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Effective nutritional interventions for diabetes control

Emily Maguire
Go Lower

Diabetes in England rose from 1.7 million in 2004 to 2.2 million in 2009 (a 30% increase), which has triggered a similar rise in the cost of the disease from £450 million to £650 million, reflecting the increase in insulin and oral hypoglycaemic agents (OHAs).1 Use of the sulphonylurea metformin, which the National Institute for Health and Clinical Excellence (NICE) recommends as the first choice for oral therapy, has more than doubled in the past five years; and yet, despite this dedication to NICE guidelines, the prevalence of diabetes is
not decreasing.

Although everyone is in agreement that a nutritional intervention approach for both the prevention and treatment of diabetes is necessary, there is disagreement with respect to the type of nutritional intervention that brings the best results. At present, the recommended diabetic diet is based on starch.

Diabetes is associated with the body's inability to utilise glucose due to impairments in insulin; and yet, starch, which metabolises into glucose, raises postprandial serum glucose, which, in turn, triggers insulin secretion. It is strange that we are recommending the treatment of impaired insulin secretion with a diet that forces the body to produce more insulin. So why is it that we recommend a meal based on starch for diabetics if starch is putting further pressure on blood glucose levels and insulin production? 

The reason given by many experts is that the introduction of starch as the main component to a meal was to deal with concerns over the intake of fat and the increased susceptibility that diabetics have to heart disease. As we now know, thanks to the World Health Organization (WHO), there is now no evidence of a link between the intake of fats and heart disease.2

Another reason for the reliance on starch is to facilitate carbohydrate counting to maintain blood glucose control. However, this raises the serum glucose level and ensures the continued use of medication.

Although it is acknowledged that total dietary carbohydrate is the major factor in glycemic control, interventions based on reducing them (with particular reference to sugars and starches) have received little support. Currently, many agencies, such as the American Diabetes Association (ADA) and Diabetes UK, do admit that such diets offer an alternative to the conventional treatment; but they continue to downplay the many benefits and try to emphasise supposed risks.
Likewise, the new Scottish Intercollegiate Guidelines Network (SIGN) guidelines (2010) now do acknowledge the use of low carbohydrate diets for diabetics, but only in the short term; so their long-term use is still being debated.

In view of the dramatic increase in diabetes, is it wise to disregard the significant studies that have been published which conclude that restricting carbohydrates offer the following benefits:3-6

  • Improves glycemic control and reduces insulin fluctuations.
  • Can reduce or even eliminate the need for medication (particularly in type 2 diabetics).
  • Are at least as effective, if not more, for weight loss as low-fat diets and provide greater satiety.
  • Improves associated markers of the metabolic syndrome and reduces the risk of CVD.

The evidence available indicates that restricting dietary carbohydrates (particularly sugar and starches) would be a logical and realistic approach to the improvement of both glycemic and metabolic control.

The published figures showing improvements in weight loss and cardiovascular markers should surely begin to open the minds of health professionals. Finally, if the restriction of dietary carbohydrates is able to reduce or even eliminate the use of medications, this would help to reduce the escalating health costs associated with the disease and so free up much needed money for other areas within the NHS.

Although it must be accepted that low carbohydrate diets may not be appropriate for everyone and different forms of the diet may need to be adopted (ie, different carbohydrate levels below the 130 g/d cut off), the option must, first and foremost at least, be on offer to the patient, and the choice of which nutritional intervention to follow be left to the individual physicians and patient.

1. NHS Information Centre. Prescribing for Diabetes in England: 2004/5 to 2009/10. London: NHS IC; 2010.
2. Fats and fatty acids in human nutrition. Proceedings of the Joint FAO/WHO Expert Consultation. November 10-14, 2008. Geneva, Switzerland. Ann Nutr Metab 55(1-3):5-300.
3. Gardner CD, Kiazand A, Alhassan S et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA 2007;297(9):969-77.
4. Nordmann AJ, Nordmann A, Briel M. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Inern Med 2006;166:285-93.
5. Feinman RD, Volek JS. Low carbohydrate diets improve atherogenic dyslipidemia even in the absence of weight loss. Nutr Metab 2006;21(3):24.
6. Westman EC, Yancy WS Jr, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutr Metab 2008;19(5):36. 

Your comments (terms and conditions apply):

"Excellent article which supports all I have instinctively felt; I can't explain to diabetics why they are told to eat carbs when they already have so much energy stored on board" - Helen Fryer, Hastings

"Very interesting. Am surprised by the lack of a link Between fats and heart disease in diabetics. Excellent article..." - Teresa Anderson, Canada