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Management of type 2 diabetes: A handbook for general practice

Lifestyle interventions for management of type 2 diabetes


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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:

  1. National Institute for Clinical Excellence. Guidance for the use of patient-education models for diabetes. Technology appraisal guidance TA60. London: NICE, 2003.
  2. Nordmann AJ, Suter-Zimmermann K, Bucher HC, et al. Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. Am J Med 2011;124(9):841–51.e2.
  3. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2019;42:S1–194.
  4. Hordern MD, Dunstan DW, Prins JB, Baker MK, Singh MA, Coombes JS. Exercise prescription for patients with type 2 diabetes and pre-diabetes: A position statement from Exercise and Sport Science Australia. J Sci Med Sport 2012;15(1):25–31.
  5. National Health and Medical Research Council. Australian dietary guidelines. Canberra: NHMRC, 2013.
  6. Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2018;42:S1–325.
  7. Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery in the treatment algorithm for type 2 diabetes: A joint statement by international diabetes organizations. Diabetes Care 2016;39(6):861–77.
  8. The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. 2nd edn. East Melbourne, Vic: RACGP, 2019.
  9. Scottish Intercollegiate Guidelines Network. Management of diabetes: A national clinical guideline (updated 2017). Edinburgh: SIGN, 2017.
  10. Colberg SR, Sigal RJ, Yardley JE, et al. Physical activity/exercise and diabetes: A position statement of the American Diabetes Association. Diabetes Care 2016;39(11):2065–79.
  11. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001;37:153–46.
  12. Gellish RL, Goslin BR, Olson RE, McDonald A, Russi GD, Moudgil VK. Longitudinal modeling of the relationship between age and maximal heart rate. Med Sci Sports Exerc 2007;39(5):822–29.
  13. Yang Z, Scott CA, Mao C, Tang J, Farmer AJ. Resistance exercise versus aerobic exercise for type 2 diabetes: A systematic review and meta-analysis. Sports Med 2014;44(4):487–99.
  14. Church T, Blair S, Cocreham S, et al. Effects of aerobic and resistance training on hemoglobin a1c levels in patients with type 2 diabetes: A randomized controlled trial. JAMA 2010;304(20):2253–62.
  15. Dijk J, Manders R, Tummers K, et al. Both resistance- and endurance-type exercise reduce the prevalence of hyperglycaemia in individuals with impaired glucose tolerance and in insulin-treated and non-insulin-treated type 2 diabetic patients. Diabetologia 2012;55(5):1273–82.
  16. Briffa T, Maiorana A, Sheerin NJ. Physical activity for people with cardiovascular disease: Recommendations of the National Heart Foundation of Australia. Med J Aust 2006;184(2):71–75.
  17. Royal Australian College of General Practitioners. Exercise: Type 2 diabetes. In: Handbook of non-drug interventions (HANDI). East Melbourne, Vic: RACGP, 2014.
  18. Zaharieva D, Riddell M. Prevention of exercise-associated dysglycaemia: A case study-based approach. Diabetes Spectr 2015;28:55–62.
  19. Shukla AP, Iliescu RG, Thomas CE, Aronne LJ. Food order has a significant impact on postprandial glucose and insulin levels. Diabetes Care 2015;38(7):e98–99.
  20. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2014;37(Suppl 1):S120–43.
  21. Anderson JW, Kendall CW, Jenkins DJ. Importance of weight management in type 2 diabetes: Review with meta-analysis of clinical studies. J Am Coll Nutr 2003;22:331–39.
  22. Bazzano LA, Serdula M, Liu S. Prevention of type 2 diabetes by diet and lifestyle modification. J Am Coll Nutr 2005;24:310–19.
  23. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346(6):393–403.
  24. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344(18):1343–50.
  25. Diabetes Prevention Program Research Group; Knowler W, Fowler S, Hamman R, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374(9702):1677–86.
  26. Look AHEAD Research Group; Wing RR, Bolin P, Brancati FL, et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369(2):145–54.
  27. Shaw K, Gennat H, O’Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database of Systematic Reviews 2006;(4):CD003817. doi: 10.1002/14651858.CD003817.pub3.
  28. Thomas D, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2006;(3): CD002968. doi: 10.1002/14651858.CD002968.pub2.
  29. Malone M. Medications associated with weight gain. Ann Pharmacother 2005;39:2046–55.
  30. Rush E, Plank L, Chandu V, et al. Body size, body composition, and fat distribution: A comparison of young New Zealand men of European, Pacific Island, and Asian Indian ethnicities. N Z Med J 2004;117(1207):U1203.
  31. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn. East Melbourne, Vic: RACGP, 2016.
  32. National Heart Lung and Blood Institute. The practical guide: Identification, evaluation and treatment of overweight and obesity in adults. Bethesda, MD: National Institutes of Health, 2000.
  33. Australian Obesity Management Algorithm working group. Australian Obesity Management Algorithm. Australia and New Zealand: Australian Diabetes Society, Australian and New Zealand Obesity Society, Obesity Surgery Society of Australian and New Zealand, 2016.
  34. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC, 2013.
  35. Lean MEJ, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): An open-label, cluster-randomised trial. Lancet 2018;391(10120):541–51.
  36. Khorgami Z, Shoar S, Saber AA, Howard CA, Danaei G, Sclabas GM. Outcomes of bariatric surgery versus medical management for type 2 diabetes mellitus: A meta-analysis of randomized controlled trials. Obes Surg 2019;29(3):964–74.
  37. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database System Rev 2014;(8):CD003641. doi: 10.1002/14651858.CD003641.pub4.
  38. Via M, Mechanick J. Nutritional and micronutrient care of bariatric surgery patients: Current evidence update. Curr Obes Rep 2017;6:286–96.
  39. US Department of Health and Human Services. How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.
  40. Targher G, Alberiche M, Zenere MB, Bonadonna RC, Juggeo M, Bonara E. Cigarette smoking and insulin resistance in patients with noninsulin-dependent diabetes mellitus. J Clin Endocrinol Metab 1997;82(11):3619–24.
  41. Pietraszek A, Gregersen S, Hermansen K. Alcohol and type 2 diabetes: A review. Nutr Metab Cardiovasc Dis 2010;20:366–75.
  42. National Health and Medical Research Council. Australian guidelines to reduce health risks from alcohol Canberra: NHMRC, 2020. [in publication].
  43. Cheyne EH, Sherwin RS, Lunt MJ, Cavan DA, Thomas PW, Kerr D. Influence of alcohol on cognitive performance during mild hypoglycaemia; implications for Type 1 diabetes. Diabet Med 2004;21(3):230–37.
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