L11 Metabolism Nutritional management and guidelines for type 1 _ 2 diabetes

Overview

This lecture covers nutrition therapy for type 2 diabetes and type 1 diabetes. For T2DM it moves from the traditional macronutrient/micronutrient framing to a food-pattern approach, sets out the NZSSD initial-management algorithm, and uses evidence (the DiRECT trial, pancreas-recovery imaging, the Fukushima Prison cohort) to argue that weight loss and dietary change can drive remission. It works through NZ serving-size guidance, glycaemic index and its limitations, and specific dietary considerations for glycaemic control. For T1DM it covers target blood glucose levels, technology funding (CGM, insulin pumps), carbohydrate counting, meal planning, and individualised insulin:carbohydrate ratios. The lecture ends with the shared topic of hypoglycaemia: recognition and treatment, and the specific risks of alcohol (via inhibition of gluconeogenesis) and exercise.

Dietitian vs Nutritionist

• Dietitian: a registered health professional, clinically trained. In NZ requires a Master’s degree and a current Annual Practice Certificate (APC) to practice. Common specialisations: Clinical (e.g. diabetes, oncology, older persons’ health, paediatric, eating disorders, sport), Public Health, Food service.
• Nutritionist: someone with a nutrition degree (undergraduate level). The title can be used by anyone; there is no statutory legislation regulating the profession.

Goals of nutrition therapy and the case for weight loss in T2DM

Goals for nutrition therapy in diabetes:

• To eliminate symptoms (if symptomatic).
• To prevent, or at least delay, the development of complications.

Diabetes mellitus recap: after a glucose load, plasma glucose normally peaks between 30–60 min and returns to near-fasting values by 2 h. In diabetes, plasma glucose values are higher at all time points and remain elevated at 2 h. Carbohydrate intake raises blood glucose level (BGL).

NZSSD initial management algorithm (T2DM)

The NZSSD “INITIAL MANAGEMENT” algorithm has three parallel starting components plus a weight-management component:

• Diagnosis: confirm the diagnosis and type of diabetes; determine an individualised glycaemic target.
• Lifestyle management: education, support, healthy eating and exercise; essential at all times throughout the duration of diabetes.
• Metformin: start unless contraindicated; increase to the maximal tolerated dose or 2 g/day.
• Weight management (applies across all of the above if overweight/obese): set an individualised weight-management plan.
  • 5% sustained total body weight loss is associated with improvement in metabolic parameters.
  • 10–15% sustained total body weight loss is typically needed for remission of diabetes.

Target HbA1c for most T2DM patients: <53 mmol/mol.

• If HbA1c >64 mmol/mol at diagnosis, consider adding an agent alongside lifestyle management and metformin:
  • Cardiovascular and/or renal disease and/or heart failure present → preferably SGLT2 inhibitor or GLP-1 receptor agonist.
  • No cardiovascular/renal disease and no heart failure → preferably a DPP-IV inhibitor.
• Consider starting insulin immediately if: symptoms of hyperglycaemia/insulin deficiency and/or HbA1c >90 mmol/mol, or suspicion of type 1 diabetes or loss of pancreatic function.

Lifestyle management (education, healthy eating, exercise) is essential throughout the entire duration of diabetes, not just at diagnosis.

Evidence that weight loss drives remission

DiRECT trial (Diabetes Remission Clinical Trial): RCT in primary care, 306 adults (age 20–65) with T2DM diagnosed <6 years, mean BMI 35.0. Intervention: total diet replacement — very-low-calorie diet (850 kcal/day) for 3–5 months, then stepped food reintroduction over up to 24 months.

• Intervention group achieved a 9.6 mmol/mol reduction in HbA1c (from a baseline of 60 mmol/mol).
• At 12 months, 46% of the intervention group had maintained diabetes remission (HbA1c <48 mmol/mol after ≥2 months off anti-diabetic medication), vs 4% of controls (odds ratio 19.7, 95% CI 7.8–49.8).
• ≥15 kg weight loss at 12 months: 24% of the intervention group vs 0% of controls.
• Odds ratio of remission per kg weight loss = 1.32 (95% CI 1.23–1.41).

