DR PAMELA DYSON (Orcid ID : 0000-0001-5391-6301)

Accepted Article
Article type : Diabetes UK Position Statements

Title: Diabetic Medicine

Created by: Maria Davie

Accepted: 08.02.2018

Email proofs to: pamela.dyson@ocdem.ox.ac.uk

Article no.: DME-2018-00093

Article type: Guideline/Position Statement

Short title/Authors running head: Diabetes UK nutrition guidelines • P. A. Dyson et al.

Diabetes UK evidence-based nutrition guidelines for the

prevention and management of diabetes

P. A. Dyson1, D. Twenefour2, C. Breen3, A. Duncan4, E. Elvin5, L. Goff6, A.

Hill7, P. Kalsi8, N. Marsland5, P. McCardle9, D. Mellor10, L. Oliver11 and K.

Watson12

1 2 3
OCDEM, University of Oxford, Oxford, Diabetes UK - Clinical Care, London, School of

Medicine, University College Dublin, Dublin, 4Nutrition and Dietetics, Guys and St Thomas' NHS

Foundation Trust, London 5Diabetes UK - Care, London, 6Division of Diabetes and Nutritional

Sciences, King's College London, 7NICHE, University of Ulster, Coleraine, Londonderry, 8Diabetes

UK - Policy, Care and Improvement, London, 9Community Nutrition, Birmingham Community

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/dme.13603
This article is protected by copyright. All rights reserved.
 Healthcare NHS Trust, Birmingham, 10School of Life Sciences, Coventry University, Coventry,
Accepted Article 11
Nutrition and Dietetics, North Tyneside General Hospital North Shields, Tyne and Wear, 12Nutrition

and Dietetics, King's College Hospital NHS Foundation Trust, London, UK

What's new?

• These updated guidelines, based on recently published studies, provide evidence-based

recommendations for the prevention and management of diabetes.

• The focus is on food, rather than nutrients, and an individualized, flexible approach to

nutritional management is recommended.

• New guidelines for remission of Type 2 diabetes and considerations for ethnic minorities are

included.

• Guidelines are assessed using adapted 'GRADE' methodology.

Abstract

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

This article is protected by copyright. All rights reserved.

 include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations
Accepted Article 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:

Introduction

‘An appropriate diet represents the cornerstone for diabetes therapy, and there is now unequivocal

evidence that Type 2 diabetes can be delayed or prevented by a well-structured diet and increased

physical activity, generally resulting in weight loss’ [1]. Most experts now agree that diet has an

increasingly important part to play in both the management and prevention of diabetes, with emerging

evidence suggesting potential remission of Type 2 diabetes. There remains little consensus, however,

about the constituents of an ideal or optimal diet, and current evidence suggests that various dietary

patterns can be effective [2]. Diabetes UK reflected these conclusions in their evidence-based

nutrition guidelines for diabetes, last published in 2011 [3] and, as the evidence remains fully

supportive of these findings, those guidelines were used as the basis for these new recommendations.

One criticism that is frequently levelled at new recommendations is that they may contradict previous

guidance, and this leads to a level of distrust. It is worth remembering that nutrition is a relatively

young and complex science, with a large amount of emerging evidence, and these new

recommendations attempt to establish the current evidence base for guidance and, in so doing, may

well contradict traditional beliefs and usual practice. Key features of the new guidelines were to try to

move from recommendations for individual nutrients to foods that meet the needs of people with

diabetes, and to make the new guidelines more accessible and usable by the individuals and groups

This article is protected by copyright. All rights reserved.

 for whom they are designed. Formulating evidence-based recommendations from the available
Accepted Article literature can be challenging for a variety of reasons, including quality, type of intervention, analysis

and application of dietary studies.

Quality of studies

Many different strategies are used to assess the effects of different diets and foods on health

outcomes, including randomized controlled trials (RCTs), intervention studies with no comparator

group, prospective cohort studies, cross-sectional cohort studies and case reports. RCTs are widely

regarded as the 'gold standard', but are often impractical or limited when assessing nutritional

outcomes which are influenced by many factors that are difficult to control, and where outcomes of

interest take place far in the future with the impossibility of following up individuals for many

decades. For this reason, well-conducted, large, prospective cohort studies supply useful data for

evaluating the relationship between dietary patterns and individual foods and diabetes-related

outcomes, and are widely used to inform these new guidelines.

