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Practice Guidelines

Diagnosis and management of type 1 diabetes in adults: summary of updated NICE guidance

BMJ 2015; 351 doi: (Published 26 August 2015) Cite this as: BMJ 2015;351:h4188

Re: Diagnosis and management of type 1 diabetes in adults: summary of updated NICE guidance

NICE has the unenviable task to establish Type 1 diabetes (T1DM) management protocol.(1)

Type 1 diabetes has become a largely forgotten disease subsumed into the epidemic of type 2 diabetes (T2DM). Type 1 diabetes accounts for only 10% of the population with diabetes. Type 1 diabetes is an autoimmune disease which is currently irreversible.and unpreventable. Whereas type 2 diabetes is considered a lifestyle disease and eminently preventable with the right measures. Sugar has been blamed for the epidemic of type 2 diabetes. which is unfortunate as it took many years to shake off the title of ‘sugar diabetes’ However, it is significant that Glucose (sugar) is of course ultimately the human bodies’ fuel; excess glucose unused by activity is stored as fat. All carbohydrate is converted to glucose by the action of insulin. This is a fact which needs public awareness..

The new NICE guidelines seem to be quite comprehensive however there is a huge elephant in the room. There is no scientific guidance on carbohydrate intake and consumption of fat in the diabetic diet. Advice which is urgently required.

From an historical perspective.T1DM patients were mostly taught to use carbohydrate-exchange units in regulating their diets; this method was used less often for T2DM. At the beginning of the insulin era diets were very low in carbohydrate and high in fat. (2)

A 1979 study concluded that in T2DM a high carbohydrate diet composed of readily available cereal foods and tuberous vegetables, resulted in lower fasting and preprandial blood glucose concentrations than a standard low carbohydrate diet. (3) Similar findings were found in T1DM. (4) By the 1980’s national diabetes associations were recommending diets with a substantial amount of carbohydrate and fibre and little fat to improve glycaemic control and reduce the risk factors for ischemic heart disease. (5)(6)

The new NICE dietary guidance suggests the low Gi (glycaemic index) diet for type 1 diabetes. should no longer be followed for blood glucose management.. However, low Gi foods include; whole foods such as meat, fish, dairy produce fruit and vegetables, nuts and pulses. Fats and oils (a major subject in itself) the very foods which promote good health and well being! The guidelines do not suggest an alternative diet. One of the fundamental disasters in human health has been the adoption of an over processed diet which is nutritionally barren, proinflammatory and therefore disease promoting. However hard health professionals work to favourably balance blood glucose levels, the spectre of very poor dietary eating habits and lack of consistency will not be overcome. It is irrefutable that human beings need food containing all essential nutrients.

The diabetic diet was supposed to be a diet which was healthy for all, based on the principle that all food groups essential for human health were consumed in appropriate amounts to suit individual need. The diet heart hypothesis inadvertently took away this balance. Commercialism took over our diet leading to consumption of food products which claimed to be heart friendly. A modern day obsession with slimming diets was also created. The diabetic diet moved away from carbohydrate management accompanied by modest amounts of fat eaten in meat and fish as part of a normal healthy diet. (In the UK a meal was described as meat with two veg) The low fat recommendations, not only reduced satiety - which can lead to overeating. It also means the body may not receive the vital nutrients of essential fats needed for homeostasis.

The new guidelines recommend dose adjustment for normal eating (DAFNE) as an education protocol. People with diabetes need to know what normal eating is. If a high carbohydrate/low fat diet is still recommended by diabetic associations there will be a high demand for insulin dosage leading to difficulties in hypoglycaemia management, erratic blood glucose levels, weight increase and injection site problems.

The principle aim of tight glycaemic control is to prevent the devastating complications of diabetes including...

• Blindness and varying stages of visual impairment
• Kidney disease including end stage renal failure
• Foot ulceration and lower limb amputation
• Sensory neuropathy
• Cardiovascular disease and stroke
• Reproductive difficulties

However the glucocentric approach does not ensure adequate nutrition fundamentally essential to ensure normal. physiology of the above.

(1) Amiel Stephani A, Pursey Nancy,Higgins Bernard, Dawoud Dalia.Diagnosis and management of type 1 diabetes in adults: summary of updated NICE guidance 2015;351 :h4188

(2) A S Truswell, Briony J Thomas, Ann M Brown British Medical Journal, 1975, 4, 7-11 Survey Of Dietary Policy And Management In British Diabetic Clinics

(3) Simpson, R W, et al, British Medical Journal, 1979, 1, 1753.

(4) R W Simpson, J I Mann, J Eaton, R D Carter, T D R Hockaday. British Medical Journal, 1979, 2, 523

(5) American Diabetes Association. Nutritional recommendations and principles for individuals with diabetes mellitus. Diabetes Care 1987;10: 126-32.

(6) Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes.Nutritional recommendations for individuals with diabetes mellitus. Diabetes, Nutrition and Metabolism 1988;1:145-9

Competing interests: No competing interests

04 September 2015
Jane E Collis
Independent Health Researcher
Kenilworth Warwickshire UK