Download The role of carbohydrate in diabetes management

Review
The role of carbohydrate in diabetes management
Paul D McArdle
BSc (Hons), MA, RD, MBDA, Birmingham Community
Healthcare NHS Foundation Trust, UK
Duane Mellor
PhD, RD, APD, Faculty of Health, University of
Canberra, Australia
Sian Rilstone
BSc, MSc, RD, Imperial College Healthcare NHS Trust,
London, UK
Julie Taplin
BSc, RD, North East London NHS Foundation Trust, UK
Correspondence to:
Paul D McArdle, St Patrick’s Centre for Community
Heath, Frank Street, Birmingham B12 0YA, UK; email:
[email protected]
Received: 2 May 2016
Accepted in revised form: 11 July 2016
Abstract
The role of carbohydrate in the diet of people living with diabetes is an area of much
debate. This relates to both type and quantity of carbohydrate consumed, with low
carbohydrate diets increasing in popularity. However, it is important to take a whole diet
approach and not just in terms of single nutrients. This review considers what
carbohydrates are and how recommendations for people with diabetes might differ from
those for the general population.
There are no obligate requirements for dietary carbohydrate. UK recommendations
suggest 50% of total energy should come from carbohydrate for the general population;
however, evidence does not support an optimal carbohydrate intake for people living with
diabetes. Equally, there is no evidence to support a change in other macronutrient intakes
including fat; thereby challenging the perspective of low carbohydrate diet advocates, which
may encourage higher saturated fat intakes.
Carbohydrate quality is important in terms of glycaemic index and fibre, and may have
other health benefits; however, the quantity of carbohydrate is a more important predictor of
glycaemic response. People with type 1 diabetes can improve the accuracy of insulin dosing
with carbohydrate counting and technology may also have a role to play in this, with the
introduction of bolus advisor meters.
There is no universal recommendation for the amount of carbohydrate for people living
with diabetes. Recommendations should therefore be based on personal preference,
individual glycaemic response and other health targets, ideally with the support of a
registered dietitian specialising in diabetes. Copyright © 2016 John Wiley & Sons.
Practical Diabetes 2016; 33(7): 237–242
Key words
carbohydrate; diabetes; dietary advice; dietitian
Introduction
The role of dietary carbohydrate in
diabetes is the subject of much
debate – especially with respect to
ideal amounts and types of carbohydrate.1 This review aims to explore
these issues in relation to clinical
practice in adults, considered in the
context of recommendations given
to the general public compared to
clinically supervised advice given as
part of therapeutic patient education. The individual preferences and
interests of the person with diabetes
are also a key consideration.
What are carbohydrates?
There are many definitions of
carbohydrate. Table 1 summarises
the definition set out by the World
Health Organisation,2 which is
based on the chemical structure
of carbohydrates.
Simply put, carbohydrates can
be defined as sugars, starches and
fibre – often referred to as simple
(sugars) and complex (starches and
fibre). However, this does not accurately reflect their biological effects:
with some starches being more readily broken down to glucose than
PRACTICAL DIABETES VOL. 33 NO. 7
some sugars. The measure of how
quickly carbohydrate-containing
foods result in a rise in blood glucose is known as glycaemic index or
‘GI’.3 Taken out of context, the use
of GI has a number of limitations
including the serving size and the
mixed nature of meals, and it may
not consider the overall nutritional
quality of the meal. Glycaemic load
(GL) reflects more accurately the
glycaemic effect and has been
described as ‘the product of the GI
of a food item and the available carbohydrate content’.4 Thereby, the
potential glycaemic effect of a meal
may be altered by changing either
the GI or the carbohydrate content,
consequently affecting the GL.
What is sugar?
As shown in Table 1, there are many
different types of ‘sugar’. For the
purpose of health advice, the
Scientific Advisory Committee on
Nutrition (SACN) and the World
Health Organisation2 now use the
term ‘free sugar’ to describe the
sugars found in honey, syrups, soft
drinks, fruit juices, smoothies and
purees, as well as sugar added in
COPYRIGHT © 2016 JOHN WILEY & SONS
237
Review
The role of carbohydrate in diabetes management
cooking and food processing.5,6
Free sugars have been associated
with an increased risk of weight gain
and developing diabetes,7 and is
a more precise term than added
sugars which has also been used.8
Sources of carbohydrate
In the UK, as in many countries,
cereal and cereal products make
the largest contribution to daily
carbohydrate intake, principally
from white bread, pasta and rice
(Figure 1).9 The greatest contributors to free sugar intake are sugars,
preserves and confectionery and
non-alcoholic drinks – each group
making up about 25% of our free
sugar intake.10
Patients and the public may misunderstand the word ‘carbohydrate’
and recent research suggests a
‘sugar-centric’ approach to dietary
behaviours in people with diabetes,
also indicating a poor understanding of the term ‘carbohydrate’.11
The biggest source of carbohydrate
in the diet is in fact not sugar, as
described above;9 however, the link
between sugar and diabetes is probably due to the association between
blood glucose and sugar intake.
