diabetes research and clinical practice 108 (2015) 7–14

Contents available at ScienceDirect

Diabetes Research
and Clinical Practice
journ al h ome pa ge : www .elsevier.co m/lo cate/diabres

Review

Systematic review of the evidence for a liberalized

diet in the management of diabetes mellitus in
older adults residing in aged care facilities

Olivia Farrer a,1, Alison Yaxley a,2, Karen Walton b,3, Erin Healy a,4,
Michelle Miller a,*
a
Nutrition and Dietetics, Flinders University, GPO Box 2100, Adelaide 5001, SA, Australia
b
School of Medicine, University of Wollongong, Northfields Avenue, Wollongong 2522, NSW, Australia

article info abstract

Article history: A systematic review of the literature was conducted to review and evaluate the evidence
Received 9 June 2014 supporting a liberalized diet for the management of diabetes mellitus in aged care homes
Received in revised form and examine the effect of this on glycaemia, nutritional status and diabetes comorbidity risk
21 October 2014 factors. A 3 step search of eight databases followed by independent data extraction and
Accepted 28 December 2014 quality assessment by two authors was undertaken. Studies which compared therapeutic
Available online 21 January 2015 diets to a liberalized diet or observation studies reviewing the effects of therapeutic diets on
glycaemia and nutritional status were included. Of the 546 studies identified, six met the
Keywords: inclusion criteria. Methodological quality of the studies was rated poor and the majority
Aged care concluded no statistically significant change in diabetes management outcomes with a
Diabetes liberalized diet, but modest increases in glycaemia were observed. Inadequate data was
Liberalized diet available to determine effects of diet change on nutritional status or diabetes risk factors.
Overall studies were in support of a liberalized diet but due to the low quality of the evidence
and a lack of significant findings it may not be appropriate to extrapolate these conclusions
to inform dietetic practice.
# 2015 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

* Corresponding author. Tel.: +61 8 8204 5328; fax: +61 8 8204 6406.
E-mail addresses: Olivia.farrer@flinders.edu.au (O. Farrer), Alison.Yaxley@flinders.edu.au (A. Yaxley), kwalton@uow.edu.au
(K. Walton), Erin.healy@flinders.edu.au (E. Healy), Michelle.miller@flinders.edu.au (M. Miller).
1
Tel.: +61 8 8204 7074; fax +61 8 8204 6406.
2
Tel.: +61 8 8204 4645; fax +61 8 8204 6406.
3
Tel.: +61 2 4221 5197; fax +61 2 4221 3151.
4
Tel.: +61 8204 4715; fax +61 8 8204 6406.
http://dx.doi.org/10.1016/j.diabres.2014.12.021
0168-8227/# 2015 Elsevier Ireland Ltd. All rights reserved.

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8 diabetes research and clinical practice 108 (2015) 7–14