Pancreas recovery (2-year DiRECT follow-up, imaging): the small, irregular pancreas typical of T2DM increased in volume, reaching 89% of the volume of a matched non-diabetic comparison group after 24 months of remission — pancreas morphology and volume both progressed toward the non-diabetic pattern over the follow-up period.

Diet as a driver of T2DM burden: an estimated 14 million cases (70%) of T2DM diagnoses globally in 2018 were attributable to suboptimal diet, with the largest individual contributors being insufficient whole grains, excess refined grains, excess processed meat, and excess unprocessed red meat (in descending order of attributable burden).

Medical nutrition therapy: a shift toward foods

Nutrition guidance is moving away from emphasising macronutrients (carbohydrates, proteins, fats) and micronutrients (vitamins, minerals), and instead focusing on foods and eating patterns:

• Encourage patients to think about eating patterns.
• Promote nutrient-dense food choices (foods high in micronutrients, relatively low in calories) — i.e. healthy food groups.

NZ food group serving guidance

The Ministry of Health’s serving-size advice is organised by food group (vegetables, fruit, grain foods, legumes/nuts/seeds/fish/eggs/poultry/lean red meat, milk and milk products), with recommended numbers of servings varying by sex, age band (19–50, 51–70, 70+), and pregnancy/lactation status, plus an allowance for additional servings from these groups.

Key nutrients supplied by each group:

• Vegetables: vitamin C, folate, dietary fibre, antioxidants, beta-carotene, carbohydrate, Mg, Fe, K+.
• Fruit: vitamin C, dietary fibre, carbohydrate, folate, beta-carotene, K+.
• Grain foods: carbohydrate, protein, dietary fibre, Fe, thiamin, folate, iodine, Mg, Zn, vitamin E.
• Legumes, nuts, seeds, fish/seafood, eggs, poultry, lean red meat: protein, Fe, Zn, vitamin B12 (animal foods only), omega-3 fatty acids, vitamin E (nuts and seeds).
• Milk and milk products: calcium, protein, riboflavin, vitamin B12, fat, carbohydrate, Mg, Zn, K+.

Standard serving sizes (selected examples):

• Vegetables: ~75 g (100–350 kJ) — e.g. ½ cup cooked vegetables, ½ cup canned vegetables, 1 cup raw/leafy salad vegetables, ½ medium potato/kūmara-equivalent, 1 medium tomato.
• Grain foods (mostly wholegrain, high fibre): ~500 kJ — e.g. 1 slice (40 g) wholegrain bread, ½ cup (75–120 g) cooked rice/pasta/noodles, ½ cup (120 g) cooked porridge, ¼ cup (30 g) muesli, 2 breakfast wheat biscuits, 3 (35 g) crispbreads.
• Fruit: ~150 g (350 kJ) — e.g. 1 medium apple/banana/orange/pear, 2 small apricots/kiwifruit/plums, 1 cup diced/canned fruit (no added sugar), 1 cup frozen fruit.
• Milk and milk products (mostly low/reduced fat): ~500–600 kJ — e.g. 1 cup (250 mL) milk, 2 slices (40 g) cheese, ¾ cup (200 g) yoghurt, 1 cup (250 mL) calcium-fortified plant milk (≥100 mg calcium/100 mL).
• Legumes, nuts, seeds, fish, eggs, poultry, lean red meat: ~500–600 kJ — e.g. 1 cup (150 g) cooked/canned legumes, 170 g tofu, 30 g nuts/seeds/nut butter, 100 g cooked fish fillet, 2 large eggs (120 g), 80 g cooked lean chicken, 65 g cooked lean red meat (beef/lamb/pork/veal) — no more than 500 g cooked (700–750 g raw) red meat per week.