Although the amount of sugar consumed will influence increases in
blood glucose,12 this viewpoint is
somewhat simplistic.
Dietary requirements for
carbohydrate
There is no direct physiological
requirement for dietary carbohydrate, since the body can make all
the glucose required.13 However,
basing nutritional recommendations on a single nutrient is unwise,
particularly as many of the less processed sources of carbohydrate are
low energy density, high in fibre and
good sources of vitamins and minerals. This makes them incredibly
valuable as part of the diet,14 not
only with respect to preventing and
managing diabetes, but also to
health in general. So, although carbohydrate is not a dietary essential,
glucose is required and needs to be
synthesised from amino acids or
glycerol if not available from the
diet. This means it is not possible to
consider carbohydrate needs independently of fat and protein as part
of the overall diet, and dietary
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PRACTICAL DIABETES VOL. 33 NO. 7
Class (degree of
polymerisation)
Subgroup
Components
Sugars (1–2)
Monosaccharides
Glucose, galactose, fructose
Disaccharides
Sucrose, lactose, trehalose
Polyols
Sorbitol, mannitol
Malto-oligosaccharides
Maltodextrins
Other oligosaccharides
Raffinose, stachyose,
fructo-oligosaccharides
Starch
Amylose, amylopectin,
modified starches
Non-starch polysaccharides
(fibre)
Cellulose, hemicellulose,
pectins, hydrocolloids
Oligosaccharides (3–9)
Polisaccharides (>9)
Table 1. The major dietary carbohydrates. (Adapted from Food and Agriculture Organisation/World
Health Organisation, 1998)2
Cereals and cereal products
Vegetables and potatoes
Fruit
Non-alcoholic beverages
Sugar, preserves and
confectionery
Meat and meat products
Milk and milk products
Other
Figure 1. Percentage contribution of food groups to average daily carbohydrate intake (male and
female, aged 19–64 years). (Adapted from National Diet & Nutrition Survey data [NDNS, 2014];
Crown copyright © 2014)9
recommendations should be based
on foods and eating patterns.15
Current recommendations
for carbohydrate
The Scientific Advisory Committee
on Nutrition6 recently updated the
recommendations for the general
population and has made subtle
changes to guidelines, as outlined in
Table 2.
It is important to note that these
recommendations may not be applicable to people living with diabetes,
as recent reviews undertaken suggest that there is a lack of evidence
to support an ideal percentage of
total energy from carbohydrate.16,17
However, the SACN report does
state that there is also no evidence
of an association between increasing
the percentage of energy consumed
from carbohydrate and the risk of
developing type 2 diabetes.
The SACN recommendations
encourage diets that are lower in
highly refined sources and higher in
minimally refined and whole grain
sources of carbohydrate. The recommendations to increase fibre and
encourage consumption of whole
grains relate to evidence that they
may lower risk of developing cardiovascular disease14,18 and some
cancers such as colon cancer.19
The Diabetes UK Nutrition
Working Group reviewed the evidence for people with diabetes and
found there was a lack of evidence
for an optimal proportion of energy
COPYRIGHT © 2016 JOHN WILEY & SONS
Review
The role of carbohydrate in diabetes management
Nutrient
Recommendation
Comment
Total carbohydrate
50% of total energy
No evidence found to change this from
previous recommendation
Of which free sugars
5% of total energy
Re-defined and reduced from 10%
(previously ‘non-milk extrinsic sugars’)
Fibre
30g per day
Re-defined and increased
Table 2. Summary of key recommendations of the Scientific Advisory Committee on Nutrition report
(SACN, 2015;6 Crown copyright © 2015)
Carbohydrate: g per day
Carbohydrate: % of energy*
Very low carbohydrate
20–50g
6–10%
Low carbohydrate
<130g
<26%
Moderate carbohydrate
130–225g
26–45%
High carbohydrate
>225g
>45%
*Based on 2000kcal diet.