3.1. Effects of intervention on glycaemic management of diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9

3.2. Effect of therapeutic diet on nutritional status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9
3.3. Effects of a therapeutic diet on comorbidity risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1. Background
Approximately 25% of patients in aged care homes have
diabetes, and it is the primary reason for 12% of admissions to
supported living institutions among adults 45 to 75 years of
age; with admission in adults 45–64 yrs often relating to
diabetes complications [1]. More commonly older adults,
defined as 65 years, are diagnosed with type 2 diabetes
although lifestyle goals for management remain the same for
type 1 diabetes. The prevalence of diabetes in aged care homes
is twice as common as in the general population [2] and
residents with diabetes frequently have higher rates of
complications and as a result require 31% more hospitaliza-
tions [3]. The goals for management of diabetes in older adults
are broad and not specific to institutionalized older adults, as
summarised in the American Diabetes Association (ADA)
review of clinical practice recommendations [4]. The recom-
mendations do include comments that ‘Older adults who are
functional, cognitively intact, and have significant life expec-
tancy should receive diabetes care with goals similar to those
developed for younger adults and that ‘Glycaemic goals for
some older adults might reasonably be relaxed, using
individual criteria, but hyperglycaemia leading to symptoms
or risk of acute hyperglycaemic complications should be
avoided in all patients’ [4]. This is further emphasised in the
International Diabetes Federation (IDF) ‘Global Guideline for
Managing Older People with Type 2 Diabetes’ [5].
Management of type 2 diabetes mellitus in adults and
functionally independent older adults is primarily through
lifestyle changes, such as regular physical activity, maintain-
ing a healthy weight and consuming a nutritious varied diet
[5]. The diet would ideally be consistent in volumes of
carbohydrate at each mealtime with a preference for low
glycemic index (GI) choices [4] to help avoid food related post
prandial hyperglycaemia. Lifestyle factors such as exercise
and modest weight loss of 5–10% if required, have well
documented benefits in improving insulin sensitivity and
glucose uptake. But for older adults, particularly those residing
in aged care homes, it may be impractical to expect regular
exercise; and weight loss of >5% can actually have a negative
impact on mortality [6], which realistically leaves diet and
drug therapy to manage glycaemia.
Historically, nutritional management of residents with
diabetes in institutions has been a prescribed therapeutic or
‘diabetic’ diet generally comprising of the following restric-
tions; no concentrated sweets and restricted calories and/or
fat, sometimes known as a ‘No concentrated sweets diet [7] or
‘‘ADA diet’’ [8]. Although with literature reporting that as
many as 50% institutionalized older adults are malnourished
[9] and limited data to demonstrate effectiveness of restrictive
diets [6] in achieving optimal glycaemia (HbA1c < 8%,
64 mmol/mol), the therapeutic ‘diabetic’ diet is no longer
recommended by the ADA and a move to liberalize diet
prescriptions for older adults in aged care has occurred [10]
albeit inconsistently, with many facilities still offering a
version of a diabetic therapeutic menu. There are limited
studies that inform current menu standards and facilities may
now opt for a generic liberalized menu incorporating less
restriction on calories, fat and carbohydrate from refined
sugar, which is offered to all residents, loosely based on the
ADA [4] and IDF guidelines [5], some with particular emphasis
on high energy foods to reduce risk of malnutrition and a
consensus from existing literature that such a diet will not
impact on diabetes management [2,11].
However, at 65 years of age, adults still have at least an
estimated 16–20 years of life expectancy (for men and
women, respectively), with 46% aged care home residents
aged 65–84 years [12] and risk factors for chronic disease
complications remaining influential and modifiable even in
older age. Ageing combined with hyperglycaemia, appears
to accelerate the onset of complications and prolonged
suboptimal glycaemia has known effects on increased
cognitive decline, poor wound healing, increased likelihood
of developing pressure ulcers, and most notably macro
vascular complications (risk of heart disease and stroke is
2–4 times higher in people with diabetes) [13]. Hypergly-
caemia is also an independent risk factor for falls in aged
care residents [14]. Studies have found that improved
glycaemic control benefits people with diabetes and in
general every percentage point drop in HbA1c blood test
results (e.g., from 8.0%, 64 mmol/mol to 7.0%, 53 mmol/mol)
can reduce the risk of micro-vascular complications (eye,
kidney, and nerve diseases) by 40% [13]. The economic cost
savings and improved quality of life for optimal glycaemic
management in older adults with diabetes has also been
stated as a benefit. It is clear that there is some benefit in
adoption of health promoting behaviours, including a diet
that may prevent or postpone complications but that is of
high nutritional value and does not precipitate weight or
muscle loss often observed in older adults [15].
In summary, the care of older adults with diabetes is
complicated by their diverse clinical and functional presenta-
tion [4]. There is limited data available on how to manage this
growing population group particularly in an aged care setting
but the limitation of implementing lifestyle changes other
than diet modification has prompted this systematic review of
the literature to review the evidence for dietary management
of diabetes in aged care homes and reviewing the effects of a
therapeutic diet versus a liberalized diet on glycaemia,
nutritional status and comorbidities.
2. Methods
A systematic review of the literature studying the effects of
either a therapeutic diet or liberalized diet on diabetes

