Interventions aimed at increasing exercise combined with diet have been shown to decrease the incidence of type 2 diabetes mellitus in high-risk groups (people with impaired glucose tolerance or the metabolic syndrome).¹ However, there are no high-quality data on the efficacy of dietary intervention for the prevention of type 2 diabetes.² Exercise appears to improve glycated haemoglobin at six and twelve months in people with type 2 diabetes.³

Nutritional advice and information are essential for the effective management of type 1 diabetes. Exercise reduces mortality in type 1 diabetes and can reduce HbA1c by 0.7% in type 2 diabetes.⁴

Dietary advice⁴

See also the separate article Healthy Diet and Enjoyable Eating. The goals of dietary advice are:

• To maintain or improve health through the use of appropriate and healthy food choices.
• To achieve and maintain optimal metabolic and physiological outcomes, including:
  • Reduction of risk for microvascular disease by achieving near normal glycaemia without undue risk of hypoglycaemia.
  • Reduction of risk of macrovascular disease, including management of bodyweight, dyslipidaemia and hypertension.
• To optimise outcomes in diabetic nephropathy and in any other associated disorder.

Diabetes UK recommendations⁵

• Eat three meals a day. Avoid skipping meals and space breakfast, lunch and evening meal out over the day.
• At each meal include starchy carbohydrate foods, e.g. bread, pasta, chapatis, potatoes, yam, noodles, rice and cereals. Eat more slowly absorbed (low glycaemic index) foods, e.g. pasta, basmati or easy cook rice, grainy breads such as granary, pumpernickel and rye, new potatoes, sweet potato and yam, porridge oats, All-Bran® and natural muesli.
• Reduce the fat in the diet, especially saturated fats. Use unsaturated fats or oils, especially monounsaturated fats, e.g. olive oil and rapeseed oil.
• Eat more fruit and vegetables. Aim for at least five portions a day.
• Eat more beans and lentils, e.g. kidney beans, butter beans, chickpeas or red and green lentils.
• Eat at least two portions of oily fish a week, e.g. mackerel, sardines, salmon and pilchards. Limit sugar and sugary foods.
• Reduce salt in the diet to 6 g or less per day.
• Drink alcohol only in moderation.
• Don't use diabetic foods or drinks (they are expensive and of no benefit).

Type 2 diabetes⁶

• A low glycaemic index diet can improve glycaemic control in diabetes without compromising hypoglycaemic events.⁷
• Although the studies are not extensive, one meta-analysis has shown that, for people with type 2 diabetes, a large fall in blood pressure similar to that of single drug therapy can be achieved with salt restriction.⁸
• Dietary advice should be personalised and take on board the individual's needs, cultural and belief, and willingness to make changes. Advice should be ongoing and available educational programmes should be offered - e.g. DESMOND (= Diabetes Education and Self-management for Ongoing and Newly Diagnosed⁹).
• Emphasis should be on eating a healthy balanced diet applicable to the general population. Control of obesity is also important. For people who are overweight , the target should be an initial bodyweight loss of 5-10%. Lesser degrees of weight loss may still be of benefit and larger degrees may provide additional metabolic advantages.
• Diet should be assessed with a view to reducing hypoglycaemia in patients using insulin secretagogues.
• Limited substitution of sucrose-containing foods for other carbohydrates is allowable but excess energy intake should be avoided.
• Patients admitted to hospital or other institutions should have their meals and snacks planned with a view to providing consistency in carbohydrate content.

Type 1 diabetes¹⁰

• Diet should be assessed with a view to reducing hypoglycaemia in all people with diabetes whose treatment includes insulin. The hyperglycaemic effects of different foods should be discussed in the context of the insulin preparation chosen to match the patient's food choices.
• Educational programmes - e.g. DAFNE (= Dose Adjustment For Normal Eating¹¹) - should be available so that patients can make an educated choice about:
  • The variety of foods they wish to eat.
  • Insulin dose changes appropriate to reduce changes in glucose levels when eating different amounts of those foods.
  • The type and amount of snacks taken between meals and at bedtime - discussed in the context of the patient's insulin regime. Those choices may need to be adjusted according to the individual's self-monitoring tests. Advise snacks only if self-monitoring suggests a need; check particularly if a high insulin analogue dose is needed to correct preprandial hyperglycaemia.
• Patients should be made aware of:
  • The effects of different alcohol-containing drinks on blood glucose excursions and calorie intake.
  • The use of high-calorie and high-sugar 'treats'.
  • The use of foods of high glycaemic index.

The National Institute for Health and Clinical Excellence (NICE) recommends that the nutritional advice given to insulin-dependent patients may need to be modified to take into account patients who are underweight, have eating disorders, have hypertension or have chronic kidney disease. The information made available to people with type 1 diabetes should consider cultural and religious diets, feasts and fasts and should include matching carbohydrate, insulin and physical activity.

