effects of glycaemic index dietary fibre and sugar on glycaemic control. Glycaemic index GI A Cochrane review reported reductions of 0.5 per cent in HbA1c in people with diabetes adopting a low GI diet but of the 11 studies included only 1 related specifically to adults with Type 1 diabetes 77. Observational studies have shown that dietary GI is independently associated with HbA1c with intakes of high GI foods showing an association with higher HbA1c levels 78. Dietary fibre The effect of dietary fibre on glycaemic control in Type 1 diabetes is unclear. Observational studies suggest that dietary fibre of any type is associated with lower HbA1c levels with an additional benefit of reduced risk of severe ketoacidosis 79. There is little evidence from randomised controlled trials all studies in people with Type 1 diabetes are small short-term and involve daily fibre intakes double that of the guidelines for daily amounts GDA of 24 g per day. Longer-term more than six months studies investigating the benefits of a high fibre intake are scarce 80 81. High fibre intakes may be beneficial for the person with diabetes but the first priority may be to encourage them to achieve GDAs for fibre 42. Sugars and sweeteners Sucrose does not affect glycaemic control of diabetes differently from other types of carbohydrates and individuals consuming a variety of sugars and starches show no difference in glycaemic control if the total amount of carbohydrate is similar 82 83. Fructose may reduce post-prandial glycaemia when it is used as a replacement for sucrose or starch 84. Non-nutritive sweeteners are safe when consumed within the daily intake levels and may reduce HbA1c when used as part of a low-calorie diet 74 see signpost. EU Directive. European Parliament and Council Directive 94/35/EC of June 1994 on sweeteners for use in foodstuffs amended by Directives 96/83 EC and 2003/115/EC. Diabetes UK position statement on Sweeteners www.diabetes.org.uk/sweeteners2 Body weight

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Nutrition recommendations for people with diabetes 16 Evidence-based nutrition guidelines for the prevention and management of diabetes There is no published evidence of a direct relationship between body weight and glycaemic control in people with Type 1 diabetes although it should be noted that a high HbA1c may be associated with weight loss 85. There is no published evidence from randomised controlled trials that weight management in itself appears to impact glycaemic control. Physical activity Physical activity in people with Type 1 diabetes is not strongly associated with better glycaemic outcomes 7086 87 and although activity may reduce blood glucose levels it is also associated with increased hypo and hyperglycaemia 88 and the overall health benefits are not well documented 8990. On a day-to-day basis activity can lead to hyperglycaemia or hypoglycaemia dependant on the timing type and quantity of insulin carbohydrate and physical activity 89. Therapeutic regimens should be adjusted to allow safe participation in physical activity. Activity should not be seen as a treatment for controlling glucose levels but instead as another variable which requires careful monitoring to guide the adjustment of insulin therapy and/or carbohydrate intake. For planned exercise reduction in insulin is the preferred method to prevent hypoglycaemia while additional carbohydrate may be needed for unplanned activity 42. Alcohol Alcohol in moderate amounts can be enjoyed safely by most people with Type 1 diabetes and it is recommended that general advice about safe alcohol intake be applied to people with diabetes see signposts. Studies have shown that moderate intakes of alcohol 1-2 units daily confer similar benefits for people with diabetes to those without in terms of cardiovascular risk reduction and all-cause mortality 9091 and this effect has been noted in many populations including those with Type 1 diabetes 92. Recent studies have reported that a moderate intake of alcohol is associated with improved glycaemic control in people with diabetes 93 although alcohol is also associated with an increased risk of hypoglycaemia in those treated with insulin and insulin secretagogues 94. Hypoglycaemia is a well- documented side-effect of alcohol in people with Type 1 diabetes 95 and can occur at relatively low levels of intake and up to 12 hours after ingestion 96 97 . There is no evidence for the most effective treatment to prevent hypoglycaemia but pragmatic advice includes recommending insulin dose adjustment additional carbohydrate or a combination of the two according to individual need. There are some medical conditions where alcohol is contraindicated and they include hypertension hypertryglyceridaemia some neuropathies retinopathy and alcohol should be avoided during pregnancy. www.nhs.uk/Livewell/alcohol www.diabetes.org.uk/Guide-todiabetes/Healthy_lifestyle/alcohol_and_diabetes

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Nutrition recommendations for people with diabetes Evidence-based nutrition guidelines for the prevention and management of diabetes 17 5.2 Glycaemic control and Type 2 diabetes Recommendations • Weight management should be the primary nutritional strategy in managing glucose control in Type 2 diabetes for people who are overweight or obese. A • Regular moderate physical activity can reduce HbA1c by 0.45 – 0.65 per cent independent of weight loss. A • Focus should be on total energy intake rather than the source of energy in the diet macronutrient composition for optimal glycaemic control. A • The total amount of carbohydrate consumed is a strong predictor of glycaemic response and monitoring total carbohydrate intake whether by use of exchanges portions or experience-based estimation remains a key strategy in achieving glycaemic control. A • Low GI diets may redcue HbA1c up to 0.5 per cent . A Weight management Between 80 and 90 per cent of people with Type 2 diabetes are overweight and approximately 60 -90 per cent of Type 2 diabetes is obesity related 98 99. Weight loss is important in people with Type 2 diabetes who are overweight or obese and should be the primary management strategy. Weight loss can also be an indicator of poor glycaemic control the relationship between blood glucose and weight is not always straightforward. Weight gain is positively associated with insulin resistance and therefore weight loss improves insulin sensitivity 100 features of the metabolic syndrome and lowers triglycerides 101102103. Intensification of therapy is often associated with weight gain. Sulphonlyurea and glitazone therapy are associated with mean weight gain of 3kg 104 and initiation of insulin therapy is associated with 5kg weight gain 105. See section 5.3 ‘Weight management’ p 17. Physical Activity Physical activity has clear benefits on cardiovascular risk reduction and glycaemic control in people with Type 2 diabetes with a meta-analysis reporting a mean weighted reduction of 0.45 per cent 106 to 0.65 per cent 107 in HbA1c . Different types of activity have different effects aerobic exercise improves glycaemia and lowers LDL cholesterol by 5 per cent but has little effect on other lipid levels 108 and resistance training has effects on both glycaemia and cardiovascular risk factors 109. Studies show it is safe for individuals with Type 2 diabetes who are treated by diet alone or in conjunction with oral hypoglycaemic agents to exercise in both the fasting and post-meal state 110 with the most beneficial effects on blood glucose levels observed post-prandially when blood glucose levels have more potential to reduce 111. For individuals treated with