Heart Foundation hand-portion guide: two cupped hands = non-starchy vegetables (choose a range of colours); one closed fist = grain foods/starchy vegetables/legumes; whole hand = a fish portion; palm = a portion of red meat, chicken, or pork; palm-sized = a single snack portion (vegetables, fruit, or nuts).

What is wholegrain?

A grain kernel has three anatomical parts:

• Bran (protects the seed): fibre, B vitamins, minerals.
• Endosperm (energy for the seed): carbohydrate, some protein, some B vitamins.
• Germ (nourishment for the seed): B vitamins, vitamin E, minerals, phytochemicals.

The bran and germ are removed when wholegrains are refined, which is why refined grains lose most of the fibre, B vitamin, and mineral content.

Carbohydrate type and glycaemic response

Glucose targets for most non-pregnant adults with T2DM: fasting <7.0 mmol/L; 2–3 h post-meal <10.0 mmol/L.

Different carbohydrate types produce different glycaemic response curves after intake:

• Refined carbohydrates (wheat, rice, potato, maize): peak blood glucose around 60 min, then decline back toward baseline by ~150 min.
• Sugars (sucrose, fructose, glucose): rise sharply to a peak around 30 min, then fall rapidly below baseline before recovering.
• Resistant starch (wholegrain cereals, fruits, legumes): rises more gradually to a lower peak around 90–120 min, stays elevated longer but flatter, and declines slowly toward baseline by 240 min.

Dietary considerations for glycaemic control

1. Have regular meals at regular times, with a consistent amount of carbohydrate.
2. Choose wholegrain, minimally-processed cereals; minimise refined grains, sugary snacks, and sugar-sweetened beverages (SSB).
3. Prioritise other carbohydrate foods within healthy eating (e.g. starchy vegetables, fruit, legumes, milk products).
4. Have only one piece of fruit at a time.

Diabetes New Zealand Healthy Plate model: people with diabetes do not need special food or separate meals — the whole family can eat the same healthy food. Principles: drink plenty of water and avoid fruit juice/sweet drinks; eat breakfast, lunch, and dinner every day; base meals on the healthy plate model; eat some carbohydrate at each meal, but not too much; choose foods low in sugar, saturated fat, and calories. Plate division: ¼ protein, ¼ carbohydrate, ½ other (non-starchy) vegetables.

Traffic-light food classification and its limitation

A simplified traffic-light system is sometimes used: avoid (red), eat some but not too much (orange), eat lots of (green). The lecture poses this as potentially misleading: the same “carbohydrate” traffic-light category groups foods with very different glycaemic effects together (e.g. bread, pasta, legumes, starchy vegetables, fruit, milk, and sugar are all classed as “carbohydrate” foods to be eaten in moderation), obscuring the differences in glycaemic response between refined/sugary carbohydrates and wholefood/resistant-starch carbohydrates covered above.

Evidence from the Fukushima Prison cohort

Study of 109 male prisoners with T2DM (mean age 51 ± 10 y) in Fukushima Prison, Japan, followed during imprisonment (14 ± 10 months), under a structured daily schedule and controlled diet.

• HbA1c fell from 69 to 42 mmol/mol (8.4% to 5.9%, p<0.001).
• Body weight fell from 65 ± 13 kg to 62 ± 10 kg (p<0.001); BMI fell from 23.7 ± 3.7 to 22.7 ± 2.6 (p<0.001).
• Fasting plasma glucose fell from 184 ± 74 mg/dL (10.2 mmol/L) to 113 ± 38 mg/dL (6.3 mmol/L, p<0.001).
• Total cholesterol fell (4.3 to 3.9 mmol/L, p<0.001); triglycerides and HDL-C changes were not statistically significant (p=0.099 and p=0.144 respectively).
• Medication use fell: insulin use 17%→12%, glibenclamide (sulfonylurea) use 31%→16% (p=0.007); proportion managed by diet alone rose from 52% to 72%.

