Management of type 2 diabetes: A handbook for general practice

Lifestyle interventions for management of type 2 diabetes

Diet

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Last revised: 17 Sep 2020

Grade: B

Consumption of cereal foods (especially three serves/day of wholegrains) is associated with reduced risk of type 2 diabetes

Grade: C

Consumption of at least 1.5 serves/day of dairy foods (eg milk, yoghurt, cheese) is associated with reduced risk of type 2 diabetes

These recommendations are drawn from the most recent recommendations from organisations including the National Health and Medical Research Council (NHMRC), the Scottish Intercollegiate Guidelines Network (SIGN), Diabetes Canada, the American Diabetes Association (ADA) and other relevant sources. Refer to ‘Explanation and source of recommendations’ for explanations of the levels and grades of evidence.

Most of the burden of disease due to poor nutrition in Australia is associated with eating too much energy-dense and relatively nutrient-poor foods, and eating too few micronutrient-dense foods, including vegetables, fruit and wholegrain cereals.

Key dietary themes for people with type 2 diabetes are eating for cardiovascular protection, and glycaemic management and meal planning.

All patients should be offered and encouraged to seek advice on medical nutrition therapy by referral to an accredited practising dietitian (APD). An APD can help people address core issues around nutrition, such as achieving sustainable healthy eating patterns and, where appropriate, healthy body weight (loss) by reducing energy intake (portion control and type of food). They can also assist with recipe modification, changing cooking techniques, label reading, eating out and understanding of fad diets.

Glycaemic management and meal planning

To influence the glycaemic response after eating, meal plans need to consider both the amount and quality of carbohydrates eaten. The total amount of carbohydrate consumed (compared with other macronutrients or the glycaemic index of the meal) may be the major dietary factor that contributes to high postprandial BGLs.19 Eating low-glycaemic-load foods instead of higher glycaemic-load foods may modestly improve glycaemic control.20

Low glycaemic index (GI) foods include dense wholegrain breads, steel-cut oats, lower fat milk and yoghurt, minimally processed (eg wholegrain, low GI) breakfast cereals, pasta, Doongara rice, legumes and most fruits. Intake of high-carbohydrate, low-nutrient-dense foods such as soft drinks, cakes and lollies should be confined to infrequent, small amounts to reduce the risk of weight gain and a worsening cardiometabolic profile.20

There is evidence that nutrition education may be particularly important for the prevention of hypoglycaemia in people with type 2 diabetes on insulin or sulfonylureas. Consistent carbohydrate intake, and spaced, regular meal consumption, may help some patients manage BGLs and weight. Inclusion of snacks as part of a person’s meal plan should be individualised and should be balanced against the potential risk of weight gain and/or hypoglycaemia.6

Evaluation of current dietary intake and the eating patterns of an individual is an initial critical step to support the management of type 2 diabetes.

Dietary habit changes are often slow and incremental. There is no need for a ‘special’ diet for diabetes, just the requirement to follow a sensible, balanced eating plan. Keep advice simple and educate patients about healthy food choices.

Identifying psychosocial issues around eating (eg binge-eating, eating when stressed or bored) is also very important. Often people with diabetes have experienced many years of ‘yo-yo’ dieting and a cycle of weight loss and gain.

The Eat for Health website, which includes the Australian dietary guidelines, is easy to access and its recommendations easy to implement. The guidelines provide advice about healthy eating patterns, including a daily food selection guide.

Not all dietary sugars need to be eliminated. Small amounts of added simple carbohydrate as part of a high-fibre, modified-fat meal plan increases the choice of food available and may aid adherence. Foods naturally high in sugars, such as fruit and dairy, do not need to be avoided.

Referral to an APD or a credentialled diabetes educator will support implementation and reinforcement of these recommendations. A list of APDs in your area can be found on the Dietitians Association of Australia website.

Further information about diet for people with diabetes, including a position statement about low-carbohydrate diets for diabetes, can be found on the Diabetes Australia website.

Aboriginal and Torres Strait Islander point

There is evidence that Aboriginal and Torres Strait Islander communities in urban and remote regions face significant access barriers to nutritious and affordable food. Nutritious food tends to cost more and require refrigeration and preparation. Food choices can be significantly altered when people have access to appropriate foods and education about nutrition.

GPs should make themselves aware of local community initiatives for the supply of fresh fruit and vegetables at affordable prices. In some areas, these include arrangements with farmers’ markets or local community gardens. For more information specific to nutrition for Aboriginal and Torres Strait Islander peoples, refer to:

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