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Nutrition recommendations for people with diabetes 18 Evidence-based nutrition guidelines for the prevention and management of diabetes sulphonylureas or insulin care should be taken to minimise the impact of hypoglycaemia which can occur up to 24 hours after physical activity 107. Diet There is little evidence for the ideal macronutrient composition of the diet in the management of hyperglycaemia in Type 2 diabetes. Small short term intervention studies investigating the relationship between macronutrients and glycaemic control have reported contradictory results 112 113 114. Epidemiological evidence has shown a relationship between high fat intake high saturated fat intake and raised HbA1c levels 115 however intervention studies have failed to show any association between the type and amount of fat in meals and post- prandial glucose response 116 117 118 119 120 121 122. It is unclear what ideal proportion of macronutrients to recommend for optimal glycaemic control for Type 2 diabetes but total energy intake and weight loss are significant. Monounsaturated fat can be substituted for carbohydrate without detrimental effect to either lipids or glycaemic control but saturated fat should be minimised 116 117 118 120 . When protein is substituted for carbohydrate short-term glycaemic control improves 113114 . A modest reduction in carbohydrate intake is associated with improvements in glycaemic control and low carbohydrate diets can be particularly effective if associated with weight loss. • Carbohydrate: Although the total amount of carbohydrate ingested is the primary determinant of post-prandial blood glucose response there is little evidence to support specific strategies for recommendations about carbohydrate intake in Type 2 diabetes. The efficacy of carbohydrate counting in those individuals with Type 2 diabetes treated with insulin is largely unknown. Carbohydrate counting based on insulin to carbohydrate ratio has been shown to be as effective in reducing HbA1c as a simple algorithm based on self-monitored blood glucose SMBG 123. • Glycaemic index: Low Gl diets have shown improvements in HbA1c of up to 0.5 per cent 77 124 and the majority of studies have been performed in people with Type 2 diabetes. Although two more recent randomised controlled trials have shown no evidence of benefit of low GI to other strategies 125 126. • Dietary fibre: Dietary fibre has many health benefits 127 but the impact on hyperglycaemia is limited. Post-prandial glucose levels have been shown to be reduced on high fibre diets 20g /1000 kcal but changes in fasting plasma glucose and lower average plasma glucose levels are not significant 128. Short term studies have demonstrated little or no effect on blood glucose insulin or HbA1c 104 128 129130131. • Sugars and sweeteners: refer to the section 5.1 ‘Glycaemic control and Type 1 diabetes’ page 13.

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Nutrition recommendations for people with diabetes Evidence-based nutrition guidelines for the prevention and management of diabetes 19 5.3 Weight management Recommendations • Weight reduction for the overweight or obese person with Type 2 diabetes is effective in improving glycaemic control and cardiovascular risk factors. A • The main requirement of a dietary approach to weight loss is that total energy intake should be less than energy expenditure. D • Dietary physical activity surgical pharmaceutical approaches that are currently recommended for people without diabetes are appropriate and can be adopted by people with diabetes. D There is an absence of evidence for the role of weight loss in people with Type 1 diabetes but weight management is the most effective treatment for overweight and obese people with Type 2 diabetes and weight loss is associated with a reduction in mortality of 25 per cent 132. Uncertainties remain over the most effective dietary intervention to promote successful weight loss 133 and the gold standard the randomised controlled trial is rarely employed to compare different dietiery interventions head-to-head. Studies investigating the effect of weight loss on glycaemic control in Type 2 diabetes have utilised low fat diets also known as healthy eating low carbohydrate diets very low calorie liquid diets VLCLD meal replacements commercial diets and increased physical activity. Low-fat diets This strategy is the most widely employed in research studies and has generated the greatest amount of evidence 88. A recent large trial in the United States has shown that lifestyle interventions including a low-fat diet significantly reduced body weight HbA1c and cardiovascular risk factors and these positive changes could be maintained over four years 134. Low-carbohydrate diets Low-carbohydrate diets have created some controversy but both a recent review and metaanalysis suggest that they are associated with significant reductions in body weight and improvements in glycaemic control 121 135. It has been shown that the main mode of action of low carbohydrate diets is simply a reduction in energy intake due to carbohydrate restriction 136. Systematic reviews have reported that although these diets may be more effective than comparison diets over the short-term there is little published evidence from studies in people without diabetes showing benefit over the longer term 44 137. Concern has been expressed about the potential adverse effects of these diets especially on cardiovascular risk but there remains no evidence of harm over the short term 137. VLCLD VLCLD consist of proprietary formula foods which are the sole source of nutrition and provide a full complement of vitamins minerals electrolytes and fatty acids. Both NICE and Dietitians

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Nutrition recommendations for people with diabetes 20 Evidence-based nutrition guidelines for the prevention and management of diabetes in Obesity Management DOM UK see signposts recommend that these diets should be used for a maximum of 12 weeks continuously or intermittently with a low calorie diet. However the National Obesity Forum NOF see signposts panel report that there is no compelling requirement to restrict to a maximum duration of 12 weeks if there is adequate support and supervision. There is a suggestion that VLCD may be more effective than other strategies for weight loss in people with Type 2 diabetes 138. Meal replacements Meal replacements consist of liquid shakes soups or bars designed to be eaten in place of one or two meals daily. A meta-analysis reported that partial meal replacements produced greater weight loss than a reduced energy diet over the short term six months 139. Commercial diet programmes There is an absence of published evidence for the effect of commercial weight loss programmes in people with diabetes. These programmes utilise a variety of interventions including group therapy dietary advice and physical activity. Physical activity Physical activity in isolation is not an effective strategy for weight loss in people with Type 2 diabetes 140 unless 60 minutes per day is undertaken 141. However evidence shows that a combination of diet and physical activity results in greater weight reduction than diet or physical activity alone 142. Physical activity does have positive effects on cardiovascular risk and leads to significant reductions in diastolic blood pressure triglycerides fasting glucose 143 and glycated haemoglobin 140 144. In terms of dietary strategies for weight loss encouraging the individual to adopt their diet of choice may well improve outcomes. It is the degree of adherence that will predict outcomes rather than type of dietary strategy 145. It is intuitive that a diet an individual enjoys and finds acceptable is more likely to succeed 146.  NICE 2004 Obesity – the prevention identification assessment and treatment of overweight and obesity in adults and children. Clinical guidelines CG43. National Institute for Health and Clinical Excellence London  www.domuk.org  www.nationalobesityforum.org.uk/ 5.4 Cardiovascular disease - blood lipids and blood pressure Recommendations • Saturated fats SFA should be limited and replaced by unsaturated fats predominantly monounsaturated fats MUFA.A