Type of intervention: foods or nutrients

Traditionally, intervention studies in people with diabetes have focused on specific nutrients, for

example, carbohydrate and fat, but there is a global movement towards more food-based guidelines

[4]. Recommendations from dietary studies can be formulated in terms of dietary patterns, foods or

specific nutrients, and the 2018 recommendations highlight the importance of foods rather than

nutrients wherever possible.

This article is protected by copyright. All rights reserved.

 Analysis
Accepted Article
Dietary intervention studies frequently report contradictory results and this has been highlighted

recently with meta-analyses reporting conflicting outcomes regarding the role of saturated fat in

cardiovascular disease (CVD) and the effect of low carbohydrate diets on glycaemic control when

compared with other dietary strategies. This is compounded by the binary nature of such intervention

studies, which typically assess the efficacy of two very different diets, whereas populations eat more

varied diets. The applicability of meta-analyses, which are intended for the aggregation of similar

studies [5], is questionable for dietary studies where there is considerable heterogeneity resulting from

differences in type, duration and intensity of the intervention, differences in comparator diets and

variation in the participants including duration of diabetes and medication use.

Application

Applying and evaluating intervention diets used in dietary studies is challenging. There are few

readily available biomarkers to assess adherence, and often the only measure used is self-reported

dietary intake. This measure is notoriously unreliable and it has long been known that under-

reporting, especially in those who are obese, is common [6]. As a result, it is challenging to establish a

causal relationship between the individual components of study diets and their reported effects, and to

formulate specific guidelines for free-living populations.

The above limitations were all considered when formulating the new recommendations, and the

following article summarizes the Diabetes UK 2018 evidence-based nutrition guidelines for the

prevention and management of diabetes in adults. The full document is available at:

This article is protected by copyright. All rights reserved.

 Methods
Accepted Article
In 2016, Diabetes UK appointed an expert Nutrition Sub-Committee to review and update the existing

2011 nutrition guidelines [3]. These previous guidelines had included studies published up to August

2010, and the current guidelines incorporated this existing evidence together with additional studies

published between January 2010 and December 2016. In addition, key publications of meta-analyses

and systematic reviews up to July 2017 were included, and an exception was made to include a major

study of diabetes remission published in December 2017 [7].

The committee made the decision to retain previous sections including education and care delivery,

prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, CVD risk

management, management of diabetes-related complications, other considerations such as

comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food

supplements, functional foods, commercial diabetic foods and nutritive and non-nutritive sweeteners.

The sections on pregnancy and prevention of Type 2 diabetes were enlarged and the weight

management section was modified to include remission of Type 2 diabetes in response to current

interest in emerging data. A section evaluating detailed considerations in ethnic minorities was

included as a new topic.

Relevant studies were identified by electronic searches in EMBASE, MEDLINE and the Cochrane

Central Register of Controlled Trials. Reference lists of selected papers were then investigated for any

further studies suitable for consideration. Existing guidelines were identified from local, national and

international reports. Search terms and keywords for each section were defined and agreed by the

committee. Inclusion criteria for studies were adults (aged >18 years) with Type 1 or Type 2 diabetes.

RCTs, intervention studies and prospective cohort studies, all with a dietary or lifestyle component,

were included.

This article is protected by copyright. All rights reserved.

 Formal meta-analyses of dietary interventions for diabetes were not undertaken because it was not
Accepted Article deemed a valid approach. The majority of studies were at high risk of bias and heterogeneous in terms

of study design, type and intensity of the intervention, the comparator diet or intervention, study

length, duration of diabetes and medication use.

The GRADE system (Grades of Recommendation Assessment, Development and Evaluation), a

systematic approach to making judgements about the quality of evidence and strength of

recommendations, was used as the basis for grading these dietary recommendations [8]. GRADE was

employed in these guidelines as it is a system widely used for nutritional recommendations and has

been adopted globally by ~100 organizations that are responsible for formulating recommendations to

support healthcare decision-making [9]. GRADE also encourages a focus on the recommendations

that are of primary importance for people with diabetes, and which are worded in manner that are

more person-focused and emphasize eating behaviour and diabetes. It is acknowledged that much of

the evidence from nutrition research is derived from prospective cohort studies rather than RCTs, and

applying GRADE downgrades evidence from prospective studies when compared with RCTs; this

should be borne in mind when considering the grading allocated to each recommendation.