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 diabetes research and clinical practice 108 (2015) 7–14
management in aged care homes was completed. An exten-
sive 3 step search, with no restriction on date of publication
was conducted using keywords in either the abstract or title of
articles found via PubMed and CINAHL databases. Following
this was a more detailed search of all key words including
MESH headings in Medline, Cochrane, Informit, Web of
Science, Scopus and Ageline databases was conducted
(Table 1). Finally, reference lists of relevant articles were
reviewed for papers of interest that had not already been
identified. Essential inclusion criteria were that studies were
set in an aged care facility, reviewed the effect of a diet
(whether liberalized or therapeutic) and its effect on diabetes
management in older adults with a mean age of 65 years. In
addition authors looked for primary outcome measures such
as HbA1c (%), fasting or post prandial BGL (mmol/L), BMI (kg/
m2) or weight change (kg) in participants with type 2 diabetes
mellitus residing in an aged care facility. Alternatively,
secondary outcomes for nutritional status were included
such as albumin levels and measures of oral intake or appetite
as well as change in comorbidity risk factors such as total
cholesterol. Observational data for one diet type, was included
provided the participants were in an aged care setting, had a
diagnosis of diabetes mellitus and outcome measures were
commented on in comparison to existing data or literature in
the event of no control group.
The initial electronic database search was conducted by the
first author (OF), but a second author (EH) assisted with the
screening of results once duplicates had been removed in
Endnote. Final screening of the reference lists from identified
papers was completed by OF and EH independently and where
discrepancies occurred a third author (MM) was consulted. Of
the six [2,11,16–19] studies included one was published in
Spanish [17] with no English translation, but due to the limited
literature available and relevancy of the outcomes it was
translated and included. The quality of each article was
assessed using the Jadad scale [20], reviewing risk of bias using
a points system based on cohort selection, blinding and
attrition and the detail in which these are described. A final
score of 0–5 is awarded, with 5 being of the highest quality
(Table 2).
3. Results
A total of 733 studies were identified from the initial search
with an additional 12 from hand searching references lists,
leaving 546 studies after duplicates were removed. From
review of the titles and abstracts 533 were discounted as not
meeting inclusion criteria for reasons such as; non-human
studies, drug trials, narrative articles and diabetes position
Table 1 – List of keyword and MESH search terms.
(nursing home* OR ‘‘long term care’’ OR ‘‘longterm care’’ OR
‘‘residential aged care’’ OR LTCF OR aged care facilit* OR care
home* OR ‘‘residential care’’ OR institutionalized elder* OR
institutionalised elder* OR institutionalized older adult* OR
institutionalised older adult* OR skilled nursing facilit* OR
(resident* AND dementia) AND (diabet* OR NIDDM OR IDDM OR
T1DM OR T2DM) AND (diet* OR ‘‘nutrition therapy’’ OR
nutritional therap* OR menu* OR food service*)
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9
statements, which left 8 full papers to retrieve (Fig. 1). Two of
these did not meet the inclusion criteria [21,22] because
primary and secondary outcome measures were not dis-
cussed. Table 3 summarizes the study design, outcomes and
findings for the six included studies.
3.1. Effects of intervention on glycaemic management of
diabetes
Of the included studies, five [2,11,16,17,19] compared the
effects of a liberalized diet compared with a therapeutic diet
on glycaemia in residents with type 2 diabetes, based on
outcomes mean (SD) HbA1c (%) and/or mean (SD) fasting blood
glucose levels (BGL, mmol/L,) as illustrated in Table 4. All three
controlled trials [2,11,19] evaluated change in glycaemia over
an 8–12 week period; providing baseline and end of interven-
tion data. In two [16,17] of the cross sectional studies data for
HbA1c (%), as a mean (SD) value, for both therapeutic and
liberalized diet cohorts was commented on from one off
medical record data collection. The sixth study [18] included in
the review, made no direct evaluation of a diet comparison but
included data for fasting BGL categorized by type of diabetes
management e.g. no treatment, diet only, diet and insulin.
Of the five studies [2,11,16,17,19] that commented on HbA1c
(%), Casimiro et al. [17] was the only study to report a
significant difference in glucose levels ( p = 0.0006) in favour of
a therapeutic diet (n = 394), with facility clinicians reporting
71% (n = 276) of residents with optimal glycaemic manage-
ment as compared to only 37% (n = 34) of those on a liberalized
diet (n = 92). Although the four [2,11,16,19] remaining studies
did not observe a statistically significant change in mean
HbA1c (%) when residents were provided a liberalized diet
(n = 103), Coulston et al. [11] did note a moderate increase
across the two aged care homes used for data collection
(n = 18), which when broken down for one cohort at the
Masonic home site (n = 8) was significant ( p = <0.05).
Four studies [2,11,18,19] evaluated mean fasting blood
glucose levels (mmol/L) in relation to dietary management.
Coulston et al. [11] noted a significant mean rise of 1.1 mmol/L
( p = <0.05) in BGL over the intervention period (8 weeks
liberalized diet). Similarly, Cooper et al. [18] found those
residents on a liberalized diet (n = 2) when compared with
those on a therapeutic diet as their only treatment (n = 9) had a
higher incidence of sub-optimal fasting blood glucose levels
but the sample size was small and not viable for statistical
analysis. The remaining two studies found no change over a 12
week intervention period, Tariq et al. [2] noted no significant
difference in fasting levels ( p = 0.45) and although Goldberg
[19] did not present actual results the author comments that
no statistical change was observed when residents were
provided with a liberalized diet ( p = 0.839).
3.2. Effect of therapeutic diet on nutritional status
Five of the studies [2,11,16,17,19] used BMI (kg/m2) or albumin
(g/L) as measures of nutritional status, two of which also
comment on weight (kg) [17] or percent ideal body weight
(%IBW) [19]. Only one of the intervention studies [2] evaluated
a change in BMI, reporting a non-significant difference
( p = 0.64) between therapeutic diet and liberalized diet cohorts
10 diabetes research and clinical practice 108 (2015) 7–14