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Nutrition recommendations for people with diabetes Evidence-based nutrition guidelines for the prevention and management of diabetes 21 • Daily consumption of foods fortified with plant sterols or stanols 2-3g /d significantly improve total and LDL cholesterol for people with diabetes irrespective of statin treatment. A • Reduced sodium intake combined with the Dietary Approaches to Stop Hypertension DASH or Mediterranean-style diets can lower blood pressure. A • A Mediterranean-style diet lowers blood pressure and improves HDL cholesterol and triglyceride levels. B • In overweight individuals a modest amount of maintained weight loss 4.5kg or more results in improvements in blood pressure. B • In individuals with Type 2 diabetes with elevated levels of blood triglycerides supplementation with up to 3 gram per day of n-3 marine fish oils DHA and EPA can improve blood triglyceride levels without adverse effects. B • Consumption of oily fish rich in n-3 unsaturated fats is recommended at least twice per week. B • 30 to 60 minutes of aerobic exercise on a minimum of three occasions per week minimum of 150 minutes each week and resistance training at least twice per week lower blood pressure. B • Intakes of trans-fatty acids should be limited. C Individuals with diabetes have a three to four-fold increase in cardiovascular disease CVD risk compared to those without diabetes 141 and as a result it is recommended that dietary intervention should reflect those for people with existing CVD. Dietary approaches resulting in a reduction in total and LDL cholesterol and improvements in blood pressure have been shown to improve CVD outcomes in people with and without diabetes 147. Fat intake There remains strong evidence that reductions in saturated fat and replacement with unsaturated fats particularly monounsaturated fats are effective in reducing the risk of CVD and form the basis of current recommendations across Europe and the USA 42 148149 . The exact proportion of energy that should be derived from fat is less clear and studies with percentages of energy from unsaturated fat of up to between 35 and 40 per cent have resulted in beneficial effects on lipid profiles blood pressure and weight that equal or are greater than low fat approaches 118 134 150. Recommendations for reduced intakes of Trans-fatty acids TFAs should be in line with those for the general population. A recent meta-analysis has shown between a 20 and 32 per cent higher risk of myocardial infarction MI or coronary heart disease CHD death for every two per cent of dietary energy from TFA isocalorically replacing carbohydrate SFA MUFA and PUFA 151.

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Nutrition recommendations for people with diabetes 22 Evidence-based nutrition guidelines for the prevention and management of diabetes A meta-analysis of randomised controlled trials RCTs which investigated increased poly- unsaturated fatty acid PUFA intakes found that advice to specifically increase n-6 PUFA without also increasing n-3 PUFA may increase the risk of CHD and death 152. High intakes of oily fish rich in n-3 unsaturated fats are associated with reduced incidence of and deaths from CHD 153 154 and interventions post-MI show reduced mortality in those consuming oily fish at least twice a week 155. One study has shown an increased risk of CHD mortality in men with angina consuming fish and in particular fish oil capsules although this increased risk remains unexplained 156. Although there is some conflicting evidence and concerns of potential adverse effects of fish oils and fish oil supplementation on lipid profiles there is evidence of the beneficial effects on reducing triglyceride levels for those with elevated blood triglycerides 157. A Cochrane review confirmed that in this subgroup of patients n-3 supplementation did not result in any adverse effects and may be a useful therapeutic strategy 158. Salt Reductions in salt alone are effective in lowering blood pressure in both normotensive and hypertensive individuals 159 as per the UK guidelines to consume no more than 5 –6 grams per day. Studies suggest further benefits from lower levels 3g per day to achieve this goal would require significant effort from the food industry 160. There are additional improvements seen when sodium reduction is combined with the DASH approach. Dietary Approaches to Stop Hypertension DASH The DASH diet reduces cardiovascular risk factors and incorporates elements of a Mediterranean diet the combined effect of which is greater than those achieved by the individual components. The improvements observed in Mediterranean-style diets are in addition to the effect of any weight loss and are seen in both people with and without diabetes 153 161 162. A recent small UK study has found a high degree of compliance and acceptability with a DASH-style diet 163. Studies using the DASH approach have shown the diets of participants to contain more calcium magnesium fibre dairy and fruit and vegetables than control diets 164. A small trial has shown DASH is more effective than potassium magnesium and fibre supplements for lowering blood pressure in obese hypertensive subjects 165. Dietary fibre There are no specific recommendations for individuals with diabetes but higher intakes particularly of soluble fibre may have beneficial effects on blood lipid profiles and reduced risk of CVD and CHD 147. Reductions of 2–3 per cent for total cholesterol and up to 7 per cent for LDL cholesterol may be obtained as a result of high fibre intakes. Intakes of total

