Patient discussions
Medical nutrition therapy
There is no ideal amount of macronutrients that people with diabetes should consume, and studies suggest that such recommendations should be decided on an individual basis.[170][177] The Mediterranean Diet, Dietary Approaches to Stop Hypertension (DASH), vegetarian, and vegan diets have all demonstrated some efficacy in people with diabetes.[170][178][179][180][181] Disclosing and communicating CV risk levels to at-risk patients has been shown to increase self-reported dietary modification.[411]
Reducing overall carbohydrate intake for individuals with diabetes has demonstrated evidence for improving glycaemia.[30] However, the optimal degree of carbohydrate restriction, and long-term effects on cardiovascular disease (CVD), are still unclear.[30] Both World Health Organization (WHO) and European guidelines emphasise that carbohydrate quality, rather than quantity, is key, with the primary marker of quality being the amount of dietary fibre consumed.[185]
Replacing saturated fats with unsaturated fats and carbohydrates from foods containing naturally occurring dietary fibre (such as whole grains, vegetables, fruits and pulses) reduces low-density lipoprotein (LDL)-cholesterol and also benefits CVD risk.[170][187] Saturated fat should comprise <10% of total energy intake and trans-fats <1%.[133][188] Dietary fats should mainly come from plant-based foods high in mono- and poly-unsaturated fats, such as nuts, seeds, and non-hydrogenated non-tropical vegetable oils (e.g., olive oil, rapeseed/canola oil, soya bean oil, sunflower oil, linseed oil).[133]
Evidence indicates that low- and very low- (<3500 kJ/day [<840 kcal/day]) energy diets, using total diet replacement formula diet products (replacing all meals) or partial liquid meal replacement products (replacing 1 to 2 meals per day) for the weight-loss phase, are most effective for weight loss and reduction of other cardiometabolic risk factors when compared with the results from self-administered food-based weight-loss diets.[133][191] Low-energy nutritionally complete formula diets with a total diet replacement induction phase also appear to be the most effective dietary approach for achieving type 2 diabetes remission.[133] One population-based cohort study found that those who achieved remission from diabetes, even for a short time, had a much lower risk of CVD events, including myocardial infarction and stroke, as well macrovascular and microvascular complications.[192]
Following the success of a pilot programme to provide a low-calorie diet treatment for people recently diagnosed with type 2 diabetes and living with overweight or obesity, the NHS has launched its Type 2 Diabetes Path to Remission (T2DR), a free one year programme to promote weight loss in those that are overweight (body mass index [BMI] of 27 kg/m² or over in people from white ethnic groups, adjusted to 25 kg/m² or over in people from black people, Asian and other ethnic groups) and recently diagnosed with type 2 diabetes, with the aim of inducing diabetes remission wherever possible.[193] Service users will follow a diet composed solely of nutritionally complete total diet replacement products, with total energy intake of 800 to 900 kilocalories a day, for 12 weeks, followed by a period of food reintroduction and subsequent weight maintenance support, with a total duration of 12 months.
Physical activity
The American Diabetes Association (ADA) recommends assessment of the following prior to starting an exercise programme; age; physical condition; blood pressure; and presence or absence of autonomic neuropathy or peripheral neuropathy, balance impairment, history of foot ulcers or Charcot foot, or untreated proliferative retinopathy.[30]
Adults with diabetes should engage in at least 150 minutes per week of moderate- to vigorous-intensity aerobic physical activity.[7][30] The physical activity should be spread over at least 3 days per week, with no more than 2 consecutive days without exercise.[30]
Younger and more physically fit individuals should aim for ≥75 minutes per week of vigorous-intensity exercise or interval training.[30]
In the absence of contraindications, 20 minutes of resistance training 2 to 3 times per week on non-consecutive days is also recommended.[7][30]
Sedentary periods should be interrupted by activity every 30 minutes.[30]
Older adults may benefit from balance and flexibility training 2 to 3 times per week.[30]
Regular motivational feedback is important to maintain patient adherence to the exercise programme.[196]
Dyslipidaemia
Lifestyle modification focused on reduced saturated fat intake, weight loss, and increased physical activity has been shown to improve lipid control in patients with diabetes.[30]
Smoking cessation
All patients with diabetes should be advised not to smoke or to stop smoking.[30] Smoking counselling and other forms of smoking cessation therapy should be incorporated into routine diabetes care.[30] Varenicline combined with nicotine replacement therapy may be more effective than varenicline alone.[197] The ADA does not support e-cigarettes as an alternative to smoking or to facilitate smoking cessation.[30]
Patients who stop smoking are often prone to weight gain; it is therefore important to have weight management strategies in place to maximise the CV benefits of smoking cessation.[48]
Hypertension
People with diabetes and hypertension should monitor their blood pressure at home in addition to having it checked regularly in the clinic setting, both to ensure accuracy of readings and to encourage adherence to treatment regimens.[30]
Heterogeneity between different racial and ethnic groups requires culturally sensitive, peer-led community and healthcare professional education.[96] Key considerations in providing culturally sensitive care are the patient’s preferred language and religion, dietary restrictions, sex identity, cultural norms and practices, health literacy, and cultural differences in communication style.[96]
Resources:
AHA/ACC: ASCVD risk calculator Opens in new window
NIDDK: diabetes, heart disease, and stroke Opens in new window
HHS: dietary guidelines for Americans, 2020-2025 Opens in new window
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