Compared with the general Japanese male population (2003 data), the prisoners’ diet had a higher total energy intake (2518 ± 226 vs 2138 kcal/day), a higher proportion of energy from carbohydrate (61–66% vs 56%), a similar or slightly lower proportion from protein and fat, and substantially higher total and soluble dietary fibre (28.4 ± 2.1 g/day total, 18.7 ± 1.2 g/day soluble, vs 14.5 g/day total, 3.4 g/day soluble in the general population). [The lecture poses “Why?” after presenting the outcomes but the transcript does not record an explicit stated explanation beyond the structured schedule and dietary comparison — slide does not elaborate further.]

NZSSD dietary guidance and comorbidity adjustments

Where a registered dietitian is not available, education should cover a diet with a moderate amount of nutrient-dense, low glycaemic-index (GI) carbohydrates, plus:

• Advice on foods not recommended, and reducing snacking/grazing in favour of regular meals.
• Reduce sugar intake in drinks.
• Reduce saturated and trans fats.
• Aim for at least 30 g of dietary fibre per day.
• Consistent carbohydrate intake across the day and from day to day is likely preferred for those on bolus insulin and/or sulfonylureas.
• Food diaries and healthy plate models are often useful for decision making.

Recent evidence suggests low-energy, low-GI, and modified-macronutrient dietary approaches can be effective for weight loss and remission of T2DM.

Dietary changes for comorbidities:

• Reduced salt intake if hypertensive and/or diabetic renal disease.
• Switch saturated fats to mono- and polyunsaturated fats if high LDL cholesterol.
• Low potassium, phosphorus, and calcium intake may be required under dietetic supervision in significant diabetic renal disease with abnormal electrolyte levels.

Glycaemic index (GI)

Definition: GI is a ratio, expressed as a percentage, of the incremental area under the blood glucose curve (iAUC) of a test food versus a reference food (glucose):

$G{I}_{testfood}(\%)=\frac{120\text{min iAUC test food}}{120\text{min mean iAUC reference food}}\times 100$

• A property of the carbohydrate-containing food.
• Ranked 0–100, where glucose = 100.
• Used to guide food choice.
• Low GI ≤ 55 | Medium GI 56–69 | High GI ≥ 70.
• The amount of carbohydrate in the reference and test food must be the same for comparison.

Example food classifications:

• Low GI: white spaghetti, rice noodles, apple, orange, barley, boiled carrot, full-fat milk, skim milk, yoghurt, soy milk, chickpeas, kidney beans, lentils, soya beans, chocolate, fructose, raw dates.
• Medium GI: brown rice, couscous, muesli, pineapple, boiled sweet potato, green banana, popcorn, potato crisps, honey, sucrose, boiled pumpkin.
• High GI: white wheat bread, white rice, glucose, rice porridge, boiled potato, rice milk, watermelon, rice crackers.

Limitations of the GI concept

• The ranking system has no clear underlying rationale.
• The concept is not appropriate for use by the general public.
• GI changes depending on how a food is cooked and for how long.
• The glucose response to the same food varies between individuals.
• Whole foods tend to be low GI regardless.

Evidence for individual variability: in a study of 20 participants each given repeated doses of white bread and glucose beverages, both the iAUC and the calculated GI of white bread varied substantially within and between individuals — individual GI values for the same food ranged from roughly 45 to 140 around a sample mean in the 75–90 range. This variability underlies why GI is described as unreliable at the individual level.

Type 1 diabetes: targets, technology, and carbohydrate counting

Recommended target BGL (T1DM)

Timing	Target level
Before breakfast	5.0–7.0 mmol/L
Before lunch and dinner	4.0–7.0 mmol/L
Post-meal (at least 90 min after eating)	5.0–9.0 mmol/L

Technology

Funding is available in NZ for continuous glucose monitors (CGM), insulin pumps, and consumables for people with T1DM. A CGM pairs a skin sensor (e.g. on the upper arm) with a smartphone app showing the current glucose reading and trend graph. An insulin pump is a wearable device with a touchscreen display showing glucose reading, insulin-on-board, and time.