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Nutrition recommendations for people with diabetes Evidence-based nutrition guidelines for the prevention and management of diabetes 23 fibre in line with dietary reference values DRV including 10–25 grams per day of soluble fibre are suggested for those at high risk of CVD 141 166. Alcohol Evidence suggests that more than two alcoholic drinks per day increases blood pressure and that drinking outside of meals may have more impact on hypertension 167 168. Low to moderate alcohol intake is associated with lower incidence of CVD but a reduction in alcohol intake in hypertensive individuals has been shown to be effective in lowering blood pressure especially if more than two drinks per day are consumed 168. A systematic review carried out for people with diabetes found one to three drinks per day is associated with between 34 and 55 per cent lower incidence of diabetes-related CHD with no impairment of glucose control 90. Plant sterol or stanol esters These are widely recognised to be effective in significantly reducing total and LDL cholesterol in people with and without diabetes 169. The reductions in LDL cholesterol are also seen in people already using cholesterol-lowering statin drugs 170. Intakes of 2 –3 grams per day of plant sterol or stanol esters are effective in lowering total and LDL cholesterol and may be recommended. Weight loss Weight loss plays an important role in reducing CVD risk. A significant loss of 10 per cent of body weight over 18 months has shown long-lasting benefits for blood pressure in Type 2 diabetes despite some weight regain 171. Small reductions in weight and waist circumference -1.3kg and -1.6cm respectively have not shown any improvements in blood pressure 172 however 4.5kg or more of sustained weight loss as part of a lifestyle approach including diet has been shown to improve diastolic blood pressure 147. Physical activity Increased physical activity is associated with reductions in cardiovascular risk in both Type 1 and Type 2 diabetes 88 106 173. The most recent recommendation from the American Dietetic Association 174 suggests that maximum benefit is obtained from undertaking moderate aerobic activity at least three times weekly a total of 150 minutes per week together with resistance training at least twice weekly.

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24 Evidence-based nutrition guidelines for the prevention and management of diabetes Nutrition recommendations for managing diabetes related complications To Cure Diabetes Naturally Click Here 6 . Nutrition recommendations for managing diabetes-related complications 6.1 Short-term complications hypoglycaemia Recommendations • 15 –20g glucose should be used to treat hypoglycaemia. If glucose levels have not risen above 4mmol/l after 15 minutes treatment should be repeated. C • A follow up 15–20g carbohydrate snack may be necessary to reduce the risk of further hypoglycaemia. C In people taking insulin or insulin secretagogues changes in food intake physical activity or medication can contribute to the development of hypoglycaemia 42. The goal of treatment is to relieve hypoglycaemic symptoms and limit the risk of injury while avoiding over-treating. Glucose is the preferred treatment for hypoglycaemia with a 10g and 20g dose of oral glucose increasing blood glucose levels by approximately 2mmol/l and 5mmol/l respectively 42 . Sucrose may be as effective 175 176 177 and may be more palatable. The glycaemic response of a food used to treat hypoglycaemia is directly related to its glucose content and as fruit juice and sucrose only contain half the amount of carbohydrate as glucose a larger portion would be needed to produce the same effect 178. Glucose levels often begin to fall approximately 60 minutes after glucose ingestion 42 hence the practice of introducing a follow-on carbohydrate snack despite the lack of robust supporting evidence. One small study has shown that a follow-on snack providing a more sustained glucose release may be useful to prevent the re-occurrence of the hypoglycaemic episode 179. Treatment regimens and individual circumstances vary and although glucose is recommended as a first-line treatment for any hypoglycaemic episode taking extra starchy

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Evidence-based nutrition guidelines for the prevention and management of diabetes 25 carbohydrate may be necessary for prolonged hypoglycaemia. It is recommended that hypoglycaemia treatment strategies are tailored to individual needs. The prevention of hypoglycaemia is preferable to its treatment. Where lifestyle factors such as exercise or alcohol consumption may contribute to hypoglycaemia proactive steps can often be taken to minimise any risks. www.diabetes.org.uk/hypo See section 5.1 ‘Glycaemic control and Type 1 diabetes’ page 12. Sports advice for people with Type 1 diabetes – www.runsweet.com Nutrition recommendations for managing diabetes related complications 6.2 Long-term complications Recommendations • Glycaemic control should be the main focus for preventing and slowing the rate of developing diabetes related complications. A • Nutritional management should be an integral part of the care package. D Glycaemic control is strongly associated with risk and progression of diabetes related complications. However the role of specific nutrition management in the prevention and management of diabetes related complications is not supported by evidence from randomised controlled trials. As nutritional management is part of the package of care used to improve glycaemic control good practice would be to offer dietetic advice and support to those with diabetes related complications. 6.2.1 Macro-vascular complications coronary artery disease peripheral artery disease and stroke . 6.2.1.1 Cardiovascular disease There have been no randomised control studies in people with diabetes and cardiovascular disease lasting longer than six months. It is well documented that people with diabetes have the equivalent CVD risk as people with pre-existing CVD and no diabetes and therefore dietary interventions should address this risk. Also see section 5.4 ‘Cardiovascular disease - blood lipids and blood pressure’ page 19.

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26 Evidence-based nutrition guidelines for the prevention and management of diabetes 6.2.2 Micro-vascular complications diabetic nephropathy neuropathy retinopathy . 6 .2.2.1 Diabetic nephropathy There are no randomised control trials investigating the effectiveness of the nutritional management of diabetes in kidney disease. One systematic review of the effect of dietary protein restriction in diabetic nephropathy concluded that the evidence was not strong enough to justify the use of protein restriction in the management of diabetic nephropathy 180 . However this review does recommend that some people may respond to low protein diets and suggests that a six month trial may be initiated and continued in those that respond. British Renal Society – www.britishrenal.org NICE 2008 Chronic Kidney Disease - early identification and management of chronic kidney disease in adults in primary and secondary care. Clinical guidelines CG73. National Institute of Clinical Excellence London. Nutrition recommendations for managing diabetes related complications 6.2.2.2 Lower limb ulcers and amputations There is no evidence for the role of diabetes-targeted nutrition in the healing of ulcers or reducing the risk of amputations and this is a field that needs further research. However the NICE guidance for pressure ulcers 181 and Type 2 diabetes foot care 182 makes reference to the importance of nutrition the multidisciplinary team including a dietitian and structured education. If an individual needs an amputation their nutritional status should be assessed and reviewed appropriately as with all surgical procedures nutritional support should be offered to those in a poor nutritional state. See section 7.1 ‘Nutrition support’ page 25. 6 .2.2.3 Gastroparesis There is very little good quality evidence for effective nutritional management of gastroparesis. Although the evidence is weak a recent review highlighted that dietary recommendations should rely on measures that promote gastric emptying or at a minimum do not retard emptying. Poor tolerance of a liquid diet is a predictive of a poor outcome 183. Artificial post-pyloric feeding should be offered when nutritional status continues to decline because of gastroparesis 184.

