Editorial: Dietary advice: Another aspect of care that should be individualised

I recently read with interest the research from Sweden that identified four different subgroups of type 2 diabetes: severe insulin-deficient diabetes, severe insulin-resistant diabetes, mild obesity-related diabetes and mild age-related diabetes (Ahlqvist et al, 2018). The study suggested that, with recognition of these subtypes, we can more effectively and assuredly plan treatment for the individual. I have long been an advocate for truly individualised care and treatment for people with diabetes, taking into account many factors, not least age at diagnosis, frailty status, comorbidities, duration of diabetes and the wishes of the individuals themselves. I have also always been mindful that the label “type 2 diabetes” did not adequately reflect the make-up of the vast array of people we see in everyday practice. This article, therefore, both fascinated and reassured me that we may, at last, have a way of more confidently individualising care.

At the Diabetes UK (DUK) Professional Conference this year there was a great focus on the role of diet and lifestyle. The DUK nutritional guidelines were launched at the conference and the early findings of the DiRECT (Diabetes In REmission Clinical Trial) study were reported. As I listened and took the opportunity to read the reports in full, it struck me that here again we have advice that can be tailored to the individual.

The DUK nutritional guideline provides a summary of the different diets that are available to our patients today (DUK, 2018). It discusses very-low-fat, low-carbohydrate, very-low-carbohydrate, very-low-calorie liquid, meal-replacement and commercial diet programmes, and recommends “an individualised approach to diet taking into consideration the person’s personal and cultural preferences”. It is available at: https://is.gd/AHi4ST

It has long intrigued me that we hear, time and time again, the phrase “3-month trial of diet and exercise”. This is to be offered at diagnosis and is the term used in our guidelines for the management of type 2 diabetes. This messaging can be easily misconstrued, and so it cannot be a surprise when the obvious impression to the individual is that the diet has “failed” after 3 months and, therefore, does not “work” for them. I have heard this far too many times from the people I see in practice, both patients and healthcare professionals.

While pondering all of this, I could really see how we can all use the knowledge learned to further individualise the advice we offer to our patients. For those with insulin-resistant type 2 diabetes, we can now strive further to support them to lose an amount of weight that can make a real difference to them. For those who do not fit this insulin resistance profile but are more likely to have insulin insufficiency, we can with confidence move quickly to effective medications to improve their glycaemic control and thus reduce their risk of complications.

It struck me that, at a time we are seeing such an increase in the number of drug classes available and rapid changes within the insulin portfolio, we now also have an improved understanding of the potential effects of dietary change, and how we can use and advise it. We should view this as a true and powerful weapon in our arsenal at all stages of diabetes management.