The evolution of the nutritional management of diabetes.

Diet and lifestyle advice for individuals with diabetes has changed dramatically. The changes in nutritional recommendations have largely been in response to advances in the knowledge of the biochemical and physiological mechanisms of impaired glucose metabolism and the micro- and macrovascular complications of diabetes. The most recent guidelines for the nutritional management of diabetes were set out by Diabetes UK in 2003. This consensus-based advice paper builds on the previous evidence-based review papers of the European Association for the Study of Diabetes in 2000 and the American Diabetes Association in 2002. The changes from previous recommendations include a more liberal use of sucrose, in line with healthy eating recommendations for the general population, and allow for greater flexibility in energy derived from carbohydrate and monounsaturated fat. In addition, monounsaturated fats are promoted as the fat of choice and active promotion of carbohydrate foods with a low glycaemic index is encouraged. These guidelines emphasise the practical application of nutritional management of diabetes and the need to provide education and support in a structured way that will facilitate change in diet and lifestyle behaviour. Structured educational programmes have been shown to be effective in reducing the progression to diabetes and also in slowing the onset and progression of the complications of diabetes. These programmes require ongoing intensive input to maintain behavioural change in diet and lifestyle. Considerable energy and resources are required to set up and maintain these educational programmes, but the cost per individual is small compared with the costs of treating the complications of diabetes.