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Evidence-based nutrition guidelines for the prevention and management of diabetes 27 6 .2.2.4 Retinopathy There are no randomised trials specifically investigating the role of diet in the management of diabetic eye disease. However as the management of glycaemic control is important dietary review and counselling should again be offered as part of the package of care.

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Additional considerations 28 Evidence-based nutrition guidelines for the prevention and management of diabetes 7 . Additional considerations 7.1 Nutrition support People with diabetes are known to have more frequent admissions to hospital and many will require nutrition support 184. There is very little published evidence for nutrition support in people with diabetes either in hospital or in the community and the same applies to end of life care. In the absence of evidence consensus recommendations have been adopted by these guidelines. Nutrition support consensus recommendations • Standard protocols for nutritional support should be followed and adjustment of diabetes medication should be prioritised over dietary restriction. Nutrition management should be in partnership with the patient and the multi-disciplinary diabetes team with the aim of improving care and optimising glucose control. Hyperglycaemia is common in hospitalised patients and an important marker of poor clinical outcome and mortality in patients 38. Optimising glucose control is paramount and is associated with better outcomes in conditions including accidental injury stroke and critical illness where hyperglycaemia predicts worse outcomes. When feeding enterally either standard or diabetes specific formula may be used but care should be taken not to over-feed as it may exacerbate hyperglycaemia 184. Adequate diabetes medication should be given to achieve and maintain normoglycaemia. There is no evidence for the most effective mode of long-term nutritional support for people with diabetes 184 but a systematic review of 23 short-term studies have shown that diabetes specific formulae containing high proportions of monounsaturated fatty acids fructose and fibre significantly reduce postprandial blood glucose levels and reduced insulin requirements with no deleterious effect on lipid levels 184. However it should be noted that diabetes-specific formulae are not available in the UK. Patients requiring parenteral nutrition should be treated with standard protocols and covered with adequate insulin to maintain normoglycaemia. End-of-life care consensus recommendations • Where palliative care is likely to be prolonged meeting fluid and nutritional requirements should utilise non-intrusive dietary and management regimens. • Avoid hypoglycaemia or symptoms of overt hyperglycaemia.

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Additional considerations Evidence-based nutrition guidelines for the prevention and management of diabetes 29 • Alterations to insulin doses or diabetes medications may be required due to changes in appetite and body weight or the use of glucocorticoids. End of life care is an important consideration. The aims of nutrition advice for these individuals are different as the risk of macro- and microvascular complications are no longer relevant. The main emphasis should be on the avoidance of symptoms due to hyper and hypoglycaemia providing short-term symptomatic relief while respecting the wishes of the individual. http://www.liv.ac.uk/mcpcil/liverpool-care-pathway/ NICE 2006 Nutrition support in adults: oral nutrition support enteral feeding and parenteral nutrition. Clinical guideline CG32. National Institute for Health and Clinical Excellence London. 7.2 Disorders of the pancreas including acute pancreatitis chronic pancreatitis and cancer of the pancreas Nutrition support is essential and the European Society for Clinical Nutrition and Metabolism ESPEN have produced nutrition guidelines related to the disorders of the pancreas which have been adopted by these nutrition guidelines. see signpost www.espen.org See section 7.1 ‘Nutrition support’ page 25. 7.3 Older person Nutrition may be compromised as people age with physical social and psychological factors all playing a part. There is some evidence that the older person with diabetes may have poorer nutritional status than those without diabetes both in the community 186 and in hospital 187. Assessment of nutritional status and support for those who may be malnourished should be available to all elderly people with diabetes. NAGE BDA specialist interest group. Diabetes UK Good clinical practice guidelines for care home residents with diabetes Jan 2010. 7.4 Cystic fibrosis related diabetes mellitus CFRD Recommendations • Standard nutrition management for cystic fibrosis should be applied to individuals with diabetes. D • Dose adjustment of insulin should be prioritised over dietary restriction. D

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Additional considerations 30 Evidence-based nutrition guidelines for the prevention and management of diabetes The prevalence of Cystic fibrosis related diabetes mellitus rises as the age of survival of CF patients increases and has features of both Type 1 and Type 2 diabetes. The onset is insidious and glycaemic status varies as it is influenced by the clinical state of the person. The UK Cystic Fibrosis Trust Diabetes Working group produced guidelines for the Management of Cystic Fibrosis Related Diabetes Mellitus currently under review and these have been adopted by these nutrition guidelines see signpost www.cftrust.org.uk/aboutcf/publications/consensusdoc/diabetes.pdf 7.5 Coeliac disease Recommendations • An experienced dietitian should provide advice about a gluten free diet and an individualised dietary plan for the person with diabetes. D Coeliac disease is more common in people who have an additional autoimmune condition such as Type 1 diabetes. Up to 10 per cent of people with coeliac disease will have Type 1 diabetes. There is no increased risk of coeliac disease in people with Type 2 diabetes. Coeliac UK has produced guidelines Dietary management of people with Coeliac disease and Type 1 diabetes which have been adopted by these nutritional guidelines see signpost www.coeliac.org.uk NICE 2004 – Type 1 diabetes: diagnosis and management of Type 1 diabetes in children and young people. Clinical guidelines CG15. National Institute for Health and Clinical Excellence London. 7.6 Pregnancy and lactation Recommendations for pre-conception care • Women with pre-existing diabetes considering pregnancy are recommended to take 5mg folic acid a day and continue until the end of the twelfth week of pregnancy. D • Women should be supported in positive health choices including weight management where appropriate and should seek pre-conception care as part of holistic care prior to subsequent pregnancies. B • Women with pre-existing and gestational diabetes should be offered individualised nutritional education and have access to a multidisciplinary team including structured education. C Women who are contemplating pregnancy should be referred to specialist services and aim to optimise their glycaemic control at least three months prior to becoming pregnant.

