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Dietary Therapies for the management of Diabetes Position
Statement
Low Carbohydrate Diets
The cornerstone of diabetes management is undoubtedly diet and lifestyle.
More recently emerging evidence, as well as increased media coverage, on low
carbohydrate and high fat diets has sparked a wave of interest by patients and
health professionals.
Gloucestershire Diabetes Teams have reviewed their local position regarding
these diets to ensure consistent and clear messages are delivered by all
professionals supporting the management of individuals with diabetes.
Two national bodies (The British Dietetic Association and Diabetes UK) have
issued statements regarding Low Carbohydrate and High Fat diets for the
management of Type 2 Diabetes.
www.bda.uk.com/improvinghealth/healthprofessionals/policystatement_diabetes
https://www.diabetes.org.uk/About_us/What-we-say/Food-nutritionlifestyle/Low-carbohydrate-diets-for-people-with-Type-2-diabetes/
A Low carbohydrate diet is a collective term used to describe any form of
carbohydrate restriction. This includes significant variation and the evidence
and strength of studies vary. The following definitions apply (Accurson et al
2008)
Moderate carbohydrate : 130g – 225g/day
Low <130g/day
Very Low 30g/day
Type 1 Diabetes
The evidence to support the use of low-carbohydrate diets in people with Type
1 diabetes is limited. The Diabetes Control and Complication Trial showed that
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lower carbohydrate, and higher saturated, monounsaturated and total fat
intake were associated with higher HbA1c levels (Delahanty et al, 2009). There
is a lack of robust, good quality and long term evidence to support the
universal use of low carbohydrate diets as a standard approach (<50g/day) for
all individuals with diabetes.
In Individuals with Type 1 diabetes we are unable to universally advise low
carbohydrate diets as a standard approach. Should an individual choose to
follow a carbohydrate restricted plan (of varying amounts) they should access
specialist diabetes care and seek advice from the specialist care team before
commencing restricted carbohydrate plans and during the time they apply this
restriction.
The local policy for the management of Type 1 diabetes is within the Secondary
care Specialist Diabetes Team where they have access to a multidisciplinary
team including a specialist dietitian.
https://g-care.glos.nhs.uk/pathway/134/resource/5#chapter_3341
Type 2 Diabetes
In Individuals with Type 2 diabetes we are unable to universally advise low
carbohydrate diets as a standard approach, carbohydrate sources, intake and
amounts are discussed in the County’s diabetes education programme which is
available to all patients in Gloucestershire with a diagnosis of Type 2 diabetes.
For patients who attend either the community or secondary care diabetes
services, assessment by a registered dietitian is a key component of care,
where carbohydrate intake and possibilities for reduction is assessed on an
individual basis.
As with many prescriptive diets, there is a lack of evidence relating to the long
term benefits and risks of following this diet for individuals with Type 2
Diabetes. There is a behavioural element to consider with all levels of
prescriptive advice and plans.
There are a range of options that would enable people to achieve an
improvement in HbA1c and weight. It is therefore an essential component of
considering carbohydrate restriction is that each individual is assessed and
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advised by an appropriately trained health care professional, preferably a
Registered Dietitian.
When considering low carbohydrate diets it is essential to ensure nutritional
adequacy from a range of nutrient dense foods. This is particularly vital when
our Type 2 population includes women of child bearing age and children.
Special consideration needs to be given where Type 2 diabetes co-exists with
other co-morbidities where there are specific dietary guidelines for their
management. Examples include chronic kidney disease, Coeliac Disease and
Cardiovascular Disease.
At present, given the current evidence base and the individualised nature of
Type 2 Diabetes, we are not currently in a position to routinely promote the
use of a Low Carbohydrate/High Fat diet for the management of Type 2
Diabetes.
