Scientific Diet and Exercise Guidelines for Type 2 Diabetes
February is the month of heart health across the USA and UK. The whole western world is focused in February around preventing heart disease which is a leading cause of death and disability worldwide.
While India does not have its heart health month, we thought we will talk about this essential health issue in our monthly newsletter and highlight two villains that often go together- Diabetes and Heart health.
And to the top of that lot of Indian often have obesity associated with both compounding the risk. Considering that almost 80 million people in India have diabetes and a lot of them are at risk for heart disease, it becomes imperative that we work with a renewed focus on prevention.
Hence, this article focuses on ever-increasing need for scientific lifestyle intervention in people with diabetes at risk of heart disease and obesity.
Lifestyle interventions for heart disease in Diabetes
Medical Nutrition Therapy (MNT)
Cardiovascular diseases (CVDs or heart diseases) pose a high risk of morbidity and mortality in people with Type 2 Diabetes Mellitus (T2DM) . The main CVDs having an impact in T2DM are coronary artery disease (CAD), heart failure (HF), and stroke.
An area of preventive focus in the 21st century in particular, is lifestyle modification. The American Diabetes Association (ADA) strongly recommends modification in dietary habits and the adoption of new recognized interventions like MNT for the management of T2DM and CVD.
Let’s begin by understanding a few key terms first:
|Glycaemic index (GI) and Glycaemic load (GL) are two important parameters for strict control of T2DM and consequently its impact on the CV risk|
|Glycemic India (GI) Definition: Compares equal quantities of available carbohydrates in food and offers a measure of carbohydrate quality.||Glycemic Load (GL) definition: The product of GI of a food item and its total available carbohydrate content.|
|The addition of the quantity of available starch, sugars, oligosaccharides, and maltodextrins provides available carbohydrates in the food item.|
|Formula to calculate GI: GI = blood glucose response 2 h after intake of 100 g of food ÷ blood glucose response on the intake of 100 g glucose||Formula to calculate GL: GL = carbohydrate content of the item × its GI ÷ 100|
The diet with low GI (< 55) and low GL (≤ 10) has been documented to show beneficial effects in T2DM and reducing its complications. A reduced intake of saturated fats and increased intake of monounsaturated fat is recommended for patients with CVDs to prevent worsening of the condition.
The main objective of nutrition therapy is in the management of blood glucose levels and CV risk factors. This also alleviates the risk for diabetes-related complications and helps in optimising pharmacotherapy to obtain favourable outcomes.
Two basic characteristics of MNT include dietary quality and energy restriction. MNT not only is intended for glycaemic control, but also to improve co-morbidities such as dyslipidaemia, obesity, and hypertension. Digital therapeutics programs such as Diabefly help in planning such diets well.
Furthermore, the patients at risk of CVD can also prevent further consequences by modifying the diet to one of the four clinically proven diet patterns:
- Low-fat diet
- Low carbohydrate diet
- Mediterranean diet
- DASH diet (Dietary Approach to Stop Hypertension).
The ADA strongly recommends physical fitness and physical activity as an integral part of T2DM management in patients with comorbid CVD. Physical activity confers several benefits such as:
- Improvement in physical fitness
- Insulin sensitivity
- Reduction in body weight
- Reduction of CV risk factors,
- Reduction of lipid levels
- Lowering of blood pressure
- Improvement in overall quality of life
- Significant reduction in death and disability due to heart disease
The lipid profile gets improved by lowering the “bad cholesterol” (total cholesterol (TC) and low- density lipoprotein cholesterol (LDL)) and increasing the “good cholesterol” (high-density lipoprotein (HDL)).
Consequently, there is a reduction in the risk of various CV events intrinsic to patients with T2DM. In the case of overweight or obese patients with high-risk CVD, exercise needs to be individualized.
The providers should remain cautious while providing exercise schedules for conditions such as uncontrolled diabetes, uncontrolled hypertension, HF, diabetic peripheral neuropathy, which is either contraindicated or might increase the mortality risk with some types of exercise.
