In this review we have used both hard copy (library based) access and Internet search facilities, to derive appropriate material. This was done at both the local University library and the local post-graduate medical centre library. Initial searches were made under the heading of Type II diabetes mellitus nutritional management.
Because it was important to provide a firm evidence base for the review, the searches were restricted solely to peer reviewed publications which, it was hoped, would make the selection process more efficient. (Berwick D 2005)
This highlighted more than enough good quality material for our initial examination of the literature.
As it transpired the four articles chosen were all from the BMJ. This is partially a coincidence, as over thirty different articles in twelve different publications were assessed in the preparation of this piece. The final decision that was made to include articles was based, not only on their relevance to the issue, but also on the fact that they were on aspects of diabetic nutritional management that was not more commonly covered in some of the more “routine” articles.
Many of the articles examined were discarded because they had obvious methodological flaws in their construction. (Mohammed, D 2003).
Many were effectively opinion pieces which had little in the way of cited references to validate their findings. Others were trials which may have had a number of potentially confounding sources of bias.
Literature review
There are a great many authoritative sources in the modern literature on the subject of dietary management of the diabetic state. In any meaningful review of these resources one must always be mindful of the need for a strong evidence base. It is therefore vital to be dispassionately critical in one’s review of any literature presented. (Sackett, 1996).
We know, from established evidence, (Lean ME 2005), that obesity is an independent risk factor in the aetiology of Type II diabetes mellitus and that obesity management is a vital ingredient for good control of the diabetic state. (HSG 1997) This correlates with evidence that the incidence of long term side effects of diabetes is inversely proportional to the HbA1 readings. (Stratton I et al 2000)
A good place to start our review is a recent review paper by Hitchcock & Pugh (2002). This is a tour de force in the management of obesity in general terms, but, for the reasons outlined above, it is very pertinent to our discussions in this piece.
The review itself is cited here because it provides a particularly comprehensive overview of other work in the area together with some personal observations of patients who are both diabetic and involved in the weight management process. The paper also highlights the often overlooked problems of the need to reduce hypoglycaemic medication in conditions of both weight loss and unaccustomed exercise to minimise the risks associated with hypoglycaemic episodes.(Knowler WC et al 2002). There is a particularly pertinent set of comments relating to pharmacotherapeutics and obesity related surgery. (Wing RR et al 2001).
This paper sets itself apart from many other similar papers with comments relating to the long term strategies associated with successful weight maintenance. A critical assessment of this review would have to conclude that although written by UK based authors, there are some comments in it which are aimed at the USA and this may well be a reflection of the fact that it was supported by the USA veterans association. On the positive side, the references cited are wide ranging and authoritative, giving a balanced overview of the current situation relating to obesity control.
Lean & Hankey (2004) offer an editorial on the use of aspartame. Again, this article is a general piece, but it has distinct relevance to the management of the Type II diabetic. This piece is particularly relevant to our considerations because apart from providing an authoritative statement on the current evidence base for aspartame, it points to the fact that current dietary recommendations for Type II diabetes mellitus include the fact that up to 10% of total metabolic energy can safely come from sugars. (DNSG 2000).
Artificial sweeteners can help to avoid counterproductive weight gain. It also produces an authoritative opinion on the argument that increasing the carbohydrate component of a diet tends to displace the fat content, (Bolton Smith C et al 1999) with the associated health benefits there. (Ludwig DS et al 2001).
Nutritional management in Diabetes Mellitus was traditionally part of the almost exclusive remit of either the specialist diabetic nurse or the dietician. More modern considerations have included the concept of patient empowerment and education (Howe and Anderson 2003), which can now come from independent web-based sources.
Two eye-catching articles on this topic appeared in the same issue of the BMJ. The first (Eyesenbach G et al 2004), produces an extremely comprehensive review of the availability, accuracy and effect of this phenomenon. It provides an authoritative assessment of the literature available on this topic. Of particular relevance to our considerations was their findings that, of the five peer-reviewed studies examined that gave dietetic advice and also measured the clinical outcome (by HbA1), only one showed a statistically significant improvement. It has to be noted that the particular study was not a controlled reference study, and therefore has a great potential for experimental bias. (Gary TL et al.2003)
A more qualitative approach was taken by the second of the two papers (Ralston JD et al 2004). This paper looked at the patient’s experiences with the use of the web-based advice facilities. The study design was ambitious, but used the semi-structured interview technique which again introduces the possibility of observer bias. (Parker and Lawton 2003)
Despite being both authoritative and informative, careful reading of the article shows that the authors only used a small cohort (nine). The analysis and presentation of the results appears to be rigorous. One of the most significant findings of this particular study is, arguably, the demonstration that web-based interventions have the potential not only to work and to support the patients in general terms but advice, such as dietetic advice, is actively sought and implemented by some patients. The authors conclude that the most important pre-requisite to obtaining a successful outcome, was the fact that the patients had the opportunity to discuss the shortcomings of the project before they entered it.
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