Cautions/special considerations
 Apply extreme caution for patients on insulin who should not restrict
diet without formal advice
 Pancreatic insufficiency
 Uncertainty regarding Type of diabetes diagnosis
 Co-existing endocrine disease
 Gestational group or those planning pregnancy
Consideration for supporting an individual who wishes to restrict carbohydrate
should include the following as stated by Diabetes UK;



A range of approaches to weight loss should be considered with the overall
aim of energy intake being less than energy expenditure; and that the most
appropriate method to achieve this is identified between the person with
diabetes and their dietitian.
When considering a low-carbohydrate diet as an option for weight loss, people
with diabetes should be made aware of possible side effects such as the risk of
hypoglycaemia, head-aches, lack of concentration and constipation.
Diabetes control should be considered and blood glucose levels need to be
closely monitored with adjustments to medications as required.
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

Nutritional adequacy should be considered ensuring that optimal amounts of
vitamins, minerals and fibre are supplied by the diet.
The amount of carbohydrate to be restricted should be agreed between the
person with diabetes and their dietitian.
How to access support for someone with Diabetes where it is clinically
indicated that weight loss and/or HbA1c requires reduction.
Structured education
Diabetes and You
Diabetes Food and You
Diabetes, Insulin and You
https://g-care.glos.nhs.uk/pathway/134/resource/5#chapter_3374
This team includes registered dietitians who are also available for individual
consultations (subject to referral criteria)
Secondary Care Diabetes Team:
https://g-care.glos.nhs.uk/pathway/134/resource/5#chapter_1347
This team includes Consultants, Specialist Nurses and Specialist Dietitians
offering individualised assessment.
Tier 3 Specialist Weight Management Service
For those with a BMI greater than 40kg/m² and Type 2 Diabetes
This includes non-surgical specialist management of weight and is a prerequisite for those considering surgical management of their weight.
This service includes Specialist Dietitians, Psychologists and Nurses available for
individualised assessments and treatments.
https://g-care.glos.nhs.uk/pathway/151/resource/5#chapter_1221
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Tier 2 Slimming World
12 weeks free on referral
https://g-care.glos.nhs.uk/pathway/151/resource/5#chapter_1222
Useful websites
http://www.nhs.uk/LiveWell/Loseweight/Pages/Loseweighthome.aspx
https://www.diabetes.org.uk/Guide-to-diabetes/Enjoy-food/
https://www.bda.uk.com/foodfacts/diabetes.pdf
https://www.bda.uk.com/foodfacts/diabetestype2.pdf
https://www.bda.uk.com/foodfacts/home
www.diabetes.co.uk Caution: this is a forum for people with Diabetes. It is not
moderated by health professionals and the advice posted does not always
reflect current evidence and guidance.
This document has been jointly produced by Diabetes Specialist Teams in
Gloucestershire. July 2016
References
Accurso A, Bernstein R, Dahlqvist A, Drazini B, Finman R, Fine E, Gleed A,
Jacobs D, Larson G, Lustig R, Manninen A, Mcfarlane S, Morrison K, Nielsen J,
Ravnskov U, Roth K, Silvestre R, Sowers J, Sundberg R, Volvek J, Westman E,
Wood R, Wortman J and Vernon M (2008). Dietary carbohydrate restriction in
type 2 diabetes mellitus and metabolic syndrome: time for a critical appraisal.
Nutrition and Metabolism 5; 9
Delahanty L, Nathan D, Lachin; Hu B; Cleary P; Ziegler G; Wylie-Rosett J; Wexler
D (2009). Association of diet and glycated hemoglobin during intensive
treatment for type 1 diabetes in the Diabetes Control and Complications Trial.
American Journal of Clinical Nutrition 89; 518–524
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Dyson,P (2015). Low Carbohydrate Diets and Type 2 Diabetes: What is the
Latest Evidence? Diabetes Therapy 6; 411424.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4674467/ accessed
10.04.17
www.bda.uk.com/improvinghealth/healthprofessionals/policy_statement_diabetes
https://www.diabetes.org.uk/About_us/What-we-say/Food-nutritionlifestyle/Low-carbohydrate-diets-for-people-with-Type-2-diabetes/
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