Nursing Practice
Review
Diabetes
Keywords: Type 2 diabetes, Dietary
modification, Weight-loss surgery
●This
article has been double-blind
peer reviewed
Type 2 diabetes is associated with a range of serious complications, and accounts
for significant costs to the NHS. Dietary and lifestyle change can reduce its impact
Reversing type 2 diabetes
with lifestyle change
In this article...
Incidence of type 2 diabetes
Pathophysiology of type 2 diabetes
Effects of dietary and lifestyle modifications on type 2 diabetes
Author Val Wilson is a freelance writer,
researcher and lecturer in diabetes
Abstract Wilson V (2015) Reversing type 2
diabetes with lifestyle change. Nursing
Times; 111: 12, 17-19.
Type 2 diabetes is now at epidemic levels
in the UK and becoming increasingly
costly for the NHS to treat. Risk factors
include a high-carbohydrate diet and
sedentary lifestyle. This article examines
the effectiveness of a healthy, caloriecontrolled diet and exercise regime in
reversing type 2 diabetes.
T
ype 2 diabetes is the most
common form of the condition
and accounts for 90% of cases
worldwide (World Health Organization, 2011). In February 2014 there were
3.2 million people with the condition in
the UK, an increase of 163,000 compared
with 2012, meaning type 2 diabetes currently affects 5% of the adult population
(www.diabetes.org). This is the biggest
annual increase in diagnoses of the condition since 2008.
The condition can develop up to 12 years
before it is diagnosed, as patients frequently do not report experiencing the
main symptoms – typically increased
thirst and frequent urination – which are
far more subtle in type 2 diabetes in contrast with their rapid onset in type 1 diabetes (Diabetes UK, 2008). In 2012 it was
estimated that more than 850,000 adults
had undiagnosed type 2 diabetes, meaning
one in 20 people has the condition, diagnosed or undiagnosed (Diabetes UK, 2012).
High blood glucose causes a wide range
of complications (Box 1), as well as reduced
life expectancy and increased mortality. If
type 2 diabetes remains untreated or
poorly managed, these serious complications may also develop.
It is estimated that treatment and management of type 1 and type 2 diabetes and
their associated complications combined
currently cost the NHS around £10bn a
year to treat, which equates to 10% of its
budget (Hex et al, 2012). Since most people
with the condition have type 2 diabetes,
improving its diagnosis, treatment and
management, and the reduction of further
complications are a priority for the NHS.
Pathophysiology and causes
Type 2 diabetes usually appears in people
over the age of 40 (Diabetes UK, 2012),
although it has also been diagnosed in
children as young as seven due to obesity
and physical inactivity (Wilson, 2013;
Rosenbloom, et al, 2009). The condition
develops when the body is unable to produce enough insulin to maintain normal
glycaemic control. If obesity is also present, insulin released in response to a rise
in blood glucose cannot work effectively
because excess body fat interferes with its
usual action on cells; this is known as
insulin resistance (Hauner, 2010).
A range of disorders contribute to the
development of type 2 diabetes, such as
metabolic syndrome, fatty liver disease,
and genetic factors, but obesity is the
greatest risk factor. It accounts for 80-85%
of overall risk, and underlies the current
worldwide epidemic of the condition (Diabetes UK, 2012). However, obesity
does not cause type 2 diabetes – the condition develops in people who are not obese,
and those who are obese do not always
develop it.
Genetic and environmental factors also
contribute towards the risk of developing
17 Nursing Times 18.03.15/ Vol 111 No 12 / www.nursingtimes.net
5 key
points
1
Obesity is the
greatest risk
factor for the
development of
type 2 diabetes
An estimated
3.2 million
people in the UK
currently have a
diagnosis of type 2,
while 850,000
more are
undiagnosed
Diabetes
treatment
costs the NHS
£10bn per year
Reducing
refined
carbohydrates,
regular exercise
and lifestyle
change can
prevent or reverse
type 2 diabetes
Lifestyle
change must
be maintained
so insulin can
function correctly
2
3
4
5
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QUICK
FACT
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Management of type 2 diabetes
The management of type 2 diabetes should
address all aspects of individual patients’
lifestyle and be personalised to their specific glucose problems and other health
conditions (National Institute for Health
and Care Excellence, 2014a). This includes
dietary advice from an appropriately
trained health professional, in which the
glycated haemoglobin level (HbA1c) may
be set above the usual 6.5% target because
patients managed with diet alone have no
available means, such as injected insulin,
to reduce blood glucose levels.
Patients are taught to self-monitor their
blood glucose levels, as well as its importance and how to interpret their test
results. Self-monitoring is important for
those using either glucose-lowering medications or insulin (patients with type 2
require insulin when glucose-reducing
medication becomes less effective), so they
can respond to any change in glucose
resulting from illness, medication or lifestyle changes.
