Pamela Dyson

Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes

A summary of the latest evidence‐based nutrition guidelines for the prevention and management of diabetes is presented. These guidelines are based on existing recommendations last published in 2011, and were formulated by an expert panel of specialist dietitians after a literature review of recent evidence. Recommendations have been made in terms of foods rather than nutrients wherever possible. Guidelines for education and care delivery, prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, cardiovascular disease risk management, management of diabetes‐related complications, other considerations including comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food supplements, functional foods, commercial diabetic foods and nutritive and non‐nutritive sweeteners are included. The sections on pregnancy and prevention of Type 2 diabetes have been enlarged and the weight management section modified to include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations in ethnic minorities has been included as a new topic. The guidelines were graded using adapted ‘GRADE’ methodology and, where strong evidence was lacking, grading was not allocated. These 2018 guidelines emphasize a flexible, individualized approach to diabetes management and weight loss and highlight the emerging evidence for remission of Type 2 diabetes. The full guideline document is available at www.diabetes.org.uk/nutrition-guidelines.

Kaleidoscope model of diabetes care: time for a rethink?

National Audit Data highlight persistent sub‐optimum control among increasing numbers of people living with diabetes, with severe consequences for the individual and the NHS. The aim of the present review was to introduce a new cohesive, holistic model of care, tailored to individual needs to support optimum diabetes outcomes. This model of diabetes is necessary in order to understand the driving forces behind behaviour and their impact on diabetes management. Feelings (an emotional state or reaction) and beliefs (an acceptance that something is true or real) are fundamental behavioural drivers and influence diabetes self‐management choices. Individually, these explain some of the complexities of behaviour and, collectively, they impact on personal motivation (rationale/desire to act) to achieve a specific outcome. Inevitably, they independently affect diabetes self‐management and the environment in which individuals live. A model of care that proposes the encompassing of environment, intrinsic thought and therapy regimens to provide tailored, personalized healthcare should support enhanced diabetes self‐management and outcomes from diagnosis. The Kaleidoscope model of care could be deliverable in routine care, incorporating each of the influences on diabetes self‐management, and should benefit both individuals with diabetes and healthcare professionals.

Alcohol health literacy in young adults with Type 1 diabetes and its impact on diabetes management

To investigate the knowledge of alcohol and carbohydrate content of commonly consumed alcoholic drinks among young adults with Type 1 diabetes and to explore alcohol consumption while identifying diabetes self‐management strategies used to minimize alcohol‐associated risk.

High rates of child hypertension associated with obesity: a community survey in China, India and Mexico.

Abstract Background: Hypertension is a significant risk factor for cardiovascular disease, and epidemiological evidence suggests that it is increasing in parallel with obesity in children and adolescents in low- and middle-income countries. Aim: To identify and determine the relationship between overweight, obesity and hypertension in a community sample of school children. Methods: Anthropometric data were collected from 12,730 school children aged 12–18 years in China, India and Mexico as part of the Community Interventions for Health programme, an international study evaluating community interventions to reduce non-communicable disease by addressing the three main risk factors of tobacco use, unhealthy diets and physical inactivity. Logistic regression was used to examine the association of body mass index and gender and hypertension. Results: Prevalence rates of hypertension were 5·2% in China, 10·1% in India and 14·1% in Mexico, and pre-hypertension rates in China, India and Mexico were 13·4%, 9·4% and 11·2%, respectively. Overweight and obesity prevalence rates varied by country and were 16·6% in China, 4·1% in India and 37·1% in Mexico. In all countries there was a significant association between overweight and obesity and rates of hypertension. Overweight children were 1·7–2·3 times more likely to be hypertensive and obese children 3·5–5·5 more likely to show hypertension than those of normal weight. Conclusions: Rates of hypertension and overweight and obesity are high in school children in China, India and Mexico, and increased bodyweight is a significant risk factor for hypertension.

Successful Up-Scaled Population Interventions to Reduce Risk Factors for Non-Communicable Disease in Adults: Results from the International Community Interventions for Health (CIH) Project in China, India and Mexico

Background Non-communicable disease (NCD) is increasing rapidly in low and middle-income countries (LMIC), and is associated with tobacco use, unhealthy diet and physical inactivity. There is little evidence for up-scaled interventions at the population level to reduce risk in LMIC. Methods The Community Interventions for Health (CIH) program was a population-scale community intervention study with comparator population group undertaken in communities in China, India, and Mexico, each with populations between 150,000-250,000. Culturally appropriate interventions were delivered over 18-24 months. Two independent cross-sectional surveys of a stratified sample of adults aged 18-64 years were conducted at baseline and follow-up. Results A total of 6,194 adults completed surveys at baseline, and 6,022 at follow-up. The proportion meeting physical activity recommendations decreased significantly in the control group (C) (44.1 to 30.2%), but not in the intervention group (I) (38.0 to 36.1%), p<0.001. Those eating ≥5 portions of fruit and vegetables daily decreased significantly in C (19.2 to 17.2%), but did not change in I (20.0 to 19.6%,), p=0.013. The proportion adding salt to food was unchanged in C (24.9 to 25.3%) and decreased in I (25.9 to 19.6%), p<0.001. Prevalence of obesity increased in C (8.3 to 11.2%), with no change in I (8.6 to 9.7%,) p=0.092. Concerning tobacco, for men the difference-in-difference analysis showed that the reduction in use was significantly greater in I compared to C (p=0.014) Conclusions Up-scaling known health promoting interventions designed to reduce the incidence of NCD in whole communities in LMIC is feasible, and has measurable beneficial outcomes on risk factors for NCD, namely tobacco use, diet, and physical inactivity.