Table 2 – Quality assessment of studies included in the review according to the Jadad scale.
Author (year) RCT Blinding Attrition Randomization method Blinding method Total score
Bouillet et al. (2010) [16] 0 0 0 0 0 0
Coulston et al. (1990) [11] 0 0 0 0 0 0
Tariq et al (2001) [2] 0 0 0 0 0 0
Casimiro et al (2001) [17] 0 0 1 0 0 1
Cooper et al (1990) [18] 0 0 0 0 0 0
Goldberg (2003) [19] 1 0 0 1 0 2

at 12 weeks, despite a mean (SD) increase of 1.2  1.3 and
0.8  0.1 (kg/m2), respectively. Three [11,16,17] studies state
mean (SD) baseline BMI (kg/m2) for their sample populations
as between 24.3  1.0 and 28.5  10.7 kg/m2 but did not
measure change. Casimiro et al. [17] included baseline mean
(SD) weight (kg) for the study cohort; 72.8  14.2 kg men versus
63.7  13.7 kg women, and highlighted a need to adjust for
gender in statistical analysis. Goldberg [19] did not include
data for BMI (kg/m2) but described the %IBW of the sample as
being 124  22.5% and 128  24.8% for therapeutic and
liberalized diet cohorts, respectively, with ideal weight
between 90% and 120% considered healthy. The change in
% IBW over the course of the intervention is referred to as non-
significant ( p = >0.05) but results are not presented in the
thesis [19].
Three [2,16,19] of the studies identified albumin (g/L) as an
indicator of nutritional status. Of the controlled trials [2,19]
Goldberg [19] concluded no difference for either the therapeu-
tic ( p = 0.879) or liberalized diet group ( p = 0.629) both of which
remained within healthy parameters and had insufficient
sample size to perform statistical analysis of the change in
albumin levels for residents identified as malnourished at

Fig. 1 – Study flow diagram showing the number of studies screened, assessed for eligibility and included in the review.