Carbohydrate counting

Dietitians help individuals identify “CHO portions” — units of food containing 15 g of carbohydrate — and give individualised portion guidelines per meal and snack. Examples of one 15 g CHO portion: 1 apple, 1 slice of bread, 1 glass of milk. Other stated portions: 2-minute noodles = 40 g CHO; 1 cup of cooked rice = 45 g CHO.

Suggested meal plan structure

A carbohydrate-serve-based meal plan (1 serve = 15 g carbohydrate) organises foods into: breakfast cereals, bread/baked products, fruit, rice/pasta/grains, (starchy) vegetables, and dairy products, each with example portion sizes equal to one serve. Protein serves are given as a palm-size serve of lean meat, fish, egg, cheese, or tofu/cottage cheese. Non-starchy vegetables are listed as “as much as you like.” Meal planning is done using a grid across breakfast, lunch, dinner, and snacks, with the individual choosing a number of carbohydrate and protein serves for each.

Individualised insulin regimen (example)

An individualised insulin regimen sets an insulin-to-carbohydrate ratio for each meal and a separate correction-dose ratio, each with a dosing table mapping carbohydrate (or BGL) ranges to a unit dose:

• Breakfast: ratio 1 unit : 13 g CHO (e.g. 20–22 g CHO → 1.5 U, up to 95–100 g → 7.5 U).
• Lunch: ratio 1 unit : 10 g CHO (e.g. 20–22 g CHO → 2 U, up to 98–100 g → 10 U).
• Dinner: ratio 1 unit : 10 g CHO (same scale as lunch).
• Correction dose: ratio 1 unit : 3.0 mmol/L, target BGL 7 mmol/L (e.g. BGL 9.0–9.2 → 0.5 U, up to 28.8–30.0 → 7.5 U).

Slide 35 flag: the ratios and table endpoints above are transcribed faithfully, but the exact intermediate row values in each dosing table were small in the source image and should be cross-checked against the original slide if precise dosing figures are needed.

Hypoglycaemia: recognition and treatment

Hypoglycaemia is defined here as BGL <4 mmol/L in a non-pregnant adult with diabetes.

Signs and symptoms (may not be obvious): pale, headachy, sweaty, dizzy, drowsy, irritable, hungry, confused, shaky, grumpy.

Treat immediately — don't leave the person alone.

If the person is conscious and able to eat/drink:

1. Give fast-acting carbohydrate:
   • Type 2 diabetes with body weight <70 kg, OR type 1 diabetes → 15 g fast-acting carbohydrate (e.g. 5 Mentos, or 3 tsp sugar in water).
   • Type 2 diabetes with body weight ≥70 kg → 30 g fast-acting carbohydrate (e.g. 10 Mentos, or 6 tsp sugar in water).
2. If they feel really unwell, ring 111. Otherwise wait 15 minutes and recheck BGL: if still <4 mmol/L, repeat step 1; if >4 mmol/L, proceed to step 3.
3. Give a carbohydrate-containing snack (e.g. a sandwich).

If the person is unconscious or drowsy (can’t swallow / risk of choking):

• Ring 111 for an ambulance.
• Put the person in the recovery position and stay with them.
• Use a GlucaGen HypoKit if trained to do so.

Ways to get 15 g of rapid-acting carbohydrate

5 Dextro-Energy glucose tablets; 4 Lift glucose tablets; 15 g glucose powder; 3 teaspoons of sugar dissolved in water; 150 mL (small glass) of fruit juice or non-diet soft drink; 9 jellybeans; 5 Mentos; 1 tablespoon of honey; 1–2 tablespoons of jam; 1 Hypofit gel. Double these quantities to get 30 g.