This can be done best by an exercise prescription generated by a trained physiotherapist using remote consultation tools as are provided by Diabefly digital diabetes management program.
Lifestyle Interventions for Obesity in patients with T2DM
Each one kg of weight loss leads to a 16% reduction in diabetes risk. The results from the Look AHEAD trial that nearly half of the intensive lifestyle intervention (ILI) participants lost ≥5% and 27% lost ≥10% of their initial body weight at 8 years.
The REAL HEALTH-Diabetes trial showed that the mean percent weight loss at 6 and 12 months was remarkably higher with full lifestyle intervention (LI) compared to MNT. (Figure 1).
Best Practices to follow for diet and physical fitness (Exercise) to manage obesity in T2DM
- Dietary modifications, physical activity, and behavioural therapy aimed to achieve 5% weight loss for overweight and obese patients with T2DM.
- A high frequency (≥16 sessions in 6 months) together with attention on the diet, physical activity, and behavioural changes so there is a loss of 500–750 kcal/day.
- Individualized diet plans, which provide the same caloric limit but differ in protein, carbohydrate, and fat content are considered equally effective in achieving weight loss
For patients who have attained short-term weight loss goals
- A comprehensive weight maintenance program for one year or more (long-term) is recommended.
- These programs should offer at least monthly in-person session and encourage ongoing monitoring of body weight (weekly or more frequently)
- Besides, self-monitoring strategies, such as tracking intake, steps, continual intake of a reduced-calorie diet; and high levels of physical activity (200– 300 min/week) are recommended
- A 3-month (short-term) high-intensity lifestyle intervention to achieve a weight loss of >5%. This uses very-low-calorie diets (≤ 800 kcal/day) and total diet replacements.
ADA: American Diabetes Association CVD: Cardiovascular Diseases; DASH: Dietary Approach to Stop Hypertension; Look AHEAD: Action for Health in Diabetes; REAL HEALTH-Diabetes : Reach Ahead for Lifestyle and Health-Diabetes; T2DM: Type 2 Diabetes Mellitus
Heart disease is a major risk factor for death and disability in patients with Diabetes. New age lifestyle intervention with a triad of personalised nutrition advice, exercise prescription and cognitive behavioral therapy can help in decreasing these risks to a minimum.
Also, scientific weight loss programs for people with diabetes can be highly effective in cutting down CV risk as well as help in diabetes reversal.
Bashier A, Hussain AB, Abdelgadir E et al. Consensus recommendations for management of patients with type 2 diabetes mellitus and cardiovascular diseases. Diabetol Metab Syndr.2019;11:80. https://doi.org/10.1186/s13098-019-0476-0.
Raveendran AV, Chacko EC, Pappachan JM. Non-pharmacological treatment options in the management of diabetes mellitus. Eur Endocrinol. 2018;14(2):31–9.
American Diabetes Association. Lifestyle management: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(Supplement 1): S38–50.
Barclay AW, Brand-Miller JC, Wolever TMS. Glycemic Index, Glycemic Load, and Glycemic Response Are Not the Same. Diabetes Care. 2005, 28 (7):1839-1840
Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev. 2009. https ://doi. org/10.1002/14651 858.CD006 296.pub2.
Ajala O, English P, Pinkney J. Systematic review and metaanalysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013; 97:505–16.
Buyken AE, Goletzke J, Joslowski G, Felbick A, Cheng G, Herder C, et al. Association between carbohydrate quality and inflammatory markers: systematic review of observational and interventional studies. Am J Clin Nutr. 2014;99(4):813–33.
Choi Y, Giovannucci E, Lee JE. Glycaemic index and glycaemic load in relation to risk of diabetes-related cancers: a meta-analysis. Br J Nutr. 2012; 108:1934–47.
Davies MJ, Dalessio DA, Fradkin J, Kernan WN, Mathieu C, Mingrone G, et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2018;61(12):2461–98.
Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(Suppl. 1):S81–S89 | https://doi.org/10.2337/dc19-S008