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Additional considerations Evidence-based nutrition guidelines for the prevention and management of diabetes 31 Recommended glycaemic targets are outlined by NICE 2008 188. The recommendation for a higher than normal folic acid supplement is based upon the higher incidence of neural tube defects in infants born to women with diabetes. NICE 2008 Diabetes in Pregnancy. Management of diabetes and its complications from pre- conception to the postnatal period. Clinical guideline 63. National Institute for Health and Clinical Excellence London. Preconception information video www.diabetes.org.uk/RebelRebel Recommendations for antenatal care • Women should be encouraged to aim for normal glycaemia. A • Encourage appropriate weight gain in relation to the pre-pregnancy BMI. B In addition to the standard healthy eating and food safety advice women with diabetes should have access to a multidisciplinary team linking diabetes and obstetric professionals including an experienced dietitian so that individualised nutritional care plans can be negotiated. Although monitoring of weight is not encouraged by NICE the evidence presented by IOM 189 together with the ADA recommendations 190 191 and the findings of the Centre for Maternal and Child Enquiries CMACE enquiry in the UK 192 suggest that monitoring of weight is justified and weight gains close to that suggested by their pre-pregnancy weight should be encouraged 189. In gestational diabetes there is evidence to suggest that dietary strategies focusing on low glycaemic index carbohydrates may offer improved glycaemic control 193. Diabetes in pregnancy is associated with increased risk of hypertension and pre-eclampsia. Although it has been suggested that nutritional supplements might reduce this risk there is no evidence to support this viewpoint 194 195. Recommendations for postnatal care • Women who are breastfeeding and managing their diabetes with insulin should decrease their insulin dose consume additional carbohydrate test more frequently and have hypoglycaemia treatment close to hand. D • Women should be encouraged to set realistic goals regarding dietary behaviour and glycaemic control which are safe and compatible with having a new baby. D • Women with a history of gestational diabetes should be encouraged to follow a healthy lifestyle and consider weight management if appropriate after giving birth. D

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Additional considerations 32 Evidence-based nutrition guidelines for the prevention and management of diabetes Diabetes is not a contraindication to breastfeeding and where possible breastfeeding should be encouraged in line with World Health Organisation WHO recommendations 196. Breastfeeding may precipitate hypoglycaemia and requires increased frequency of glucose testing an increased carbohydrate intake and a reduced insulin dose. Evidence of breastfeeding upon glucose levels is limited. However the protective effects of breastfeeding on the infant and mother both initially and in terms of chronic disease risk reduction suggest that where possible it should be encouraged. Gestational diabetes is a strong predictor of future gestational diabetes and Type 2 diabetes and women should be encouraged to follow a healthy lifestyle and consider weight management if appropriate after giving birth 193. 7.7 HIV and insulin resistance Recommendations • Diabetes pharmaceutical interventions are of limited value in HIV due to interactions with antiretroviral medication. A • Lifestyle treatment guidelines for diabetes prevention and treatment for the general population should be applied in HIV. D Obesity rates in people living with HIV are higher than expected and the metabolic syndrome is present in up to 18 per cent of HIV patients 197. New diagnoses of HIV remain high 198 and the risk of developing Type 2 diabetes is up to four times higher than the general population. Insulin resistance should be routinely assessed with HIV particularly in those at higher risk eg those with central obesity lipodystrophy or with a longer exposure to antiretroviral medication 199. A meta-analysis indicated that pharmaceutical interventions for diabetes are of limited value in HIV due to the interactions with antiretroviral medication 200 and evidence suggests that metformin can actually lead to a worsening of lipoatrophy 201. Therefore expert opinion suggests lifestyle intervention as advised for the general diabetes population should be the primary treatment 202. 7.8 Nutrition provided by external agencies care homes prisons and hospitals Some people with diabetes are not in charge of their own nutrition and have their food provided to them with varying degrees of choice. Although little sound research could be sourced in the UK common themes were drawn from existing guidelines 203 204205206207 208 to formulate consensus guidelines which are listed below: Consensus recommendations

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Additional considerations Evidence-based nutrition guidelines for the prevention and management of diabetes 33 • All staff and carers should have sufficient training and understanding about diabetes and its dietary management. • Education about food should be provided so that the individual can manage their own food choices where possible. • All people with diabetes should be offered access to a registered dietitian and have a personalised assessment and nutritional plan as part of their regularly updated care plan. • Menus food trolleys shops and vending machines should include snacks and meals that allow food choices that are in line with the dietary recommendations for people with diabetes. • Meals and snacks should be made available around appropriate timing of medications. • People with diabetes who are carbohydrate counting should have access to the carbohydrate values of meals and snacks. 7.9 Fasting Fasting is a significant part of many religions varying in timings duration and restriction. Practitioners should be aware that many people with diabetes may choose to fast for their own personal spiritual or religious reasons despite being exempt. Little evidence is available on which to make recommendations about fasting and most of it usually focuses on Ramadan 209 so consensus guidelines have been formulated: • Fasting can be safe if a specific individual care plan is put in place that considers adjustments to timing and dosing of medication frequent blood glucose monitoring and food and drink choices that are made when breaking the fast. • Considerations should also be made to the carbohydrate and energy density of the food and drink choices. • Education of the person with diabetes prior to and possibly during fasting is essential for successful self-management of fasting with diabetes. 7.10 Eating disorders Consensus recommendations • Members of the multi-disciplinary team MDT should be alert to the possibility of Bulimia nervosa Anorexia nervosa and insulin dose manipulation C • The risk of morbidity from poor metabolic control suggests that consideration should be given early to adults with Type 1 diabetes and where appropriate an urgent referral to local eating disorder units may be needed D

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Additional considerations 34 Evidence-based nutrition guidelines for the prevention and management of diabetes Eating disorders such as anorexia and bulimia are 2.4 times more likely in teenage girls with Type 1 diabetes 210 the reasons being multi-factorial 211212 213. The deliberate omission of insulin to aid weight loss has serious consequences 214 and is referred to as diabulimia in the media. These eating disorders in people with Type 1 diabetes affect physical and emotional health and can be associated with impaired metabolic control DKA and increased risk of diabetic complications 212. Eating disorders also co-exist with Type 2 diabetes where binge eating seems to be most prevalent among younger women 215. Although screening tools and treatment guidelines for eating disorders exist see signposts and are probably applicable to people with diabetes they have not been validated for use in diabetes 216. Most eating disorder guidelines support a multidisciplinary approach and if healthcare professionals involved with diabetes care feel ill-equipped to deal with patients who have eating disorders 217 they should refer the patient to eating disorder units see signpost . NICE 2004 – Eating disorders: core interventions in the treatment and management of anorexia nervosa bulimia nervosa and related eating disorders. Clinical guideline CG9 National Institute for Health and Clinical Excellence. NICE 2004 – Type 1 diabetes: diagnosis and management of children young people and adults. Clinical guideline CG15. National Institute for Health and Clinical Excellence London. National Centre for Eating Disorders - www.eating-disorders.org.uk/ National Charity for People with Eating Disorders and their Families: B-EAT - www.beat.co.uk