Alcohol and hypoglycaemia

Ethanol metabolism in the liver disrupts gluconeogenesis:

1. Ethanol is converted to acetaldehyde by alcohol dehydrogenase (NAD+ → NADH).
2. Acetaldehyde is converted to acetate by aldehyde dehydrogenase (NAD+ → NADH; this step is inhibited by disulfiram).
3. Both reactions massively increase cytosolic NADH concentration in the liver.
4. The raised NADH diverts gluconeogenic intermediates away from glucose synthesis — pyruvate is pulled toward lactate, and oxaloacetate toward malate (both NADH/NAD+-linked conversions) — instead of proceeding through the gluconeogenic pathway (glucose ⇌ glucose-6-phosphate ⇌ … ⇌ phosphoenolpyruvate ⇌ pyruvate/oxaloacetate).
5. Net effect: decreased synthesis of glucose, i.e. impaired gluconeogenesis, which increases hypoglycaemia risk.

Preventing hypoglycaemia when drinking

• Always eat before drinking.
• Avoid excessive drinking.
• Have a carbohydrate-containing snack before bed.
• Have breakfast the next day.
• Let friends know that a hypo could occur and what to do about it.
• Monitor BGL at minimum before drinking and before bed.
• Education about alcohol and hypoglycaemia risk should be given well before drinking age, and friends should be told the person has diabetes and how to treat a hypo.

[Note: exercise is named in the lecture objectives as another cause of hypoglycaemia requiring prevention measures, but the transcript does not contain a slide elaborating the exercise-specific mechanism or prevention steps — slide does not elaborate.]

Self-test

1. What is the difference between a dietitian and a nutritionist in New Zealand, in terms of qualifications and regulation?
2. What are the two goals of nutrition therapy for adults with diabetes?
3. List the three components of the NZSSD initial management algorithm for T2DM, plus the fourth cross-cutting component.
4. What percentage of sustained total body weight loss is associated with improvement in metabolic parameters, and what percentage is typically needed for remission of T2DM?
5. In the DiRECT trial, what dietary intervention was used, and what proportion of the intervention group achieved diabetes remission at 12 months?
6. What happened to pancreas volume after 24 months of diabetes remission in the DiRECT follow-up study?
7. According to the lecture, what proportion of T2DM diagnoses in 2018 was attributable to suboptimal diet, and what were the two largest individual contributing dietary factors?
8. What is the shift described in “medical nutrition therapy” — away from what, and toward what?
9. Name two nutrients supplied by grain foods and two supplied by legumes/nuts/fish/eggs/poultry/lean red meat.
10. Explain how the bran, endosperm, and germ of a grain differ, and why refined grains lose nutritional value.
11. Describe how the glycaemic response curve differs between refined carbohydrates, sugars, and resistant starch after intake.
12. List the four dietary considerations for glycaemic control given in the lecture.
13. Why does the lecture suggest the traffic-light food classification system may be misleading?
14. In the Fukushima Prison study, what happened to HbA1c, body weight, and diabetes medication use over the follow-up period?
15. How did the prisoners’ dietary fibre intake compare with that of the general Japanese male population, and what target fibre intake does the NZSSD recommend?
16. Distinguish two dietary comorbidity adjustments given in the lecture (e.g. for hypertension/renal disease vs high LDL cholesterol).
17. Define glycaemic index and state the three GI category cut-offs.
18. List the limitations of the GI concept given in the lecture.
19. What evidence does the lecture present for individual variability in glycaemic response to the same food?
20. State the target BGL ranges for a person with T1DM before breakfast, before lunch/dinner, and post-meal.
21. What does carbohydrate counting mean, and how many grams of carbohydrate is one “CHO portion”?
22. Describe how an individualised insulin regimen uses an insulin-to-carbohydrate ratio, using the breakfast ratio as an example.
23. A person with T1DM has a BGL of 3.5 mmol/L and is conscious and able to swallow. Walk through the recommended treatment steps.
24. How does the recommended treatment for hypoglycaemia differ between a type 2 diabetic weighing under 70 kg and one weighing 70 kg or more?
25. What should be done if a person with diabetes is found unconscious with suspected hypoglycaemia?
26. Describe, step by step, the mechanism by which alcohol consumption inhibits gluconeogenesis and increases hypoglycaemia risk.
27. List three practical measures to prevent hypoglycaemia when drinking alcohol.
28. Integrative: explain why a single “carbohydrate” food category (as in the traffic-light system) can be misleading, drawing on both the GI concept and the differing glycaemic response curves of refined carbohydrate, sugar, and resistant starch.
29. Integrative: using the DiRECT trial and the Fukushima Prison study together, what do these two pieces of evidence suggest about the relationship between diet/weight loss and T2DM remission?