Patients who are obese and whose blood
glucose is inadequately controlled by diet
and exercise alone are prescribed the oral
biguanide drug metformin, which may
also be used to lower blood glucose levels
in those who are not overweight. However,
the drug has gastrointestinal side-effects
and is introduced gradually to minimise
these. It is contraindicated in patients with
reduced kidney function and caution is
required for those with liver dysfunction
or cardiac impairment.
For patients who cannot tolerate metformin or who are not overweight, insulin
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Signs and symptoms
Ongoing symptoms such as excessive
excretion of urine, increased thirst, persistent hunger, tiredness, numbness in the
feet and legs and changes in vision may be
subtle, and so not considered of note. For
this reason, type 2 diabetes may not be
diagnosed until secondary long-term complications, such as circulatory system disease, eye disease or peripheral nerve
damage has occurred.
secretalogues, such as sulphonylurea
drugs, may be prescribed. Acarbose may
be used as an alternative if there is intolerance to other glucose-reducing medications, while thiazolidinediones such as
pioglitazone may be used as a secondary
glucose-lowering medication to first-line
metformin when HbA1c remains elevated.
Insulin therapy may be combined with
metformin when glucose control is inadequate (HbA1c >7.5%), although patients
must be made aware of potential hypoglycaemia and how to treat it.
Management of type 2 diabetes also
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type 2 diabetes, meaning that those with
close family members with the condition
are two to six times more likely than the
general population to develop it (Vaxilliare
and Froguel, 2010). South Asian people are
six times more likely to develop type 2 than
the general population, predominantly
around the age of 25, and those of AfroCaribbean origin are three times more
likely to develop the condition than Caucasians (Department of Health, 2001).
5%
Percentage of the adult
population currently
affected by type 2 diabetes
involves the annual measurement of blood
pressure for those without hypertension
or renal disease, especially where there is
poor glucose control. Other risk factor
evaluations include cardiovascular function, management of blood lipids, the
introduction of anti-thrombotic therapy,
and assessment of the development of diabetes complications, such as retinopathy,
neuropathy and nephropathy.
Dietary change and weight loss
Although there is little evidence that dietary modification alone can provide a cure
for type 2 diabetes, clinical trials show that
a combination of lifestyle change and
weight loss for obese patients is highly
effective in reversing glucose impairment
(Ahmad and Crandall, 2010).
The benefit of adopting a low-carbohydrate diet to achieve weight loss has been
shown for over 10 years for those with type
2 diabetes (Harder et al, 2004; Yip et al,
2001). In the US, an intensive lifestyle
change programme comprising a calorie,
carbohydrate and fat restricted diet prevented type 2 diabetes in at-risk obese individuals (Mayer-Davis et al, 2004).
In my work I have seen five obese
patients with type 2 diabetes achieve type 2
diabetes reversal via dietary modification
and regular cardiovascular exercise taken
three times a week. The patients avoided
refined carbohydrates and incorporated
regular exercise into their routines,
achieving an average weight loss of two
stone (under medical supervision), and an
HbA1c within the non-diabetic range (2041mmol/L). They maintained this status
without the use of metformin or insulin
for an average of four years, with varied
reasons for ceasing to maintain the behavioural change, such as personal choice and
change in circumstances. However, this
demonstrates that those with obesityrelated type 2 diabetes may, with medical
guidance, reverse the condition, reducing
their risk of life-threatening secondary
complications. Reduction in body weight,
however, must be maintained; if weight is
regained, type 2 diabetes returns.
Previous studies support the experiences of the patients discussed above.
Westman et al (2008) found that with a sustained low-carbohydrate diet (<20g per day
for 24 weeks) but no calorific restriction, 85
volunteers with type 2 diabetes achieved
reduced glucose levels and improved glycaemic control. Low carbohydrate diets
are also low glycaemic-index diets because
carbohydrates (starch) convert to glucose,
raising blood glucose levels. Carbohydrate
reduction eliminated or reduced the need
for glucose-reducing medication in motivated subjects, leading to the conclusion
lifestyle change improves type 2 diabetes.
Other studies have shown similar results
(Boden et al, 2005; Vernon et al, 2003).
Healthy eating with a reduced carbohydrate intake is not the same as adopting a
very low-calorie diet (VLCD) as low-carbohydrate diets may allow a normal fat intake
and are, therefore, not low in calories. For
some who have a clinical need to lose
weight quickly, such as obese patients
awaiting joint replacement surgery,
VLCDs (<800 calories/day) may be necessary. However, patients should maintain
these diets for a maximum of 12 weeks and
under medical supervision (NICE, 2014b),
or complications such as vitamin and mineral deficiency are likely.
Some patients with type 2 diabetes and
secondary complications would not be
suitable for a restricted diet, such as those
with reduced kidney or liver function, cardiac impairment, eating disorders or other
psychopathology.