Table 3. Consensus definition of different levels of dietary carbohydrate. (Adapted from Feinman, et
al. Nutrition 2015;31(1):1–13)25
from carbohydrate.12 The American
Diabetes Association reached the
same conclusion,20 and current recommendations for carbohydrate
suggest flexibility tailored to the individual, and acknowledge at least the
short to medium term benefits of
carbohydrate reduction.16 However,
there is also agreement on the need
to look beyond single dietary components and look at dietary patterns in
a more holistic manner.12,20
Quantity of carbohydrate
in diabetes
Evidence is lacking on the optimal
quantity of carbohydrate to consume
for glycaemic control in both type 1
and type 2 diabetes. Many individual
studies are confounded by differential changes in weight between
groups, differences in the total energy
intake of participants consuming the
different diets (with carbohydrate
restriction often inducing a greater
relative energy deficit)21 and wide
variations in the definitions of ‘low’
and ‘high’ carbohydrate. This makes
it difficult to state confidently that the
change in carbohydrate intake was
responsible for any differences in
glycaemic control.
Several recent reviews have
examined the effect of differing
proportions of macronutrients
(carbohydrate, protein and fat) on
PRACTICAL DIABETES VOL. 33 NO. 7
blood glucose control and weight
loss in type 2 diabetes,16,17,22 none
of which were able to demonstrate
superiority for any proportion of
macronutrients in terms of glycaemic control. Franz et al.22 found
trials comparing high and low
carbohydrate diets resulted in
non-significant changes in HbA1c,
lipids and blood pressure at 12
months. Dyson16 reports that low
carbohydrate diets were no more
effective in achieving weight loss in
type 2 diabetes, and significantly
lower HbA1c values occurred in
only three of the eight included
studies. The outcomes with regard
to blood pressure and lipids also
showed no overall superiority in
low carbohydrate diets. However,
low carbohydrate diets have shown
greater potential to reduce medication requirements.23
The debate around low carbohydrate diets warrants continued
attention. ‘Low carbohydrate’ can
refer to a wide range of carbohydrate intakes, which can lead to
confusion. Anything from just less
than the recommended intake, e.g.
<50% of total energy down to 25g
of carbohydrate per day, has been
described ‘low carbohydrate’;24
however, a consensus definition
is now emerging, as outlined in
Table 3.25,26
Van Wyk et al.17 found in many
studies the participants were unable
to maintain the level of carbohydrate prescribed and the ‘high’ and
‘low’ groups often converged with
as little as an 8g difference per day
in carbohydrate intake between
groups. This may also explain the
lack of a definitive conclusion about
carbohydrate quantity and is an
important observation about the
acceptability of particularly high or
low carbohydrate diets to patients.
The other challenge in considering low carbohydrate diets is the
impact that changing the proportion
of carbohydrate has on the quantity
of other macronutrients, particularly
fat. If the carbohydrate in the diet is
dramatically reduced, then something is needed to replace it. Fat is
typically preferred to protein by proponents of low carbohydrate diets, as
protein can be synthesised back to
glucose so this may not improve
glycaemic control, whereas fat will
promote increased ketone synthesis.27
This has been hypothesised to have
additional metabolic benefits in type
2 diabetes; however, there is no clear
evidence to support the role of
ketones in improving glycaemia and
cardiovascular risk. There is also no
evidence of the benefits of high fat
diets including increased intakes of
saturated fat in reducing cardiovascular risk.28 Despite this, reviewing the
evidence for low saturated fat intakes
also reveals an absence of evidence to
support saturated fat intakes below
10% of total energy. Emerging evidence suggests that diets based
on unsaturated fat such as the
Mediterranean diet – which includes
around 10% of energy from saturated
fat and a total of 40% of total energy
from fat (approximately half is from
monounsaturated fats) – have been
shown to reduce the risk of cardiovascular disease, including in people
with type 2 diabetes in Spain.29
Weight loss in those who are
overweight remains the most effective strategy to improve glycaemic
control in type 2 diabetes.12 Limiting
carbohydrate intake often serves to
limit energy intake, and thus aid
weight management.16 The ultimate
fate of all carbohydrate as glucose
and its effect on insulin is often
used as a rationale for severe carbohydrate restrictions,25 with type 2
COPYRIGHT © 2016 JOHN WILEY & SONS
239
Review
The role of carbohydrate in diabetes management
diabetes in particular being
described by low carbohydrate advocates as a condition of carbohydrate
intolerance. Evidence to support
this is limited and it is likely that it
works primarily by energy restriction,30 which may be achieved
through portion control of all
energy-dense foods.
