Type 2 Diabetes and Lifestyle Interventions: by Nina Sawicki
By Nick Allen 29/11/2018 10:15 pm

So sorry Joe, but I’m afraid the tests indicate diabetes," the doctor says. Joe had visited his G.P. because he is feeling fatigued. The diagnosis comes as a complete shock. He leaves his doctor’s office armed with a mountain of pamphlets, a list of do’s and don’ts and a machine to prick his finger every day. Joe feels overwhelmed and is woefully ill-equipped to face the diagnosis.

This scenario plays out many times between patients and clinicians each year in New Zealand. For clinicians like myself, the most pressing question of the case is: How can we best support Joe with evidence-based advice? There is considerable misinformation about diabetes. Let’s summarise what we do know about diabetes and its context, what emerging research is indicating and questions which remain yet unanswered. 

Radix Nutrition Breakfast | Credit: Radix Nutrition

What is Diabetes?

The number of people with diabetes in New Zealand exceeds 200,000. It’s likely that there are an additional 100,000 people who remain yet undiagnosed. Historically diabetes has been classified as type 1 (onset in early life with rapid depletion of insulin) and type 2, which has a more gradual onset that presents in later life. Type 2 is often but not always associated with obesity and a sedentary lifestyle. Within New Zealand, the prevalence of diabetes in Māori and Pacific communities is about three times higher than amongst other New Zealanders. South Asian populations are also at higher risk (www.health.govt.nz). The management and emerging research of type 1 diabetes is beyond the scope of this article which focuses on type 2.

Diabetes is not one single disease state but a spectrum of physiological (functional) and endocrine (hormonal) changes in which there is increasing resistance to insulin. Insulin is the hormone that facilitates the transport of glucose molecules from the bloodstream into the cells. With either absence of insulin or ineffective insulin (insulin resistance) the glucose is trapped within the capillaries (the smallest blood vessels) and cannot enter the cells, where it is needed for cellular energy. As a result, the body is awash with glucose, but it is stuck in the wrong place. The presence of high levels of glucose within the bloodstream is toxic to the vessel wall and causes both micro- and macro-vascular pathology in the long term. 

Sociological Context

Although children are increasingly diagnosed with type 2 diabetes, it is more commonly associated with obesity. Many factors have contributed to these changes. In the 1970s and 1980s, there was questionable research causally linking increased rates of vascular disease (both cardiac and cerebral) to high levels of saturated fats in our diet. However, research now shows that saturated fat is but one of several risk factors in vascular disease. Unfortunately, this misinformed view remains, and many people have adopted a low-fat diet in good faith, reducing their intake of both saturated and unsaturated fats. 

There was an unintended consequence of reducing fat in our diet: people began consuming more sugar. Fat is a necessary part of our diet, makes food palatable and gives satiety. To make this lower-fat food tasty, people began to rely increasingly on sugar. Simultaneously, we became less active, using our cars more, and began consuming the tasty, increasingly accessible pre-prepared foods and fruit juices. Obesity in New Zealand rose, giving us the third highest adult (>15) obesity rate in the OECD, with 10 % of children now being classified as obese.1

Epigenetic factors play a role in the development of diabetes. However, factors such as eating practices and patterns are complex and poorly understood. For example, in Britain many families do not have a dining table, eat their dinner watching the television and are less likely to engage in interactive conversation. The long-term impact of food choices on children in these situations is poorly understood. 

Radix Nutrition, Cambridge New Zealand | Credit: Radix Nutrition

While nutritional needs vary across age groups and activity levels, people most don’t seek the expertise of a trained dietitian. For example, athletes need calorie dense foods, whereas an inactive person may have similar nutrient needs, but without the calorific requirements. However, people’s sugar-rich food choices often result in a calorific intake that is larger than they require. What is needed then, is a higher level of education and understanding around people’s eating practices and food choices.

Complicating this is the reality that most of the research around diabetes focuses on newer medications, the delivery of insulin (e.g. infusions), and on non-invasive methods for testing glucose. Unfortunately, the potential impact of a lifestyle intervention does not attract the same level of research funding as newer pharmaceutical options. 