Exercise⁴

• Regular physical activity improves insulin resistance and lipid profile (reduction in triglyceride and increase in high-density lipoprotein (HDL)) and lowers blood pressure (although blood pressure will rise during exercise).
• The metabolic benefits in type 2 diabetes are lost within 3-10 days of stopping regular exercise.
• Physical activity also protects against the development of type 2 diabetes.

Diabetes UK recommendations⁵

• The recommended minimum amount of activity for:
  • Adults - 30 minutes on at least five days of each week.
  • Children - one hour each day.
• It is essential to find activities that are enjoyable, achievable and sustainable, e.g. walks, dancing, swimming, bowling, cycling, golf, playing with the children, DIY.

Special considerations when advising diabetics about exercise¹²

• Always consider insulin/oral hypoglycaemic therapy and meal schedule: test blood glucose before exercise, postpone exercise until after a snack if blood glucose is low, and always keep glucose at hand.
• Autonomic neuropathy is common and can be associated with silent ischaemia, postural hypotension and a blunted heart rate response to exercise.
• Peripheral neuropathy is common and may lead to numbness, paraesthesiae, reduced balance, Charcot's joints.
• Peripheral vascular disease: there may be intermittent claudication, leg ulcers, etc.
• Avoid high-impact exercise, as this may traumatise the feet (emphasise foot care, proper shoes and cotton socks).
• Hypoglycaemia may occur up to several hours after exercise.
• Exercise is contra-indicated if there is active retinal haemorrhage or recent retinal photocoagulation.

Type 2 diabetes

NICE only gives generalised advice concerning the role of physical exercise in type 2 diabetes. Guidance can be found in the St Vincent Declaration and from the American College of Sports Medicine.^12,13 Advise that physical exercise:

• Can benefit insulin sensitivity, blood pressure, and blood lipid control.
• Should be taken at least every 2-3 days for optimum effect.
• May increase the risk of acute and delayed hypoglycaemia.

Manage physical exercise using:

• Formal recording of levels of physical activity
• Identification of new exercise opportunities (see under 'Exercise', above), and encouragement to develop these.
• Appropriate self-monitoring, additional carbohydrate, and dose adjustment of glucose-lowering therapy for those using insulin secretagogues.

Warn about:

• Alcohol, which may exacerbate the risk of hypoglycaemia after exercise.
• The risks of foot damage from exercise (advise low-impact exercise).
• The need to consider ischaemic heart disease in those beginning new exercise programmes.

Type 1 diabetes

Advise that physical activity can reduce enhanced arterial risk in the medium and longer term. Give information on:¹⁰

• Appropriate intensity and frequency of physical activity.
• Self-monitoring of changed insulin and/or nutritional needs.
• Effect of exercise on blood glucose levels when insulin levels are adequate (risk of hypoglycaemia) or when hypoinsulinaemic (risk of exacerbation of hyperglycaemia and ketonaemia).
• Appropriate adjustments of insulin dosage and/or nutritional intake for exercise and for 24 hours afterwards.
• Interactions of exercise and alcohol.
• Where to find more information.

Document references

1. Orozco LJ, Buchleitner AM, Gimenez-Perez G, et al; Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD003054. [abstract]
2. Nield L, Summerbell CD, Hooper L, et al; Dietary advice for the prevention of type 2 diabetes mellitus in adults. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005102. [abstract]
3. Nield L, Moore HJ, Hooper L, et al; Dietary advice for treatment of type 2 diabetes mellitus in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004097. [abstract]
4. The implementation of nutritional advice for people with diabetes, Diabetes UK
5. Diabetes UK
6. Type 2 diabetes - newer agents (partial update), NICE Clinical Guideline (May 2009); Type 2 diabetes - newer agents for blood glucose control in type 2 diabetes
7. Thomas D, Elliott EJ; Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006296. [abstract]
8. Suckling RJ, He FJ, Macgregor GA; Altered dietary salt intake for preventing and treating diabetic kidney disease. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD006763. [abstract]
9. DESMOND project; Website containing information about the project, training and programmes
10. Diagnosis and management of type 1 diabetes in children, young people and adults, NICE Clinical Guideline (July 2004)
11. Dose Adjustment For Normal Eating (DAFNE) Website
12. International Diabetes Guidelines; Newcastle University 2008.; St Vincent Declaration
13. Exercise Management for Persons with Chronic Diseases and Disabilities, American College of Sports Medicine 2003

Internet and further reading

• ISPAD Clinical Practice Consensus Guidelines 2009 Compendium; Nutritional management in children and adolescents with diabetes

Acknowledgements