To summarise: The object of determining the ‘ideal’ carbohydrate
intake for each individual must be
based on a number of factors, including individual preferences, current
and future diabetes treatment,
degree of overweight and, where
appropriate, individual blood glucose responses. The goal is to equip
the person with diabetes with
knowledge of the range of dietary
approaches available, their relative
holistic merits and potential impacts
on blood glucose, and a means of
assessing the success of each
approach. This needs to be delivered
in the context of the overall nutritional benefit of the diet, and for
reducing cardiovascular risk.
Carbohydrate quality in diabetes
Fibre and whole grains
Evert31 concluded that people with
diabetes should consume the same
quantity of fibre as the general population (30g per day) but another
review found higher intakes (up to
about 42.5g per day) improved
HbA1c by 6mmol/mol.32 It could be
argued this is an unrealistic target
given that many people do not
achieve the recommended 30g per
day, and so to achieve this higher
intake would probably require supplementation. Evert et al.20 also
reported no association between
whole grain intake and glycaemic
control; however, whole grains are
known to reduce the risk of cardiovascular disease and cancer and so
should be promoted to all patients.33
Glycaemic index
A Cochrane review suggested the
potential benefit of low GI diets is a
reduction in HbA1c of approximately 5–6mmol/mol,34 and one
recent meta-analysis showed low GI
diets resulted in a <2mmol/mol
reduction.35 However, the studies
are often small in number, the definitions of low GI diets differ and, in
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PRACTICAL DIABETES VOL. 33 NO. 7
some cases, even the quantities of
carbohydrate vary between groups.
In the review by Ajala et al.,35 the
methods under which the metaanalysis was conducted have also
been questioned for their validity.36
The majority of research into the
value of low GI diets in diabetes
focuses on type 2 diabetes and the
Cochrane review34 included just one
study involving people with type 1
diabetes. Therefore, low GI diets are
not recommended in the management of type 1 diabetes;37 however,
many people with type 1 diabetes
will need to be aware of the GI and
the slower release of glucose from
low GI foods, as studies have shown
that foods that are low GI as a result
of a high fat content can still be
releasing glucose into the bloodstream up to 8–12 hours after consumption.38 The relevance of GI in
type 1 diabetes is mostly concerned
with understanding the use of very
high GI foods as effective treatments for hypoglycaemia, and optimising insulin dose adjustment,
which will be discussed later.
It is clear from the available evidence that the quantity of carbohydrate is of greater importance than
the GI with respect to glycaemic
control in diabetes,39 but there does
appear to be a small additional
benefit to reducing the GI of the
diet in type 2 diabetes.
Carbohydrate counting
Carbohydrate is the nutrient that
has the greatest effect on postprandial blood glucose and it is widely
acknowledged that monitoring of
carbohydrate intake and matching
mealtime insulin doses is an important strategy in the glycaemic
management of type 1 diabetes.12
However, evidence is lacking in type
2 diabetes, since very few studies in
this area have been published.
In type 2 diabetes, Bergenstal et
al.40 found that there was no difference in blood glucose control between
a weekly dose adjustment algorithm
based on blood glucose, versus matching insulin doses at each meal based
on the carbohydrate content. Both
approaches yielded similar improvements in glycaemic control.
The most widely used insulin regimen for people with type 1 diabetes
is a combination of background
(long or intermediate acting) insulin
and mealtime (quick or short acting)
insulin, although this is increasingly
also seen in patients with type 2 diabetes. This multiple daily injections
(MDI) regimen, sometimes known
as ‘basal-bolus’, permits the greatest
flexibility by allowing patients to
adjust insulin doses based on carbohydrate intake. Insulin pumps use a
similar strategy and are increasingly
common, especially in children and
young people.
NICE37 recommends that carbohydrate counting should be offered
to adults with type 1 as part of
self-management structured education. Those who are unable to
attend structured education groups
should be provided with the same
education on a one-to-one basis.
Counting carbohydrates to enable adjustment of mealtime insulin
doses has been shown as an effective
way of not only improving glycaemic
control but also improving quality
of life.12,41 This approach is vastly
different from the advice given 15
years ago that focused on healthy
eating and glycaemic index.42
Carbohydrate counting and insulin
adjustment should be taught by
someone with specific expertise and
competencies, such as a diabetes
specialist dietitian.
There are many practical tools
used in carbohydrate estimation,
such as: food models, food plates,
carbohydrate reference tables, food
weighing scales, food labels, various
commercial nutritional analysis
books and mobile applications, and
the internet.
Although the dose of insulin
required for each meal will depend
on several factors, including physical activity, illness and pre-meal
blood glucose results, the accuracy
of carbohydrate estimations is paramount in determining the correct
insulin dose. Brazeau et al.43 found
that underestimation of carbohydrate intake occurred in over 60%
of meals when compared with
results from computer analysis,
resulting in higher and more variable blood glucose results. Accurate
carbohydrate counting is important
but challenging in everyday life.
