Survey of the management of diet in 26 diabetes centres in Europe

Carbohydrate sources and glycaemic control in Type 1 diabetes mellitus. EURODIAB IDDM Complications Study Group

AIMS

Little information is available on the relationship between glycated haemoglobin levels and the source or amount of dietary carbohydrate. The present study compares the association of carbohydrate intake with HbA1c between European individuals with Type 1 diabetes mellitus injecting insulin once or twice per day and those with > or = 3 daily injections.

METHODS

The relation of carbohydrate intake (total, cereal, fruit, vegetable, milk, and potato carbohydrate assessed by a 3-day dietary record) to HbA1c was examined in 2084 patients (age 32.6 +/- 10.2 years, duration of diabetes 14.8 +/- 9.5 years) included in the EURODIAB Complications Study.

RESULTS

In both insulin injection regimens, an increased intake of total carbohydrate (% of energy) and a higher consumption of potato carbohydrates (g) were associated with higher levels of HbA1c, whereas an increased intake of vegetable carbohydrate (g) was inversely related to HbA1c. These tendencies were all more pronounced in persons with one or two daily insulin injections. Consumption of cereal and fruit carbohydrates (g) was not related to HbA1c, irrespective of the insulin injection regimen. A trend of HbA1c to increase with higher intakes of milk carbohydrate was confined to those with one or two insulin injections per day (test for interaction: P = 0.01).

CONCLUSIONS

In particular, subjects with only 1 or 2 daily insulin injections per day should receive specific advice to correctly consider milk and potato carbohydrates. On the other hand, people with Type 1 diabetes may profit from a higher consumption of vegetable carbohydrates for their levels of HbA1c.

Nutritional intake of 2868 IDDM patients from 30 centres in Europe. EURODIAB IDDM Complications Study Group

The EURODIAB IDDM Complications Study, a cross-sectional, clinic-based study, was designed to measure the prevalence of diabetic complications in stratified samples of European insulin-dependent diabetic (IDDM) patients. As diet may be related to diabetic complications, nutritional intake was analysed in the study population. The aims of this first nutritional paper are to describe the nutrient intake in 2868 IDDM patients from 30 centres in 16 countries throughout Europe, to investigate the degree of regional differences in nutrient intake and to compare current intakes with recommended levels. Nutritional intake from 1458 male and 1410 female IDDM patients was assessed by a validated 3-day record (two weekdays, Sunday) and centrally analysed. Mean energy intake for all patients was 2390 +/- 707 kcal/day. Mean protein intake was 1.5 +/- 0.5 g/kg body weight. Carbohydrate intake was 43% and fibre intake 18 g/day. Alcohol intake for the total cohort was 2% of energy. Total fat contributed 38% of energy, with 14% from saturated fat. The Italian centres reported lower total and saturated fat intakes compared with other centres. Recommendations from the Diabetes and Nutrition Study Group of the EASD for total fat, saturated fatty acids and carbohydrate were only achieved by 14%, 14% and 15% of patients, respectively. The data of the present study clearly indicate current problems in the nutritional intake of European IDDM patients. These findings contribute to the definition of future targets in the nutritional management of IDDM patients, to be achieved as part of the initiatives taken by the St. Vincent Declaration action programme.

British Diabetic Association's discussion paper on the role of 'diabetic' foods. Nutrition Subcommittee of the British Diabetic Association's Professional Advisory Committee

1. Most diabetic foods provide slightly, but not substantially, less energy than comparable non-diabetic products. 2. Many diabetic foods have a higher fat content than their non-diabetic equivalents. This is contrary to the requirements of the 1984 Food Labelling Regulations. 3. Many diabetic products have a relatively high content of protein. 4. In percentage terms, the greatest difference between diabetic and non-diabetic foods remains that of carbohydrate content, particularly carbohydrate other than fructose or sorbitol. On a per portion basis (for instance, per teaspoon of jam) the difference is relatively small and likely to be of minimal practical significance. 5. Diabetic foods cost between 1.5 and 4 times as much as their non-diabetic equivalents. 6. Some ordinary reduced-sugar/low calorie products are preferable to diabetic products in terms of fat and energy content and cost. 7. The promotion and widespread availability of diabetic foods tend to delude patients into believing that these products are advantageous, or even necessary. Their existence also undermines current dietary teaching by implying that people with diabetes cannot eat normal foods. 8. Diabetic foods offer no significant physiological or psychological benefits to diabetic patients and can even be counterproductive to good diabetic control. There is no longer a need for special diabetic foods in the modern dietary management of diabetes.

Dietary therapy in NIDDM

Clearly the dietary treatment of the NIDDM patient remains an act of faith bearing in mind the poor compliance of the patient to dietary advice, and the lack of long-term studies confirming the efficacy of diets (old or new) in the prevention of diabetic vascular complications. Few of the newer recommended diets seem to have been tested in the hurly-burly of the busy, understaffed diabetic clinic. Perhaps another major hurdle has been the attitude of patients and doctors in failing to regard diet therapy as a form of treatment, akin to tablets. The phrase 'I eat my diet, doctor, then I have my usual meal' sums up the problem. There needs to be a change in attitude to diet by both doctors and patients so that the dietary changes suggested should be eating habits which would become second nature to patients--the so called 'healthy eating'--more fibre, less refined carbohydrate, less total and saturated fat and more polyunsaturated fats. It seems difficult for a majority of NIDDM patients to add onto 'healthy eating' calorie restriction to achieve weight loss. This difficulty also applies to non-diabetic obese subjects with similar poor results. One cannot help but feel that NIDDM patients should benefit from the general change in attitude of the general population towards nutrition, but reinforced education concerning diet goals for NIDDM patients is an urgent requirement and needs closer examination by the diabetic health care team as to how it may be delivered to the individual NIDDM patients. Perhaps dietitians in particular should become more critical in their approach to diet strategies and should investigate and report on the results of this treatment.