Answers

Reveal answers

1. A dietitian is a registered health professional, clinically trained, requiring a Master’s degree in NZ and a current Annual Practice Certificate (APC) to practice. A nutritionist has an undergraduate nutrition degree; the title can be used by anyone and the profession is not regulated by statutory legislation.
2. To eliminate symptoms (if symptomatic), and to prevent or at least delay the development of complications.
3. Diagnosis (confirm diagnosis/type, set individualised glycaemic target); Lifestyle management (education, support, healthy eating, exercise — essential throughout); Metformin (start unless contraindicated, up to 2 g/day). The cross-cutting fourth component is Weight management (individualised plan if overweight/obese).
4. 5% sustained weight loss is associated with improved metabolic parameters; 10–15% sustained weight loss is typically needed for remission.
5. Total diet replacement (850 kcal/day VLCD) for 3–5 months, then stepped food reintroduction over up to 24 months. 46% of the intervention group achieved remission at 12 months (vs 4% of controls).
6. Pancreas volume increased, reaching 89% of the volume of a matched non-diabetic comparison group, with morphology becoming progressively fuller and more regular over the 24 months.
7. 70% (14 million cases) of T2DM diagnoses in 2018 were attributable to suboptimal diet. The two largest contributors were insufficient intake of whole grains (~25%) and excess intake of refined grains (~24%).
8. Away from emphasising macronutrients (CHO, protein, fat) and micronutrients (vitamins, minerals); toward focusing on foods, eating patterns, and nutrient-dense food choices.
9. Grain foods: carbohydrate, protein, dietary fibre, Fe, thiamin, folate, iodine, Mg, Zn, vitamin E (any two). Legumes/nuts/fish/eggs/poultry/lean red meat: protein, Fe, Zn, vitamin B12 (animal foods only), omega-3 fatty acids, vitamin E (nuts/seeds) (any two).
10. Bran protects the seed and supplies fibre, B vitamins, minerals; endosperm provides energy (carbohydrate, some protein, some B vitamins); germ nourishes the seed (B vitamins, vitamin E, minerals, phytochemicals). Refining removes the bran and germ, so refined grains lose most of the fibre, B vitamin, and mineral content.
11. Refined carbohydrates peak around 60 min then decline to near baseline by ~150 min. Sugars rise sharply to a peak around 30 min, then fall rapidly below baseline before recovering. Resistant starch rises more gradually to a lower peak around 90–120 min, stays elevated longer but flatter, and declines slowly by 240 min.
12. (1) Regular meals at regular times with consistent CHO amounts; (2) choose wholegrain/minimally processed cereals, minimise refined grains/sugary snacks/SSBs; (3) prioritise other CHO foods (starchy vegetables, fruit, legumes, milk products); (4) have only one piece of fruit at a time.
13. Because it groups foods with very different glycaemic effects into the same “carbohydrate” category (bread, pasta, legumes, starchy vegetables, fruit, milk, sugar are all classed together), obscuring the real differences in glycaemic response between refined/sugary carbohydrates and wholefood/resistant-starch carbohydrates.
14. HbA1c fell from 69 to 42 mmol/mol; body weight fell from 65±13 kg to 62±10 kg; the proportion managed by diet alone rose from 52% to 72%, while insulin use fell from 17% to 12% and glibenclamide use fell from 31% to 16%.
15. The prisoners had much higher total (28.4 g/day) and soluble (18.7 g/day) fibre intake than the general Japanese male population (14.5 g/day total, 3.4 g/day soluble). NZSSD recommends aiming for at least 30 g of dietary fibre per day.
