General practice management of type 2 diabetes


Diet
×
☰ Table of contents


Recommendations

Reference

Grade*

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

71
NHMRC, 2013

B

Consumption of at least one and a half serves of dairy foods (eg milk, yoghurt, cheese) per day is associated with reduced risk of type 2 diabetes

71
NHMRC, 2013

C

*Refer to Summary, explanation and source of recommendations for an explanation of the level of evidence and grade of evidence


Clinical context


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.

Composition of a healthy diet

The Australian dietary guidelines promotes healthy eating patterns, emphasising a range of nutrient-dense foods in appropriate portion sizes.71

  • Enjoy a wide variety of nutritious foods from these core food groups every day:
    • plenty of vegetables, including different types and colours, and legumes/beans
    • fruit (consumption of fruit is not associated with risks of type 2 diabetes)
    • grain (cereal) foods, mostly wholegrain and/or high cereal fibre varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley
    • lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans
    • milk, yoghurt, cheese and/or their alternatives, mostly reduced fat (reduced fat milks are not suitable for children under two years of age).
  • Drink plenty of water.
  • Limit intake of foods containing saturated fat, added salt, added sugars and alcohol:
    • Restrict foods high in saturated fat such as many biscuits, cakes, pastries, pies, processed meats, commercial burgers, pizza, fried foods, potato chips, crisps and other savoury snacks.
    • Limit foods and drinks containing added salt.
    • Avoid foods and drinks containing added sugars such as confectionary, sugar- sweetened soft drinks and cordials, fruit drinks, vitamin waters, energy and sports drinks.
    • Alcohol intake should be as per the Australian dietary guidelines. For women who are pregnant, planning a pregnancy or breastfeeding, not drinking alcohol is the safest option.

Reproduced with permission from the National Health and Medical Research Council. Australian dietary guidelines. Canberra: NHMRC, 2013.  55[Accessed 29 August 2016].

Two other key themes are eating for cardiovascular protection, and glycaemic management and meal planning.

Eating for cardiovascular protection

Consultation with an APD will allow individualised advice on CVD risk reduction with healthy food choices to be provided. A variety of eating patterns are acceptable for the management of metabolic control. However, personal preferences for cultural, religious and economic preferences should also be considered.72 One such dietary choice is the Mediterranean diet, which is associated with a lowering of morbidity and mortality for some chronic diseases, including CVD.73 In persons with high CVD risk, the Mediterranean diet reduced CVD events when compared to a low-fat diet.74

Glycaemic management and meal planning

Evaluation of current dietary intake and the eating patterns of an individual is an initial critical step and should be recommended in all people to support the management of type 2 diabetes. All patients should be offered and encouraged to seek advice on medical nutrition therapy by referral to an APD. The APD can help support a person living with diabetes to address the core themes around nutrition such as promoting healthy eating patterns and, where appropriate, healthy body weight (loss) with reduction in energy intake (portion control and type of food).

To influence the glycaemic response after eating, the amount and quality of the carbohydrate eaten may be the most important factor. The amount of carbohydrate eaten within a meal should therefore be considered when meal planning. Eating lowglycaemic-load foods instead of higher glycaemic-load foods may modestly improve glycaemic control.75 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.75 The total amount of carbohydrate consumed (compared with other macronutrients or GI of the meal) may be the major dietary factor contributing to high post-prandial BGLs.76

There is evidence that nutrition education may be particularly important for the prevention of hypoglycaemia in people with type 2 diabetes on insulin or oral glucose lowering medications that may cause hypoglycaemia (eg sulphonylureas). Consistency in carbohydrate intake, and spacing and regularity of meal consumption may help some patients manage BGL 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.77


In practice


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 rather than on unhealthy food choices or what they should not eat. All sugars do not need to be eliminated. A small amount of sugar as part of a mixed meal or food (eg one teaspoon of sugar/honey added to breakfast cereal) may not adversely affect the blood glucose level. Small amounts of added sugar 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.

Consider recommending/referring to the Eat for Health website, which is easy to access and its recommendations easy to implement. Referral to an APD or a CDE will support implementation/reinforcement of these recommendations. For basic dietary advice, visit eating well
 

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 requires refrigeration and preparation, so lack of food security may affect the choice of glucose-lowering medications. 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. Information in regards to Aboriginal and Torres Strait Islander peoples nutrition is available at:

Australian Bureau of Statistics

Australian Institute of Health and Welfare

Department of Health


Diabetes Australian and RACGP logo's
 
  1. White RO, Wolff K, Cavanaugh KL, Rothman R. Addressing health literacy and numeracy to improve diabetes education and care. Diabetes Spectr 2010;23(4):238–43.
  2. National Health and Medical Research Council. Australian Dietary Guidelines. Canberra: NHMRC, 2013.
  3. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2013;36(11):3821–42.
  4. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999;99(6):779–85.
  5. Estruch R, Ros E, Salas-Salvado J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368(14):1279–90.
  6. 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.
  7. 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.
  8. Cheng AY. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Introduction. Can J Diabetes 2013;37 Suppl 1:S1–212.