Updated guidance on management of
obesity recommends that gastric band surgery be offered to more people with type 2
Box 1. complications
of type 2 diabetes
● Cardiovascular disease
● Nephropathy
● Retinopathy
● Neuropathy
● Amputations
● Depression
● Sexual dysfunction
● Complications in pregnancy
www.nursingtimes.net / Vol 111 No 12 / Nursing Times 18.03.15 18
Nursing Practice
Review
Diabetes
diabetes. This should mean the long-term
cost to the NHS of treating diabetes is
reduced (National Institute for Health and
Care Excellence, 2014b). However, lifestyle
change and steady weight loss are cheaper
than surgery, and avoid the risk of surgical
complications. The ideal strategy, therefore, is to motivate and support patients
with type 2 diabetes to lose weight through
diet and lifestyle changes where possible,
and to address the underlying issues that
cause them to overeat.
Conclusion
Excess body fat impedes the action of
insulin on cells, resulting in insulin resistance and high blood glucose levels, so
weight loss can improve glycaemic control
in obese individuals. Achieving a normal
body weight allows insulin to function
correctly, which can eliminate the need for
blood glucose-lowering medication.
Dietary modification and exercise recommendations have the potential to
reverse type 2 diabetes without the risks
associated with weight-loss surgery, but
regimes must be tailored to individual
patients’ needs by appropriately trained
clinicians. Lifestyle change requires a high
degree of motivation, so patients need
ongoing support to achieve and maintain
weight loss, and to address the underlying
issues that have caused obesity. NT
References
Ahmad LA, Crandall JP (2010) Type 2 diabetes
prevention: a review. Clinical Diabetes; 28 : 2,
53-58.
Boden G et al (2005) Effect of a low-carbohydrate diet on appetite, blood glucose levels and
insulin resistance in obese patients with type 2
diabetes. Annals of Internal Medicine; 142: 403-411.
Department of Health (2001) National Service
Framework for Diabetes. Bit.ly/DHNSFDiabetes
Diabetes UK (2012) Diabetes in the UK 2010: Key
statistics on diabetes. London: Diabetes UK. Bit.ly/
DiabetesUKStats2010
Diabetes UK (2008) Early Identification of Type 2
Diabetes and the new Vascular Risk Assessment
and Management Programme. Position Statement
Update, London: Diabetes UK. Bit.ly/
DiabetesUKEarlyIdentification
Harder H et al (2004) The effect of a rapid
weight loss on lipid profile and glycaemic control
in obese type 2 diabetic patients. International
Journal of Obesity 28: 180-182.
Hauner H (2010) Obesity and diabetes. In: Holt
RIG et al (eds) Textbook of Diabetes. Oxford:
Wiley-Blackwell.
Hex et al (2012) Estimating the current and future
cost of Type 1 and Type 2 diabetes in the United
Kingdom, including direct costs and indirect
societal and productivity costs. Diabetic Medicine;
29: 7, 855-862.
Mayer-Davis EJ et al (2004) Dietary intake in the
diabetes prevention program cohort: baseline and
1-year post-randomisation. Annals of Epidemiology 14: 763-772.
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19 Nursing Times 18.03.15 / Vol 111 No 12 / www.nursingtimes.net
National Institute for Health and Care Excellence
(2014a) The management of Type 2 diabetes.
London: NICE. nice.org.uk/cg87
National Institute for Health and Care Excellence
(2014b) Obesity: identification, assessment and
management of overweight and obesity in
children, young people and adults. Nice.org.uk/
cg189
Rosenbloom AL et al (2009) Type 2 diabetes in
children and adolescents. Pediatric Diabetes; 10:
(supplement 12), 17-32.
Vaxilliare M, Froguel P (2010) The genetics of
type 2 diabetes: from candidate gene biology to
genome-wide studies. In: Holt RIG et al (eds)
Textbook of Diabetes. Oxford: Wiley-Blackwell.
Vernon MC et al (2003) Clinical experience of a
carbohydrate-restricted diet: Effect on diabetes
mellitus. Metabolic Syndrome and Related
Disorders; 1: 233-238.
Westman EC et al (2008) The effect of a
low-carbohydrate, ketogenic diet versus a low
glycaemic index diet on glycaemic control in type
2 diabetes mellitus. Nutrition and Metabolism; 5:
36.
Wilson VL (2013) Type 2 diabetes in children and
adolescents: a growing epidemic. Nursing
Children and Young People; 25: 2, 14-17.
World Health Organisation (2011) Diabetes.
Factsheet 312. Geneva: WHO. Bit.ly/WHODiabetesFacts
Yip et al (2001) Liquid meal replacement and
glycaemic control in obese Type 2 diabetes
patients. Obesity Research 9(4): 341S-347S.
For more on this topic go online...
Carbohydrate counting in diabetes
Bit.ly/NTCarbCounting