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The role of nutrition in the management of type 2 diabetes

In this review we have used both hard copy (library based) access and Internet search facilities, to derive appropriate material. This was done at both the local University library and the local post-graduate medical centre library. Initial searches were made under the heading of Type II diabetes mellitus nutritional management.

Because it was important to provide a firm evidence base for the review, the searches were restricted solely to peer reviewed publications which, it was hoped, would make the selection process more efficient. (Berwick D   2005)
This highlighted more than enough good quality material for our initial examination of the literature.

As it transpired the four articles chosen were all from the BMJ. This is partially a coincidence, as over thirty different articles in twelve different publications were assessed in the preparation of this piece. The final decision that was made to include articles was based, not only on their relevance to the issue, but also on the fact that they were on aspects of diabetic nutritional management that was not more commonly covered in some of the more “routine” articles.

Many of the articles examined were discarded because they had obvious methodological flaws in their construction. (Mohammed, D 2003).
Many were effectively opinion pieces which had little in the way of cited references to validate their findings. Others were trials which may have had a number of potentially confounding sources of bias.

Literature review

There are a great many authoritative sources in the modern literature on the subject of dietary management of the diabetic state. In any meaningful review of these resources one must always be mindful of the need for a strong evidence base. It is therefore vital to be dispassionately critical in one’s review of any literature presented. (Sackett, 1996).

We know, from established evidence, (Lean ME 2005), that obesity is an independent risk factor in the aetiology of Type II diabetes mellitus and that obesity management is a vital ingredient for good control of the diabetic state. (HSG 1997) This correlates with evidence that the incidence of long term side effects of diabetes is inversely proportional to the HbA1 readings. (Stratton I et al 2000)

A good place to start our review is a recent review paper by Hitchcock & Pugh (2002). This is a tour de force in the management of obesity in general terms, but, for the reasons outlined above, it is very pertinent to our discussions in this piece.

The review itself is cited here because it provides a particularly comprehensive overview of other work in the area together with some personal observations of patients who are both diabetic and involved in the weight management process. The paper also highlights the often overlooked problems of the need to reduce hypoglycaemic medication in conditions of both weight loss and unaccustomed exercise to minimise the risks associated with hypoglycaemic episodes.(Knowler WC et al 2002). There is a particularly pertinent set of comments relating to pharmacotherapeutics and obesity related surgery. (Wing RR et al 2001).

This paper sets itself apart from many other similar papers with comments relating to the long term strategies associated with successful weight maintenance. A critical assessment of this review would have to conclude that although written by UK based authors, there are some comments in it which are aimed at the USA and this may well be a reflection of the fact that it was supported by the USA veterans association. On the positive side, the references cited are wide ranging and authoritative, giving a balanced overview of the current situation relating to obesity control.

Lean & Hankey (2004) offer an editorial on the use of aspartame. Again, this article is a general piece, but it has distinct relevance to the management of the Type II diabetic. This piece is particularly relevant to our considerations because apart from providing an authoritative statement on the current evidence base for aspartame, it points to the fact that current dietary recommendations for Type II diabetes mellitus include the fact that up to 10% of total metabolic energy  can safely come from sugars. (DNSG 2000).

Artificial sweeteners can help to avoid counterproductive weight gain. It also produces an authoritative opinion on the argument that increasing the carbohydrate component of a diet tends to displace the fat content, (Bolton Smith C et al 1999) with the associated health benefits there. (Ludwig DS et al 2001).

Nutritional management in Diabetes Mellitus was traditionally part of the almost exclusive remit of either the specialist diabetic nurse or the dietician. More modern considerations have included the concept of patient empowerment and education (Howe and  Anderson  2003), which can  now come from independent  web-based sources.

