Background

In 2015, the International Diabetes Federation estimated that the prevalence of diabetes in Bermuda was around 13%, affecting 6,700 adults.  Around 28% or 1,900 don’t yet know they have diabetes and a further 6,900 are estimated to have impaired glucose tolerance or ‘pre-diabetes’. 

In Bermuda, the vast majority of diabetes cases are type 2 diabetes, which arises as a result of modern day lifestyles, particularly in those who are overweight. This is a particular problem in Bermuda where 74% of the population are overweight or obese.

It is now well established that type 2 diabetes can be prevented by adopting a healthy lifestyle; more recently, it has been shown that such a lifestyle can not only control type 2 diabetes, it can in some cases lead to reversal.  There is thus an urgent need in Bermuda, as elsewhere, to promote healthier lifestyles to those at risk of type 2 diabetes to help reduce their risk, and to help those that have type 2 diabetes to achieve better control, or even reversal.  Failure to do so will result in many people developing complications of diabetes that in turn can lead to premature death.  This will not only have a devastating impact on the individuals concerned, but will put a further burden on the health system.

Until relatively recently, the focus of management of type 2 diabetes has been on medication, with consequent large increases in expenditure on drugs for diabetes.  However, while these drugs may lead to some improvement in blood glucose control, these improvements are not always sustained, and further medication is often required.

In the last few years, a number of studies have shown the benefits of a low carbohydrate diet as the treatment of choice for people with type 2 diabetes.  A recent primary care practice-based study in the UK showed that introduction of such an approach led to significant improvements in HbA1c, body weight and lipid profile that led to the withdrawal of medication in many cases. This has led to a reduction in diabetes-related drug expenditure for the practice of over 33%1[1]

‘Reverse your diabetes – the step by step plan to take control of type 2 diabetes’ by Dr David Cavan[2] describes how individuals can adopt this approach themselves, by introducing changes in their diet to reduce their carbohydrate intake to less that 100g per day, and by increasing physical activity. Many have done so, with remarkable results:

With this carb-restricted diet I found I could happily reduce my calorie intake to 2000 per day. From June 2015 to May 2016 my weight reduced from 106Kg to 76Kg and my HbA1c progressively reduced from 10.5% to 5.2%. I have been able to stop using the Pioglitazone and Metformin altogether.  I now have a BMI below 25 for the first time in my adult life!’

Lifestyle Management Program (For six weeks: During months 1-3)

Patients will be invited to attend a weekly Lifestyle Management Program for six weeks that will reinforce dietary messages, provide peer support and encourage increased physical activity within their lifestyles.  The curriculum will be developed with local experts so as to be as culturally relevant as possible. The program will run continuously with a rolling curriculum that repeats every six weeks. Participants will be encouraged to attend all six sessions consecutively and as much as possible over the first three months; however attendance will be according to the needs and wishes of participants. Each session will accommodate up to 12 patients in a group setting and be facilitated by staff with expertise in nutrition, behaviour change and psychology, with input from a Diabetologist as required.

Each session will follow a detailed written curriculum, backed up by written material for participants. Sessions will be facilitated to encourage active engagement and discussion between participants. Each week will focus on a specific theme and participants will be asked to complete related tasks during the following week, adapted to meet their own goals.  A suggested schedule is shown in the table.

Lifestyle Update Groups (Every two months: During Months 5 to 11)

Having completed the above programme, patients will be enrolled into group updates every two months to help them consolidate lifestyle changes, review their goals and seek additional support in achieving them as required. Each participant will be invited to four update sessions, and each one will recap part of the content of sessions 1-4 above, with extended time to review the progress to date of each participant and supporting them in overcoming any obstacles to achieving their goals.

Follow-up Consultation With Diabetologist (Every two months: During months 2 to 12)

The aim is to review progress in changing diet and physical activity, reducing body weight and improving blood glucose levels. Blood will be taken for HbA1c and lipids at each visit. Medication (for diabetes, blood pressure and lipids) will be adjusted as appropriate. Patients can be referred back into the group lifestyle programme if appropriate.

In patients who are able to come off of all diabetes medication and whose HbA1c is <6% (42mmol/mol), a glucose tolerance test will be performed as part of the final assessment at one year to document the extent of reversal (eg to IGT or normal).

[1] Unwin D, Unwin J.   Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice. Practical Diabetes 2014: 31

 [2] Cavan DA. Reverse your diabetes – the step-by-step plan to take control of type 2 diabetes. London, Random House 2014