The dietitians challenge: the implementation of nutritional advice for people with diabetes.
The evidence base for current nutritional recommendations has been extensively reviewed on behalf of the European Association for the Study of Diabetes (EASD) 1998 and the American Diabetes Association (ADA) 2002. The nutrition Sub-Committee of Diabetes UK is in general agreement with those recommendations. This paper provides consensus-based recommendations that emphasize the practical implementation of nutritional advice for people with diabetes, and describe the provision of dietetic services required to provide the information. Important changes from previous Diabetes UK (previously British Diabetic Association Diabet. Med. 9, 189) recommendations include greater flexibility in the proportions of energy derived from carbohydrate and monounsaturated fat, further liberalization in the consumption of sucrose, more active promotion of foods with a low glycaemic index, and greater emphasis on the provision of nutritional advice in the context of wider lifestyle changes, particularly physical activity. Monounsaturated fats are now promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation--and consequent lower atherogenic potential. Consumption of sucrose for patients who are not overweight can be increased up to 10% of daily energy derived from carbohydrate provided that this is eaten in the context of a healthy diet and distributed throughout the day. The role of the dietitian is outlined in facilitating lifestyle changes and evidence is presented for the effectiveness of advice provided by trained dietitians. The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented at local level.