The final guidelines underwent internal review by all members of the committee, and were then

submitted to external peer review by three experts in the field. They were subsequently reviewed by

Diabetes UK’s Council of People with Diabetes, Diabetes UK’s Council of Healthcare Professionals,

British Dietetic Association’s Diabetes Specialist Group, Association of British Clinical

Diabetologists, Primary Care Diabetes Society, Royal College of Nursing and Royal College of GPs.

This article is protected by copyright. All rights reserved.

 Summary of guidelines with evidence 'GRADE'
Accepted Article
An overview of the guidelines is provided below. The evidence GRADE is marked by a number from

1 to 4, where a higher number denotes stronger evidence and lower numbers indicate deductions made

for lower-quality studies with limited generalizabilty, see below:

• Grade 4: strong recommendation based on high-quality evidence.

• Grade 3: moderate recommendation based on moderate-quality evidence.

• Grade 2: low-strength recommendation based on low-quality evidence.

• Grade 1 (or less): very-low-strength recommendation based on very-low-quality

evidence.

Not Rated: A key aspect of current approaches to supporting people with diabetes is to encourage

practice that is individualized. It is challenging to rate such recommendations using the GRADE

system, particularly in situations where multiple conditions influence health and dietary approaches.

In response to this, a deliberate decision was made to report these recommendations as ‘Not Rated’,

indicated by the letters NR.

The references to the evidence linked to the following recommendations can be found in the full

document available at:

This article is protected by copyright. All rights reserved.

 Nutrition management and models of education and care delivery
Accepted Article
Recommendations and their grade are given in the text boxes below.

• Nutrition management is recommended as part of an integrated package

of education and clinical care for all people with diabetes and those at risk
4
of developing Type 2 diabetes

• Offer on-going nutritional advice guided by a registered dietitian to all 3

people with diabetes, and those at high risk of Type 2 diabetes

• Offer structured diabetes education at the time of diagnosis with annual 3

follow-up

• Offer culturally sensitive multi-component education and interventions to 4

people from ethnic minority groups

• Adopt a person-centred approach and a variety of learning styles during NR

education

Prevention of Type 2 diabetes

• Aim for weight loss of at least 5%, where appropriate, to reduce the risk 4

of Type 2 diabetes in high-risk groups

• Key recommendations for lifestyle interventions to reduce risk of Type 2

diabetes in high-risk groups include:

 restrict energy intake;

4

This article is protected by copyright. All rights reserved.

  reduce total and saturated fat intake;
Accepted Article
 increase fibre intake;

 increase physical activity.

• Dietary patterns associated with reduced risk in general populations

include:

 Mediterranean diet;
4

 DASH (Dietary Approaches to Stop Hypertension) diet;

2

 vegetarian and vegan diets;

2

 the Nordic healthy diet;

2

 moderate carbohydrate restriction.

1

• Include more specific foods associated with reduced risk in general

populations such as wholegrains, some fruit, green leafy vegetables,

2
yogurt and cheese, tea and coffee

• Reduce specific foods associated with increased risk in general

populations including red and processed meat, potatoes, particularly

2
French fries, sugar-sweetened beverages and refined carbohydrates

• Offer culturally tailored, multi-component lifestyle interventions to 3

reduce the risk of Type 2 diabetes in ethnic minority groups

This article is protected by copyright. All rights reserved.

 Weight management and remission of Type 2 diabetes
Accepted Article
• For overweight or obese people with Type 2 diabetes:

 for Type 2 diabetes remission, aim for weight loss of at least

3
15 kg, as soon as possible after diagnosis;

 to improve glycaemic control and CVD risk. aim for at least

5% weight loss achieved by reducing calorie (energy) intake

and increasing energy expenditure.

4

• Adopt an individualized approach which may include dietary, physical

activity, surgical and medical stratagies that are recommended for people
NR
without diabetes

Glycaemic control and Type 1 diabetes

• Offer education to support people with Type 1 diabetes to identify and

quantify their dietary carbohydrate intake for glycaemic control.

Specifically:

 adjust insulin to carbohydrate intake in people using multiple

daily injections or continuous subcutaneous insulin infusion 4

(insulin pump);

 aim for consistent quantities of carbohydrates on a day-to-day

basis in people on fixed-insulin regimens. 1

This article is protected by copyright. All rights reserved.