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35 Evidence-based nutrition guidelines for the prevention and management of diabetes Micronutrients supplements and functional foods To Cure Diabetes Naturally Click Here 8 . Micronutrients supplements and functional foods There has and continues to be research into a range of micronutrients supplements and functional foods eg vitamin B3 chromium magnesium anti-oxidants vitamin D zinc caffeine cinnamon chilli karela and methi and their effect on diabetes management or their association in causing the onset of diabetes. However there is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes compared with the general population who do not have underlying deficiencies 42. There are varying degrees of evidence from a range of studies looking into other supplements and functional foods. More robust research is required into micronutrients supplements and functional foods before further recommendations about safety and effectiveness can be made. Individuals choosing to or considering using supplements or functional foods should be encouraged to discuss their individual needs with a registered dietitian or medical practitioner taking into account safety and risks. Note: The use of n-3 supplements and plant stanols/sterols is discussed in section five. The use of folic acid supplementation in pre-conception and pregnancy is discussed in section seven.

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Appendix Two: Overview of the major nutrition recommendations in the guidelines 36 Evidence-based nutrition guidelines for the prevention and management of diabetes Appendix One: Grading scheme for recommendations in the “Evidence-based nutrition guidelines for the prevention and management of diabetes” Appendix One: Grading scheme for Factors related to increased risk recommendations in the “Evidence-based nutrition guidelines for the prevention and management of diabetes” The criteria for the grading of recommendations in this document are based upon a paper by Petrie et al published on behalf of the Scottish Intercollegiate Guidelines Network. The evidence was reviewed and the recommendations were linked to the evidence supporting them and graded according to the level of evidence upon which they were based using the grading system below. It should be noted that the level of evidence determines the grade assigned to each recommendation. The grade does not reflect the clinical importance attached to each recommendation.

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Evidence-based nutrition guidelines for the prevention and management of diabetes 37 Appendix Two: Overview of the major nutrition recommendations in the guidelines Aims of the “Evidence-based nutrition guidelines for the prevention and management of diabetes” To establish individualised evidence-based recommendations for people with diabetes and those at high risk of developing Type 2 diabetes which: • support self management to reduce the risk of diabetes and its associated co-morbidities • promote quality of life and healthy lifestyles • provide flexibility and meet the needs of all individuals including those with co-morbidities such as coeliac disease and cystic fibrosis. 3. Recommendations for nutrition management and models of education • Nutrition therapy is effective in people with diabetes and those at high risk of diabetes when it is an integrated component of education and clinical care. A Classification of evidence Factors related to reduced risk Ia A B C D Based on category I evidence Based on category II evidence or extrapolated from category I Based on category III or extrapolated from category I or II Based on category IV evidence or extrapolated from category I II or III Evidence from meta analysis of randomised controlled trials Evidence from at least one randomised controlled trial Evidence from at least one controlled study without randomisation Evidence from at least one other of quasi experimental study Evidence from non- experimental descriptive studies such as comparative studies correlation studies and case control studies Evidence from expert committee reports or opinions and/or clinical experience of respected authorities IV III IIb IIa Ib

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Appendix Two: Overview of the major nutrition recommendations in the guidelines 38 Evidence-based nutrition guidelines for the prevention and management of diabetes • Everyone with diabetes should receive individual ongoing nutritional advice from a registered dietitian. A • All people with diabetes and/or their carer should receive structured education at the time of diagnosis with an annual follow-up. A • Education should involve a patient-centred approach and a variety of learning styles. A 4. Recommendations for prevention of Type 2 diabetes in high risk groups • Weight loss is the most important predictor of risk reduction for Type 2 diabetes. Weight loss of at least 5–7 per cent is effective for Type 2 diabetes prevention. A • Lifestyle interventions that incorporate energy restriction low fat diets and increased physical activity can effectively reduce the risk of Type 2 diabetes in high risk groups. A • There is no evidence for the most effective dietary approach over another to achieve weight loss and prevent Type 2 diabetes. D • Interventions promoting diet alone increased physical activity alone or a combination of the two is equally effective in reducing risk. A • Dietary patterns characterised by low intakes of saturated fat and higher intakes of unsaturated fat are protective. B • Diets of low glycaemic index/load and higher in dietary fibre and wholegrains are protective. B • Some specific foods low fat dairy foods green leafy vegetables coffee and moderate Appendix Two: Overview of the major nutrition recommendations in the guidelines intakes of alcohol are associated with reduced risk of Type 2 diabetes. B • Other foods red meats processed meat products and fried potatoes are associated with increased risk of Type 2 diabetes. B 5. Recommendations for people with diabetes Glycaemic control and Type 1 diabetes • Carbohydrate is the main nutritional consideration for glycaemic control in individuals with Type 1 diabetes. A • People using MDI and CSII benefit from adjusting insulin to carbohydrate intake and should be offered education to support this. A