Two eye-catching articles on this topic appeared in the same issue of the BMJ. The first (Eyesenbach G et al 2004), produces an extremely comprehensive review of the availability, accuracy and effect of this phenomenon. It provides an authoritative assessment of the literature available on this topic. Of particular relevance to our considerations was their findings that, of the five peer-reviewed studies examined that gave dietetic advice and also measured the clinical outcome (by HbA1), only one showed a statistically significant improvement. It has to be noted that the particular study was not a controlled reference study, and therefore has a great potential for experimental bias. (Gary TL et al.2003)

A more qualitative approach was taken by the second of the two papers (Ralston JD et al 2004). This paper looked at the patient’s experiences with the use of the web-based advice facilities. The study design was ambitious, but used the semi-structured interview technique which again introduces the possibility of observer bias. (Parker and Lawton 2003)

Despite being both authoritative and informative, careful reading of the article shows that the authors only used a small cohort (nine). The analysis and presentation of the results appears to be rigorous. One of the most significant findings of this particular study is, arguably, the demonstration  that web-based interventions have the potential not only to work and to support the patients in general terms but advice, such as dietetic advice, is actively sought and implemented by some patients. The authors conclude that the most important pre-requisite to obtaining a successful outcome, was the fact that the patients had the opportunity to discuss the shortcomings of the project before they entered it.

References

Berwick D   2005
Broadening the view of evidence-based medicine
Qual. Saf. Health Care, Oct 2005; 14: 315 - 316.



Bolton Smith C, Woodward M. 1999
Dietary composition and fat to sugar ratios in relation to obesity.
Int J Obes 1999;18: 820-8



DNSG 2000
Diabetes and Nutrition Study Group (DNSG) of the European Association for the study of diabetes.
Recommendations for the nutritional management of patients with diabetes mellitus.
Eur J Clin Nutr 2000;54: 353-5.

Eysenbach G, John Powell, Marina Englesakis, Carlos Rizo, and Anita Stern 2004
Health related virtual communities and electronic support groups: systematic review of the effects of online peer to peer interactions
BMJ, May 2004; 328: 1166 ;

Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL.  2003
Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes.
Diabetes Educ. 2003;29: 488-501.

Hitchcock P,  Pugh N & JA  2002
Management of overweight and obese adults
BMJ, Oct 2002; 325: 757 - 761 ;

Howe and  Anderson  2003
Involving patients in medical education
BMJ, Aug 2003; 327: 326 - 328.

HSG (97)45: 1997
Key features of a good diabetes service
Department of Health document 01/10/1997

Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al.2002
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
N Engl J Med 2002; 346: 393-403

Lean MEJ and Hankey CR 2004
Aspartame and its effects on health
BMJ, Oct 2004; 329: 755 - 756 ;

Lean  MEJ 2005
Prognosis in obesity: Author's reply
BMJ, Aug 2005; 331: 453 ;

Ludwig DS, Peterson, Gortmaker SL. 2001
Relation between consumption of sugar sweetened drinks and childhood obesity: a prospective, observational analysis.
Lancet 2001;357: 505-8

Mohammed, D Braunholtz, and T P Hofer   2003
The measurement of active errors: methodological issues
Qual. Saf. Health Care, Dec 2003; 12: 8 - 12.

Parker and Lawton 2003
Psychological contribution to the understanding of adverse events in health care
Qual. Saf. Health Care, Dec 2003; 12: 453 - 457.

Ralston JD, Debra Revere, Lynne S Robins, and Harold I Goldberg 2004
Patients' experience with a diabetes support programme based on an interactive electronic medical record: qualitative study
BMJ, May 2004; 328: 1159

Sackett, (1996).
Doing the Right Thing Right: Is Evidence-Based Medicine the Answer? 
Ann Intern Med, Jul 1996; 127: 91 - 94.

Stratton I, Adler A, Neil A, Matthews D. (2000)
Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35); prospective observational study.
BMJ 2000; 321: 405-412.

Wing RR, Hill JO.  2001
Successful weight loss maintenance.
Annu Rev Nutr 2001; 21: 323-341