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 Table 3 – Summary of studies that examine a relationship between diet and diabetes management, nutritional status and comorbidity risk factor outcomes.
Authors (year) Study design Sample Outcomes as measured by Results Summary

Glycaemia Nutritional Comorbidity

status risk factors
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Goldberg Randomized controlled trial, 34 Residents with type 2 Baseline HbA1c %IBW at Nil Liberalized diet did not
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(2003) [19] 12 weeks liberalized diabetes usually receiving a and Fasting BGL baseline significantly affect glycaemia or
diet compared to residents therapeutic diet Albumin at nutritional status
current ‘no sweets’ diet, baseline

diabetes research and clinical practice 108 (2015) 7–14

follow up over 16 weeks
Coulston et al Non randomized controlled
(1990) [11] trial, therapeutic diet
liberalized for 8 weeks.
Follow up over 16 weeks
Tariq et al. Non-randomized controlled
(2001) [2] trial, therapeutic diet
liberalized for 12 weeks.
Follow up over 6 months
Casimiro et al. 1 Day cross sectional survey
(2001) [17] of residents provided a
therapeutic diet (n = 394)
in aged care facility as
compared to those
receiving a liberalized diet
(n = 92)
Bouillet et al. Retrospective cross
(2010) [16] sectional study of residents
receiving a therapeutic diet
(n = 54) compared with a
liberalized diet (n = 46).
Data collected on 1 occasion
Cooper et al. 1 Day Retrospective
(1990) [18] observation study of aged
care home residents with
diabetes
18 T2DM residents  70 yrs
usually receiving therapeutic
diets
28 Residents with T2DM.
Non acute issues and able to
self-feed usually receiving
therapeutic diets
486 Older adults residing in
AGED CARE HOMES, with
non -complicated type 2 diabetes
100 Participants with
diabetes 65 yrs old
Across 7 institutions
41 Residents of aged care
facility >36 months with
type 2 diabetes
Fasting BGL BMI Triglyceride Liberalized diet increased calorie
Cholesterol intake with modest effect on
HbA1c diabetes management but authors
argue that there is more positive
gain to patient not to be restricted
Baseline, 3 months Baseline and Nil No significant changes in
and 6 month 3 month glycaemia or nutritional status.
HbA1c & Baseline, weight, BMI Authors conclude that a liberalized
3 month fasting BGL & Albumin diet including sucrose containing
foods should be recommended
Glycaemic control Weight Total Residents on a therapeutic diet
BMI cholesterol demonstrated better glycaemic
Satisfaction management independent of age
with diet and physical ability and were
happy with food choices.
Therapeutic diet did not affect
appetite, intake or malnutrition
risk and may support best diabetes
management
HbA1c BMI Total Study shows no significant change
Albumin Cholesterol in glycaemia, nutritional status or
Triglycerides risk factors between diets
Fasting BGL %IBW Nil Those residents receiving a
therapeutic diet and also
overweight were deemed
non-compliant with diet as no
significant changes in weight.
Overall mortality was similar
between groups but
hospitalizations were
more frequent in those with diabetes

11
12 diabetes research and clinical practice 108 (2015) 7–14

Table 4 – Study methodology and findings for studies evaluating effects of a liberalized diet on glycaemia.
Author, Methodology Sample (n) Changes in glycaemic outcomes for therapeutic diet
year vs liberalized diet

Mean (SD) p Value Mean (SD) fasting p Value

HbA1c (%) BGL (mmol/L)