The other macronutrients (fat and
protein) present in food may also
influence insulin requirements;44
COPYRIGHT © 2016 JOHN WILEY & SONS
Review
The role of carbohydrate in diabetes management
Practice recommendations
Key points
• Encourage all people with diabetes to attend a structured patient education programme
to improve their understanding of carbohydrate and the range of dietary options available
to them
• All people with diabetes should have access to a registered dietitian, and those having
particular difficulty in achieving glycaemic control should be referred to a diabetes
specialist dietitian
• In type 2 diabetes: support dietary changes that result in weight loss in the overweight
• In type 1 diabetes: support carbohydrate estimation and insulin dose adjustment to allow
flexibility and improve quality of life
Useful websites and apps
• Carbs and Cals: www.carbsandcals.com
Best-selling books and award-winning app supporting people with diabetes to track their
carbohydrate and calorie intake (plus other nutrients). An excellent pictorial resource
• Myfitnesspal: www.myfitnesspal.com
A popular personal exercise and food tracker for smartphones (not diabetes specific)
• DAFNE online: www.dafneonline.co.uk
Free smartphone app available to anyone, containing a carbohydrate portion database and
ability to record blood glucose. Website resources restricted to people with type 1 diabetes
who have completed the DAFNE course
• MySugr: https://mysugr.com
Smartphone app allowing users to track and sync information about blood glucose and
their wider diabetes management
• Diabetes UK: www.diabetes.org.uk
A wide array of information on all aspects of diabetes for patients and health care
professionals. The free Carbs Count resource is a downloadable book guide to
carbohydrate counting and insulin dose adjustment in type 1 diabetes
however, this is an area needing
further development and outside
the scope of this article.
People with type 1 diabetes
using continuous subcutaneous
insulin infusion, also known as
insulin pump therapy, are able to
extend the duration of insulin
bolus infusion to match the delayed
glucose release from low GI foods.
People on MDI are unable to do
this in the same way but may choose
to split their bolus dose into two,
delaying the second injection in
order to extend the duration of
active insulin, or may need to give a
correction bolus several hours after
the meal.
New technology
Specialist blood glucose meters
are now available incorporating
bolus advice systems. These devices
can help increase accuracy of
insulin dose estimation; however,
accuracy of carbohydrate estimation remains paramount to ensure
accurate bolus advice, as users are
required to input this information
themselves. Research suggests that
PRACTICAL DIABETES VOL. 33 NO. 7
the use of bolus advice meters,
along with carbohydrate counting
education, has a positive effect on
glycaemic control.45
Various mobile phone apps and
online resources also exist to help
with the estimation of carbohydrate
counting, examples of which are
provided in the boxed panel above.
Carbohydrate awareness
This term is used frequently by
health professionals, particularly
in type 2 diabetes, but there is not
currently an agreed definition.46
The general principle is to support patients’ understanding of
sources of carbohydrate and the
effects of differing the types and
quantities of carbohydrate on
glycaemic control. This is an area
that warrants further research and
the development of more clearly
defined interventions.
Conclusion
There is no universal recommendation regarding carbohydrate for
people with diabetes. In line with
recommendations for the general
● E vidence is lacking with respect to the
optimal quantity or proportion of
dietary carbohydrate for people with
diabetes (type 1, type 2, maturity-onset
diabetes of the young [MODY] or
gestational diabetes)
● Dietary recommendations should be
based on foods and overall eating
patterns, not focused on single nutrients
● P eople with diabetes should be offered
appropriate and ongoing education and
support to determine an individual
approach to carbohydrate that helps
optimise their blood glucose control,
based on their preferences and
considering the overall nutritional
quality of the diet
population, dietary advice should
include information on weight management and reducing cardiovascular risk, as well as blood glucose
control.47 Advice should be individualised based on an assessment of
the person with diabetes, their clinical and personal needs, and ideally
undertaken by a registered dietitian
specialising in diabetes.
Declaration of interests
This report is independent research
arising from a Clinical Doctoral
Research Fellowship, awarded to
Paul McArdle (CDRF-2014-05-030),
supported by the National Institute
for Health Research and Health
Education England. The views
expressed in this article are those of
the authors and not necessarily
those of the NHS, the National
Institute for Health Research or the
Department of Health.
Julie Taplin has received speaker
honoraria from Roche, Lilly,
Boehringer and AstraZenica.
There are no other potential
conflicts of interest.
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