Diet and Lifestyle with Diabetes

Let’s return to Joe, who has just been diagnosed with type 2 diabetes. There are several established risk factors associated with insulin resistance: obesity, inactivity and a diet that’s high in simple sugars — Joe ticks all these boxes. He is 52 years old, overweight, has a sedentary corporate job smashing out figures and documents all day. Because there are no local buses or cycleways, he commutes by car to work and is too tired at night to go to the gym. His food choices for breakfast and lunch are nutritionally inadequate and often sugary. Joe smokes during the day and relaxes with a few beers when he gets home at night. In addressing Joe’s situation, what is an evidence-based approach?

Lifestyle management is a significant mechanism for controlling diabetes. The American Diabetes Association recently wrote a position statement about the needs of young diabetics.2 They underscore, along with newer treatment options and self-management, the importance of lifestyle management (nutrition and exercise), and the need for special attention to the behavioural aspects of self-management, including depression, anxiety and eating disorders. 

There is a strong link between body weight and the risk of type 2 diabetes. The Australian Endocrinology Society noted that obesity is a complex progressive chronic multifactorial disease and such patients should have access to suitable and appropriate treatments of not only lifestyle intervention and medication but also bariatric surgery (weight loss surgery, e.g. banding or gastric bypass).3 There are strong biological and genetic factors that make some individuals susceptible to obesity, and insulin dysregulation or resistance. It follows that we should not apportion blame to obese individuals but to take an eclectic solution-focused approach that recognises it as a chronic disease. Within this approach, lifestyle management offers valuable preventative solutions that could help people control their body weight before they reach the point of becoming diabetic.

Radix Nutrition Performance Breakfasts | Credit: Radix Nutrition

Changes in lifestyle are relatively simple but not necessarily easy to make. For example, Joe needs to lose weight, walk or cycle to work and learn new cooking skills, possibly in combination with daily medication — all of which individual pose a significant challenge. While it may be more convenient (and sometimes essential) to use medication and or insulin, it should not be at the expense of tackling changes to ones’ lifestyle. For Joe to successfully make these changes, he may need significant support. Joe needs more streamlined access to healthy food options, non-medical support services and educational resources. He may benefit from a dietitian, a cooking mentor, a psychologist and an exercise coach, all working alongside his medical team, which consists of a doctor and diabetes nurse. 

Current research adds urgency to these changes and the need for support. In the early stages of diabetes, the metabolic changes can potentially be reversed before any organ damage has occurred. Optimal control of blood glucose in the early stages of the illness appears to be beneficial. Furthermore, those with better glycaemic control have fewer of the complications typically associated with diabetes: for example, retinal damage, cataracts, kidney disease and atherosclerosis. That's why an evidence-based approach should encourage newly-diagnosed individuals to adopt lifestyle (diet and exercise) interventions that aid glycaemic control.

In summary, supporting Joe requires a multifaceted approach. Ease of access needs to sit at the very core of any evidence-based solution. There are many obstacles to Joe's regaining a measure of health, and to his mitigation of diabetes' damaging effects. The best support we can offer Joe will minimise these obstacles and aid Joe’s access to a healthier lifestyle.


Dr Nina Sawicki, on a mission up the Travers Valley, Nelson Lakes National Park | Credit: Nick AllenDr Nina Sawicki has worked as a GP for 20 years and currently works in Wellington CBD. In addition to her medical training, she has a Master’s Degree in General Practice and works part-time for PHARMAC, assessing individual requests for non-funded medicines. Nina also works as an Assessor for the Royal New Zealand College of General Practitioners. More importantly, perhaps, Nina is passionate about eating well and the outdoors. She is also an accomplished tramper and climber, having summited many significant peaks, including Aoraki / Mt Cook and Mont Blanc (France). 


1 www.health.govt.nz

2 Diabetes Care. 2018 Sept. 44(9): 2016-2044

3 Diabetes Practice Review. Issue 3. 2018. www.researchreview.com.au