Elaine Allerton has worked in the NHS as a senior diabetes specialist dietitian for the past six years. She provides one to one support and group education to adult patients with type 1 diabetes (T1DM), type 2 diabetes (T2DM) and gestational diabetes. In addition to her NHS work and private caseload, she is a media spokesperson for the British Dietetic Association (BDA). To coincide with World Diabetes Day on 14th November 2021, we sat down with Elaine to ask her all about nutrition support and diabetes.
Is there any research into malnutrition in patients with T2DM?
Yes, there’s some limited research in this area. One study found the prevalence of malnutrition in elderly patients with T2DM to be approximately 28%.1 Interestingly, people with T2DM and a low BMI (< 18.5 kg/m2) have been found to have significantly higher levels of HbA1c, random blood glucose, insulin and glucagon compared to people with T2DM and a normal BMI (18.5–24.9 kg/m2).2 Given the prevalence of malnutrition in elderly people and what we already know about the negative effects of malnutrition, further research is needed to explore how it impacts the health outcomes of people with T2DM.
Are there different aims for nutrition support in patients with T2DM compared to those without diabetes?
The goals of nutrition support shouldn’t be any different for people living with diabetes. The main aim is to meet the patients’ nutritional requirements and to treat and minimise any risks associated with malnutrition and unintentional weight loss (e.g., sarcopenia or nutritional deficiencies).
Does nutrition support advice differ for someone with T1DM?
Nutrition support principles are the same for someone with T1DM as any other type of diabetes. I would calculate their nutritional requirements, estimate what their current dietary intake is contributing, and then consider how best to meet the shortfall. A food first approach would be my first line intervention, focusing on increasing calories with a higher intake of protein and fats. If this intervention isn’t successful, I would consider oral nutritional supplement products.
Can a patient with T2DM living with obesity be at risk of malnutrition?
Patients living with obesity can be at risk of malnutrition. For example, a patient with T2DM and obesity who has experienced rapid, unintentional weight loss and/or reduced oral intake whilst in hospital for a foot ulcer could be at risk of malnutrition. They may require nutrition support to optimise their protein intake to support wound healing.
All inpatients with diabetes should undergo regular nutritional screening using a validated tool such as the malnutrition universal screening tool (MUST), and any patient at risk of malnutrition should have an appropriate nutritional care plan put in place.
Is hypoglycaemia a concern in patients with T2DM and malnutrition?
Hypoglycaemia, often referred to as a ‘hypo’, is when a patient’s blood glucose level falls below 4 mmol/l. The risk of hypoglycaemia is only a concern for patients who are prescribed insulin or sulfonylureas to manage their T2DM. It’s important to note that the warning signs of a hypo will not be easily identified in patients who are unwell or unable to communicate, and regular glucose testing will be necessary for these patients (on insulin or sulfonylureas). Hypo episodes can also increase the risk of falls in this already vulnerable group, which can further exacerbate the poor health outcomes of malnutrition.
Can oral nutrition supplements (ONS) be used for patients with T2DM?
Contrary to popular belief, ONS can be used for patients with T2DM. For patients who are malnourished or at risk of malnutrition, ONS can be a source of energy and protein. However, there are additional considerations for healthcare professionals (HCPs) when they’re thinking about using ONS with a T2DM patient.
What are the factors healthcare professionals should consider when providing nutrition support to a person with T2DM?
There are several considerations when providing nutritional support to a patient with T2DM. These include:
- Assessing how well managed the patient’s T2DM is (e.g., What is their recent HbA1c? What is the pattern of their recent blood glucose levels?).
- Considering the patients’ diabetes medications and liaising with their diabetes specialist nurse for a medication review and adjustment as needed.
- The patients’ health beliefs should be considered.
- Nutritional advice should be adapted to the patient’s dietary requirements (e.g., gluten free, lactose free, vegan, vegetarian).
- A ‘food first’ approach and food fortification should be used as first-line nutrition support advice.