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Evidence-based nutrition guidelines for the prevention and management of diabetes 39 • Consistent quantities of carbohydrates on a day-to-day basis are beneficial for those individuals on fixed insulin regimens. C • Increased physical activity offers general health benefits although there is no evidence of benefit in glycaemic control. A Glycaemic control and Type 2 diabetes • Weight management should be the primary nutritional strategy in managing glucose control in Type 2 diabetes for people who are overweight or obese. A • Regular moderate physical activity can reduce HbA1c by 0.45–0.65 per cent independent of weight loss. A • Focus should be on total energy intake rather than the source of energy in the diet macronutrient composition for optimal glycaemic control. A • The total amount of carbohydrate consumed is a strong predictor of glycaemic response and monitoring total carbohydrate intake whether by use of exchanges portions or experience- based estimation remains a key strategy in achieving glycaemic control. A • Low GI diets have been shown to reduce HbA1c up to 0.5 per cent. A Weight management • Weight reduction for the overweight or obese person with Type 2 diabetes is effective in improving glycaemic control and cardiovascular risk factors. A • The main requirement of a dietary approach to weight loss is that total energy intake should be less that energy expenditure. D • Dietary physical activity surgical and pharmaceutical approaches that are currently recommended for people without diabetes are appropriate and can be adopted by people with diabetes. D Cardiovascular disease- blood lipids and blood pressure • Saturated fats SFA should be limited and replaced by unsaturated fats predominantly monounsaturated fats MUFA. A • Daily consumption of foods fortified with plant sterols or stanols 2–3g/day significantly improve total and LDL cholesterol for people with diabetes irrespective of statin treatment. A • Reduced sodium intake combined with the Dietary Approaches to Stop Hypertension DASH or Mediterranean-style diets can lower blood pressure. A • A Mediterranean-style diet lowers blood pressure and improves HDL cholesterol and triglyceride levels. B

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Appendix Two: Overview of the major nutrition recommendations in the guidelines 40 Evidence-based nutrition guidelines for the prevention and management of diabetes • In overweight individuals a modest amount of maintained weight loss 4.5kg or more results in improvements in blood pressure. B • In individuals with Type 2 diabetes with elevated levels of blood triglycerides supplementation with up to 3g per day of n-3 marine fish oils DHA and EPA can improve blood triglyceride levels without adverse effects. B • Consumption of oily fish rich in n-3 unsaturated fats is recommended at least twice per week. B • 30 to 60 minutes of aerobic exercise on a minimum of three occasions per week minimum of 150 minutes each week and resistance training at least twice per week lower blood presure. B • Intakes of trans-fatty acids should be limited. C 6. Recommendations for managing diabetes related complications Short-term complications: mild to moderate hypoglycaemia • 15 –20g glucose should be used to treat hypoglycaemia. If glucose levels have not risen above 4mmol/l after 15 minutes treatment should be repeated. B • A follow up carbohydrate snack 15–20g may be necessary in order to reduce the risk of further hypoglycaemia. C Longterm complications • Glycaemic control should be the main focus for preventing and slowing the rate of developing diabetes-related complications. A • Nutritional management should be an integral part of the care package. D 7. Special considerations Nutrition support consensus guidelines • Standard protocols for nutritional support should be followed and adjustment of medication should be prioritised over dietary restriction. End-of-Life Care consensus guidelines • Where palliative care is likely to be prolonged meeting fluid and nutritional requirements should utilise non-intrusive dietary and management regimens. • Avoid hypoglycaemia or symptoms of overt hyperglycaemia. Appendix Two: Overview of the major nutrition recommendations in the guidelines

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Evidence-based nutrition guidelines for the prevention and management of diabetes 41 • Alterations to insulin doses or diabetes medications may be required due to changes in appetite and body weight or the use of glucocorticoids. Cystic fibrosis • Standard nutrition management for cystic fibrosis should be applied to individuals with diabetes. D • Dose adjustment of insulin should be prioritised over dietary restriction. D Coeliac disease • An experienced dietitian should provide advice about a gluten free diet and an individualised dietary plan for the person with diabetes. D Pregnancy and Lactation Pre-conception care: • Women with pre-existing diabetes considering pregnancy are recommended to take 5 mg folic acid a day and continue until the end of the twelfth week of pregnancy. D • Women should be supported in positive health choices including weight management where appropriate and should seek pre-conception care as part of holistic care prior to subsequent pregnancies. B • Women with pre-existing and gestational diabetes should be offered individualised nutritional education and have access to a multidisciplinary team including structured education C Antenatal care • Women should be encouraged to aim for normal glycaemia. A • Encourage appropriate weight gain in relation to the pre-pregnancy BMI. B Postnatal care • Women who are breastfeeding and managing their diabetes with insulin should decrease their insulin dose consume additional carbohydrate test more frequently and have hypoglycaemia treatment close to hand. D • Women should be encouraged to set realistic goals regarding dietary behaviour and glycaemic control that are safe and compatible with having a new baby. D • Women with a history of gestational diabetes should be encouraged to follow a healthy lifestyle and consider weight management if appropriate after giving birth. D HIV and insulin resistance • Diabetes pharmaceutical interventions are of limited value in HIV due to interactions with antiretroviral medication. A

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Appendix Two: Overview of the major nutrition recommendations in the guidelines 42 Evidence-based nutrition guidelines for the prevention and management of diabetes • Lifestyle treatment guidelines for diabetes prevention and treatment for the general population should be applied in HIV. D Eating disorders • Members of the MDT should be alert to the possibility of Bulimia nervosa Anorexia nervosa and insulin dose manipulation C • The risk of morbidity from poor metabolic control suggests that consideration should be given early to adults with Type 1 diabetes and where appropriate an urgent referral to local eating disorder units may be needed D

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References Evidence-based nutrition guidelines for the prevention and management of diabetes 43 References 1. Kahn R Gale EAM 2010. Gridlocked guidelines for diabetes. The Lancet 375 9733 2203–4. 2. Lindström J Ilanne-Parikka P Peltonen M et al 2006. Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of Type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. The Lancet 368 9548 1673–9. 3. Knowler WC Barrett-Connor E Fowler SE et al 2002. Diabetes Prevention Program Research Group. Reduction in the incidence of Type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine 346 6 393–4034. 4. Pastors JG Warshaw H Daly A et al 2002. The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care 25 608–613. 5. Franz MJ. Evidence-Based Medical Nutrition Therapy for Diabetes. 2004 Nutrition in Clinical Practice 19 137–144. 6. Kulkarni K Castle G Gregory R et al 1998. Nutrition practice guidelines for Type 1 diabetes mellitus positively affect dietitian practices and patient outcomes. J Am Diet Assoc 98 62–70. 7. DAFNE Study Group 2002. Training in flexible intensive insulin management to enable dietary freedom in people with Type 1 diabetes: dose adjustment for normal eating DAFNE randomised controlled trial. British Medical Journal 325 746–752. 8. Deakin TA Cade JE Williams R et al 2006. Structured patient education: the diabetes X- PERT Programme makes a difference. Diabetic Medicine 23 944–954.

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