Therapeutic Liberalized Therapeutic Liberalized

Goldberg n = 17 Residents randomly 34 6.5  0.88% – 0.507 6.9  1.9 – 0.839
(2003) [19] assigned to receive a liberalized
diet for 12 weeks.
Coulston n = 18 Residents non randomized 18 7.8  0.4 8.1  0.5 >0.05 6.7  0.4 7.3  0.4 <0.05
et al. to receive a liberalized diet
(1990) [11] for 8 weeks
Tariq S. n = 14 Residents non randomized 28 6.7  1.5 7.0  1.1 – 8.2  3.0 7.3  2.1 –
et al. to receive a liberalized diet for
(2001) [2] 12 weeks
Casimiro Questionnaire administered to 486 – – 0.0006 – – –
et al physicians of residents with
(2001) [17] diabetes; n = 394 receiving
therapeutic diets compared with
n = 92 on liberalized diets
Bouillet Data collection from medical 100 7.26  1.36 7.11  1.10 0.27 – – –
et al records of residents with diabetes
(2010) [16] over 7 institutions
n = 54 received therapeutic diet,
n = 46 liberalized diet

baseline (n = 4). Tariq et al. [2] saw a slight increase in mean
(SD) albumin levels (g/L) for the therapeutic diet group of
2  4.0 g/L but no change for the liberalized diet cohort
( p = 0.80). Bouillet et al. [16] describes his sample population
as being within normal levels for albumin.
In addition to albumin and weight change, three [11,17,19]
of the studies compared oral intake for residents on both the
therapeutic and liberalized diet and one [17] included
qualitative data on resident satisfaction for each diet.
Coulston et al. [11] observed a mean increase of 240 kcals
per day from carbohydrate and fat on a liberalized diet which
was not statistically significant. Conversely, Goldberg [19]
observed no change in either the therapeutic ( p = 0.603) or
liberalized diet cohorts ( p = 0.845) for estimated % oral intake
of required calories consumed. Based on a descriptive scale
and completed by the residents physician, Casimiro et al. [17]
concluded there was no difference in appetite ( p = 0.306), oral
intake ( p = 0.349) or resident satisfaction with the diet; with
69% of those on a therapeutic diet (n = 236) versus 82% on
liberalized diet (n = 75), always being satisfied with their meals
( p = 0.103) and almost always eating all of their meals
( p = 0.306).
3.3. Effects of a therapeutic diet on comorbidity risk
factors
Two of the studies [11,16] made comment on lipid profiles
related to residents diet, specifically total cholesterol and
triglycerides. Bouillet et al. [16] provided baseline mean values
only (mmol/L) all within the normal range (<4 mmol/L Total
cholesterol, <1.5 mmol/L Triglycerides [23]) for both thera-
peutic and liberalized diet cohorts. Coulston et al. [11] is the
only study to compare baseline with post intervention data but
also reports non-significant results. However, on closer
examination of the two data collection sites, in one of the
cohorts again (n = 8) a modest rise in mean triglycerides
(mmol/L) of 0.3  0.1 and cholesterol (mmol/L) 0.2  0.1 was
observed whilst residents received a liberalized diet.
Aside from comorbidity risk, Cooper et al. [18] conducted
data collection from medical records to review the difference
in outcomes for residents with and without diabetes residing
in an aged care home. Residents with diabetes were defined by
their treatment as either, no treatment/diet prescription
(n = 2), diet alone (n = 9), diet and insulin (n = 25) or diet and
oral hypoglycaemic agent (OHA) (n = 5). Comparison of
incidence of complications for those residents managed with
a therapeutic diet (n = 9) and those with no treatment (n = 2) is
not statistically viable but overall residents with diabetes,
regardless of treatment, were more frequently hospitalized
and those residents managed with diet and insulin (n = 25) had
higher incidence of both hyper and hypoglycaemia, amputa-
tion and congestive heart failure.
4. Discussion
This review found a majority consensus in favour of a
liberalized diet for diabetes management which the literature
proposes to improve nutritional status while not impacting on
glycaemic management in residents of aged care homes.
Overall, all but one [17] of the six studies included in this
review are in support of a liberalized dietary approach, but on
inspection of the literature, data is limited, the overall quality
is poor and relevancy to practice out-dated.
Four [2,11,16,19] of the five studies commenting on
glycaemic control found that there was no significant change
overall in HbA1c or fasting blood glucose levels when
comparing a liberalized diet to a therapeutic diet. However