16. Reduced salt intake is recommended if hypertensive and/or has diabetic renal disease; switching saturated fats to mono- and polyunsaturated fats is recommended if LDL cholesterol is high.
17. GI is the ratio (as a %) of the 120-min iAUC of a test food to the 120-min mean iAUC of a reference food (glucose), where glucose = 100. Low GI ≤55; Medium GI 56–69; High GI ≥70.
18. The ranking system has no clear rationale; it is not appropriate for the general public; GI changes with cooking method/duration; individual glucose responses vary; whole foods tend to be low GI anyway.
19. A study of 20 participants given repeated white bread and glucose beverage doses showed substantial within- and between-participant variability in iAUC, and individual GI values for white bread ranged from roughly 45 to 140 around a sample mean of about 75–90.
20. Before breakfast: 5.0–7.0 mmol/L. Before lunch and dinner: 4.0–7.0 mmol/L. Post-meal (≥90 min after eating): 5.0–9.0 mmol/L.
21. Carbohydrate counting identifies “CHO portions” of food, individualised per meal/snack; one CHO portion = 15 g of carbohydrate.
22. An insulin:carbohydrate ratio sets how many units of insulin are given per gram of carbohydrate eaten, with a dosing table for each meal. For breakfast the example ratio is 1 unit per 13 g CHO — e.g. 20–22 g CHO requires 1.5 U, rising to 7.5 U for 95–100 g CHO.
23. Give 15 g fast-acting carbohydrate immediately (T1DM applies regardless of weight) — e.g. 5 Mentos or 3 tsp sugar in water. If they feel really unwell, ring 111; otherwise wait 15 minutes and recheck BGL. If still <4 mmol/L, repeat the 15 g carbohydrate; if >4 mmol/L, give a carbohydrate-containing snack (e.g. a sandwich).
24. Type 2 diabetics under 70 kg (and all T1DM) get 15 g fast-acting carbohydrate; type 2 diabetics 70 kg or over get 30 g fast-acting carbohydrate.
25. Ring 111 for an ambulance, put the person in the recovery position and stay with them, and use a GlucaGen HypoKit if trained to do so.
26. Ethanol is converted to acetaldehyde by alcohol dehydrogenase (NAD+→NADH), then acetaldehyde to acetate by aldehyde dehydrogenase (NAD+→NADH, inhibited by disulfiram). Both steps massively raise cytosolic NADH. The excess NADH diverts gluconeogenic intermediates away from glucose synthesis (pyruvate→lactate, oxaloacetate→malate), decreasing glucose synthesis and increasing hypoglycaemia risk.
27. Any three of: always eat before drinking; avoid excessive drinking; have a CHO-containing snack before bed; have breakfast the next day; let friends know about hypo risk and treatment; monitor BGL before drinking and before bed.
28. The traffic-light system groups all carbohydrate foods into one “eat some but not too much” category, but GI theory and the glycaemic-response curves show that carbohydrate type matters: refined carbohydrates and sugars cause fast, sharp glucose peaks (high GI), while resistant starch/wholefood carbohydrates cause a slower, flatter, more prolonged response (low GI) — so treating all carbohydrate foods identically obscures clinically meaningful differences in glycaemic effect.
29. Both provide evidence that structured dietary change (reduced calories/refined carbohydrate, higher fibre, weight loss) can substantially improve glycaemic control and reduce or eliminate the need for diabetes medication — DiRECT via a controlled VLCD trial showing dose-dependent remission with weight loss, and the Fukushima Prison cohort via a real-world setting with a structured, higher-fibre diet showing large HbA1c reductions and reduced medication use.