Reducing Health Risk Factors in Workplaces of Low and Middle-Income Countries

OBJECTIVE To reduce risk factors in workplace settings in low- and middle-income countries. DESIGN AND SAMPLE Workplace interventions were utilized as part of the Community Interventions for Health program, a nonrandomized, controlled study undertaken in three communities in China, India, and Mexico. Exactly, 45 industrial, 82 health and 101 school workplace settings with a target population of 15,726. Two independent cross-sectional surveys of workers were conducted at baseline and follow-up, after 18-24 months of intervention activities. MEASURES Culturally appropriate interventions to reduce tobacco use, increase physical activity, and improve dietary intake were delivered in the intervention areas. RESULTS Exactly, 12,136 adults completed surveys at baseline, and 9,786 at follow-up. In the intervention group, the prevalence of tobacco use reduced significantly in men (-6.0%, p < .001) and the proportion eating five portions of fruit and vegetables daily increased (+6.9%, p < .001) compared with the control group. There were no significant differences between the groups for changes in physical activity or prevalence of overweight. CONCLUSIONS Workplace interventions improved risk factors in China, India, and Mexico.

Saturated fat and Type 2 diabetes: where do we stand?

Dietary treatment of Type 2 diabetes has long been open to controversy and debate, and this is especially true of the relationship between saturated fat (SFA) and cardiovascular disease (CVD). Over the past couple of years, various studies [1–3] have resulted in headlines claiming that experts have got it wrong for the past 30 years, that there is no link between SFA and heart disease, and that healthy diets should include plenty of butter and bacon. In addition, a small (but vocal) group of activists now claim that carbohydrate, not fat, is the culprit and that people with Type 2 diabetes should adopt low-carbohydrate, high (saturated)-fat diets in order to lose weight, improve glycaemic control and reduce CVD risk. This has led to much confusion among both people with diabetes and health professionals alike, and in August 2015 Diabetes UK and the British Dietetic Association’s (BDA) Diabetes Specialist Group joined forces to review the evidence for dietary fat intake in people with Type 2 diabetes and to formulate a Policy Statement [4].

James Lind Alliance research priorities: what role do carbohydrates, fats and proteins have in the management of Type 2 diabetes, and are there risks and benefits associated with particular approaches?

To assess the role played by carbohydrates, fat and proteins in the management of Type 2 diabetes.

Diabetes and Diet: A Patient and Dietitian’s Perspective

This article has been co-authored by a patient with type 2 diabetes and a specialist dietitian. Here they discuss the patient’s experience and difficulties with controlling weight and strategies that can help a patient in this situation. The patient discusses how stress and her corresponding comfort eating dampened weight loss progress, and how adopting a lifestyle change aided through group support helped to deal with this. The physician discusses the importance of recognizing the mental and physical challenges faced by patients in this situation.

Community Interventions for Health can support clinicians in advising patients to reduce tobacco use, improve dietary intake and increase physical activity

AIMS AND OBJECTIVES To increase clinical interventions to reduce modifiable risk factors for noncommunicable disease in low- and middle-income countries. BACKGROUND Noncommunicable disease is the leading cause of death in the world and is common in low- and middle-income countries. Risk factors for noncommunicable disease are modifiable and health professionals are in an unique position to intervene and influence them. DESIGN Clinical interventions were used as part of the Community Interventions for Health programme, a nonrandomised, controlled study undertaken in three communities - one each in China, India and Mexico. METHODS All clinicians in intervention and control areas of the study were invited to complete surveys. A total of 2280 completed surveys at baseline and 2501 at follow-up. Culturally appropriate interventions to reduce tobacco use, improve dietary intake and increase physical activity were delivered in the intervention areas. RESULTS Clinicians in the intervention group felt more prepared to advise smoking cessation and improvement of diet. They were more likely to test serum cholesterol and blood pressure, but less likely to take measurements of height, hip, waist and skin-fold thickness. There were more resources available to clinicians in the intervention group and they used counselling more and complementary medicine less than those in the control group. CONCLUSIONS Community interventions which have been shown to have a positive effect in the community and workplace also change clinical practice. RELEVANCE TO CLINICAL PRACTICE Community interventions make clinicians, including nurses, more likely to feel prepared to offer advice and more likely to use counselling. This would be expected to reduce risk factors in patients.