- A nutritional care plan should consider the patient’s likes and dislikes (e.g., flavours and textures). If a patient doesn’t like the ONS prescribed or foods suggested, they probably won’t follow your advice!
Are juice-style oral nutrition supplement (ONS) products suitable for those with T2DM?
I would trial a milk style supplement first as these are lower in carbohydrates. Although the juice-style options have a higher carbohydrate content and will have a greater effect on blood glucose levels, a patient-centred approach should be taken. If a patient can’t meet their nutritional requirements without ONS, and their preference is for a juice-style ONS, this option should be trialled.
It’s important to note that these patients will need to test their blood glucose more frequently to see if their insulin and/or sulfonylurea medications need changing.
A ‘food first’ approach to malnutrition often advises high energy, high sugar foods. Does this advice change for patients with T2DM
If a patient experiences weight loss and is at risk of malnutrition, I recommend a ‘food first’ approach focusing on high-fat and protein foods. However, it’s also important to continue to have starchy carbohydrates with meals, especially for patients who take insulin and sulfonylurea medications. If the malnutrition risk is very high and the patients’ T2DM is well managed, I would also encourage high sugar foods as part of the food-first approach
Nutrition support and T2DM is a balance of risk; it’s important to weigh up whether the risks of malnutrition (which can manifest in months) are greater than the complication risks associated with T2DM (which can take years to develop). The patient should always be the focus, rather than the condition.
What barriers do you face as a dietitian when delivering nutrition support advice to patients with T2DM?
People often assume that those with T2DM should avoid all forms of sugar and carbohydrates. However, if a person with T2DM is losing weight and is at risk of malnutrition, the nutritional advice will change to ensure they have adequate macronutrients and micronutrients to help improve their nutritional status. When their nutritional intake is optimal, the advice will revert to the general dietary recommendations for people living with T2DM.
In my experience, people tend to fear ‘full fat’ products due to the concern that these negatively affect cholesterol levels, and high cholesterol is a risk factor for the common long-term complication of diabetes, cardiovascular disease (CVD). Although, if a patient is already taking a statin, their cholesterol levels will be managed. Again, it’s important to have the discussion and weigh up the risks; are the risks of malnutrition more immediate than the increased risk of CVD?
Are there any considerations for HCPs when using ONS with T1DM patients?
The carbohydrate content of the ONS should be considered. Most ONS products have a carbohydrate content similar to a light meal (~30-40g carbohydrate, similar to a sandwich). The individual with T1DM would need to ‘carb count’ their ONS product so that they can give a bolus insulin dose to cover this carbohydrate intake. If the ONS is liquid, it will be digested faster than a solid meal and therefore raise glucose levels at a faster rate; I would advise the person with T1DM to sip the ONS rather than gulp it all down in one.
If someone is acutely ill, they are likely to have higher glucose levels and may have higher insulin requirements. In this case, they should also be checking their ketone levels and following ‘sick day rules’. Many people with type 1 diabetes are very skilled at carb counting and adjusting their insulin doses to their meals, activity levels etc. However if they are unwell, they may need advice on adjusting insulin doses from their diabetes specialist nurse and/or their diabetes specialist dietitian.
Another very important consideration is whether the patient likes the flavour and texture of the ONS product.
Where can dietitians go for further information on supporting patients with malnutrition and type 2 diabetes?
I would recommend liaising with their local diabetes specialist dietitians or diabetes specialist nurse for further support. The Diabetes UK website is also a useful resource for current guidelines and advice.
- Silva E, Andrade C, Narciso L, et al. Prevalence of malnutrition risk in elderly with type 2 diabetes mellitus. Endocrinology and Metabolism International Journal. 2021. 9(2):25-30. [Internet]. Available from: DOI: 10.15406/emij.2021.09.00304
- Rajamanickam, A., Munisankar, S., Dolla, C.K. et al. Impact of malnutrition on systemic immune and metabolic profiles in type 2 diabetes. BMC Endocrinology Disorders. 2020. 20(1):168 [Internet]. Available from: https://doi.org/10.1186/s12902-020-00649-7