 Glycaemic control and Type 2 diabetes
Accepted Article
• Prioritize sustained weight loss of at least 5% in overweight people by

reducing calorie (energy) intake and increasing energy expenditure

4

• Aim for a Mediterranean-style diet or equivalent healthy eating pattern. 4

(See CVD section)

• Offer individualized education to support people to identify and quantify

their dietary carbohydrate intake, encourage low glycaemic index foods

NR
and consider reducing the total amount of carbohydrates

• Aim for at least 150 min per week of moderate to vigorous physical 4

activity, over at least 3 days

Cardiovascular disease risk reduction: blood lipids and blood pressure

• Dietary patterns, specifically the Mediterranean and DASH-style diets,

are recommended to reduce CVD risk factors and CVD events in people

with diabetes. Key features of these diets include:

 decrease salt intake (<6 g/day);

 eat two portions of oily fish each week;

 eat more wholegrains, fruit and vegetables, fish, nuts and legumes

(pulses);

 consume less red and processed meat, refined carbohydrates and 3

sugar-sweetened beverages;

This article is protected by copyright. All rights reserved.

  replace saturated fats with unsaturated fats, and limit intake of
Accepted Article trans-fatty acids;

 limit alcohol intake to ≤14 units/week.

• Aim for modest weight loss of at least 5% in overweight individuals 3

• Aim for at least 150 min per week of moderate to vigorous physical 4

activity, over at least 3 days

• Products containing 2–3g of plant stanols and sterols per day can be 3

recommended

Considerations in ethnic minority groups

Evidence reviewed in this section informed the recommendations for ethnic considerations in other

sections such as prevention of Type 2 diabetes, and models of education and care delivery (see above

sections).

Nutritional management of diabetes complications

Hypoglycaemia

• An individualized approach to hypoglycaemia management with NR

appropriate monitoring is recommended. One example of a strategy

commonly recommended includes the following:

 take 15–20 g glucose;

This article is protected by copyright. All rights reserved.

  repeat treatment if blood glucose level has not risen above 4
Accepted Article mmol/l after 15 min;

 depending on individual needs and treatment, a follow-up snack

providing 15–20g carbohydrate may be necessary.

Diabetic nephropathy

• Offer individualized approach to minimize risk of malnutrition NR

 Provide advice on potassium, phosphate, salt and energy intake as

clinically required

 Do not routinely restrict protein intake

Lower limb ulcers and amputation

• Assess nutritional status and offer individualized approach to minimize NR

malnutrition, and optimize glycaemic control

This article is protected by copyright. All rights reserved.

 Diabetic gastroparesis
Accepted Article
• Offer individualized care to meet nutritional requirements, manage NR

symptoms and optimize glycaemic control

Recommendations for dietary management of people with diabetes and existing CVD are similar to

those for people with diabetes without established CVD (see CVD risk reduction section above) so

these were not repeated. There was a lack of published evidence to make evidence-based

recommendations for the specific role of diet in the management of other diabetes complications

including retinopathy and diabetic ketoacidosis.

Other special considerations

Nutrition support

• Aim to meet nutritional requirements and adequacy 2

 Adjust diabetes treatment to optimize glycaemic control

 Deliver support from a multi-disciplinary team

• General enhanced recovery after surgery protocols can be recommended, NR

depending on individual clinical situation

• Diabetes-specific formulae enteral feeds can be recommended, but are not 2

routinely used in the UK

This article is protected by copyright. All rights reserved.

 Older people
Accepted Article
• Offer education, including dietary intervention, to older people with 4

diabetes. Age should not restrict access to education

• Assess nutritional status and care plans under the supervision of a NR

dietitian

• Adapt general guidelines for people with diabetes for those with dementia NR

Diabetes care in institutions

• Offer access to education, including dietary intervention, to people in NR

institutions

• Provide menus with nutritional information, including carbohydrate 1

content

Pregnancy

Women living with diabetes (both Type 1 and Type 2) prior to conception should: NR

• receive support from a multidisciplinary team, including referral to a

dietitian;

• aim to achieve and maintain optimal glycaemic control before and during

This article is protected by copyright. All rights reserved.

 pregnancy;
Accepted Article
• aim to lose weight before pregnancy if overweight or obese and maintain

appropriate weight gain during pregnancy;

• take 5 mg folic acid/day before pregnancy until the end of the 12th week

of pregnancy.

Women diagnosed with gestational diabetes should: NR

• be referred to a dietitian for dietary advice;

• aim to achieve appropriate weight gain;

• take regular physical activity, including walking for 30 min after a meal

to lower postprandial glucose concentrations.

Coeliac disease

• Offer individualized advice by a specialist dietitian to all people with NR

coeliac disease and diabetes

• Recommend adherence to a gluten free diet 4

Cystic fibrosis-related diabetes mellitus

This article is protected by copyright. All rights reserved.

 • Provide individualized dietary and insulin education and advice to NR
Accepted Article optimize nutritional status, weight and glycaemic control

• Avoid unnecessary dietary energy restrictions 1

• Provide education to support people to identify and quantify

carbohydrates to manage glycaemic control, including during

1
supplementary feeding

Diabetes in people with HIV

• Offer individualized multi-component interventions to treat antiretroviral-

associated weight gain to reduce risk of Type 2 diabetes

NR

• Follow diet and physical activity recommendations for the general NR

diabetes population to manage diabetes in people with HIV

Eating disorders

• Consider the possibility of disordered eating or other control behaviours NR

relating to food in adults with diabetes

• Use suitable screening tools to identify possible eating disorders at the 2

earliest opportunity

• Consider an early referral to local eating disorder services NR

This article is protected by copyright. All rights reserved.

 Micronutrients, food supplements and functional foods
Accepted Article
• Do not recommend micronutrient supplementation to manage or 4

prevent diabetes

• Encourage individuals choosing to use supplements to discuss their NR

individual needs with a registered dietitian

Commercial diabetic foods, sugars and other sweeteners

• Avoid food labelled ‘diabetic’ or ‘suitable for diabetics’ NR

• Reduce intake of free sugars, sugar-sweetened beverages and added 2

fructose

• Non-nutritive (artificial) sweeteners are safe and may be NR

recommended

Conclusions

The 2018 recommendations for adults with diabetes or at risk of Type 2 diabetes are based on current

evidence, and are worded to encourage accessibility by people with diabetes, the general public and

healthcare professionals. These recommendations should form the basis for dietary management of

adults with diabetes and those at risk of Type 2 diabetes in the UK. They should be adapted to suit an

individual’s culture, preferences, needs and personal goals. Diabetes UK commits to regular review

of emerging evidence and to update the 2018 recommendations as appropriate.

This article is protected by copyright. All rights reserved.

 Acknowledgements
Accepted Article
We gratefully acknowledge the expertise of our peer reviewers Nita Forouhi, Programme Leader at

the MRC Epidemiology Unit, University of Cambridge, Mike Lean, Chair of Human Nutrition at the

University of Glasgow and Mike Trennell, Professor of Movement and Metabolism at Newcastle

University for their constructive comments and suggestions.

References

1. Pozzilli P, Fallucca F. Diet and diabetes; a cornerstone for therapy. Diabetes Metab Res Rev

2014; 30(Suppl. 1):1–3.

2. Ley SH, Hamdy O, Mohan V, Hu FB. Prevention and management of type 2 diabetes: dietary

components and nutritional strategies. Lancet 2014; 383:1999–2007.

3. Dyson PA, Kelly T, Deakin T, Duncan A, Frost G, Harrison Z et al.; on behalf of Diabetes

UK Nutrition Working Group. Diabetes UK evidence-based nutrition guidelines for the

prevention and management of diabetes. Diabet Med 2011; 28:1282–1288.

4. Food and Agricultural Organization/World Health Organization. FAO/WHO Technical

consultation on national food-based dietary guidelines. FAO/WHO, 2006.

5. Higgins JPT, Green S (eds). Cochrane handbook for systematic reviews of interventions.

Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available at:

www.handbook.cochrane.org.

6. Livingstone MB, Prentice AM, Strain JJ, Coward WA, Black AE, Barker ME et al. Accuracy

of weighed dietary records in studies of diet and health. BMJ 1990; 300: 708–712.

7. Lean MEJ, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L et al. Primary care-

led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-

randomised trial. Lancet 2017; http://dx.doi.org/10.1016/S0140-6736(17)33102-1.

This article is protected by copyright. All rights reserved.

 8. Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a
Accepted Article new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol 2011; 64:

380–382.

9. Grade Working Group. Available at: http://www.gradeworkinggroup.org

This article is protected by copyright. All rights reserved.