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 diabetes research and clinical practice 108 (2015) 7–14
in the three controlled trials [2,11,19] there were significant
limitations with study design, specifically, efforts to reduce
bias, small sample size (n = <18), short duration of the studies
(<12 weeks) and recruitment of healthy cohorts (BMI >18 kg/
m2) with already optimal diabetes management (<8%,
64 mmol/mol HbA1c) which is unlikely to accurately represent
the clinical diversity seen in aged care residents with diabetes
and not addressed in the literature. Similarly the cross
sectional study by Bouillet et al. [16] scored poorly for study
validity and although the sample size was larger (n = 100), the
cohort was recruited across seven different aged care
facilities, each of which offered different therapeutic and
liberalized menus despite direct comparison for outcomes.
Only one of the five studies [11] supporting a liberalized diet,
controlled for diabetes medication dosage throughout the
study whereas others note that medication had to be
increased [2,19] during the liberalized diet intervention or
was too heavily prescribed overall [16] which may have
influenced glycaemic outcomes throughout.
Additionally these studies [2,11,16,19] concluded therapeu-
tic diets were restrictive in nature and increased risk of
malnutrition and affected quality of life for institutionalized
older adults. It may be difficult to extrapolate findings to
current practice as the therapeutic diets described in all six
[2,11,16–19] of the studies were typically restrictive of sucrose
containing foods and calorie restricted which is unlikely to be
representative of a therapeutic diet for diabetes currently, if
provided at all. At present, dietary guidelines for management
of diabetes in adults typically promote consistent carbohy-
drate intake at mealtimes, a low GI influence, with preference
to wholegrain foods, fruit and vegetables and normalized
sugar recommendations in the form of allowed discretionary
foods [24,25] and no longer reflect the ADA diet [8]. It is likely
that a current day analysis of an institutionalized therapeutic
diet would appear different to those described in the studies
and therefore risk of malnutrition associated with a restrictive
diet may not be a relevant assumption [21]. However only one
study measured change in BMI [2] with no negative outcomes
and in the others [11,16,19], contrary to the authors’ assump-
tions’, BMI or weight measures were within healthy param-
eters for residents already receiving a therapeutic diet as
standard care and therefore suggests that neither a therapeu-
tic or liberalized diet negatively impact on nutritional status.
In relation to quality of life assumptions which in the
reviewed studies was solely attributed to satisfaction with diet;
only one [17] discussed outcomes for patient satisfaction.
Casimiro et al. [17] was in favour of a therapeutic diet for
diabetes management (n = 394) based on an observed positive
effect on glycaemia and qualitative findings that there was no
difference in resident dietary preference or intake when
compared to residents provided a liberalized diet (n = 92). The
author also comments that on reviewing modifiable risk factors
for diabetes management and its comorbidities, it is known that
weight loss is often not advisable for this potentially frail
population group and can even increase morbidity; physical
activity is more difficult and unlikely to be of an intensity which
would benefit glycaemia and therefore the administration of a
therapeutic diet might actually counteract a lack of exercise and
benefit overall metabolic control. Unfortunately the study is not
without its own limitations in study design such as lack of
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13
randomization, no reporting of reference ranges used for
comparison and differences in dietary provision over multiple
data collection sites with a skewed sample size in favour of a
therapeutic diet. In addition data on appetite and satisfaction
with meals was reported by residents’ physicians and are
therefore at high risk of bias.
The remaining study [18] included in this review, had
inadequate data from which to draw any conclusions, as
outcomes were not discussed in relation to the effects of
dietary management of diabetes. Instead their findings
support those in the wider literature [3] of the higher incidence
of hospitalization and complications for aged care residents
with diabetes, primarily related to hypo- and hyper-glycaemia
and the need for optimal glycaemic management in this
population group.
Overall comparison between studies was challenging as
study outcomes were often not directly comparable and only
three of the studies were controlled trials in design providing
data for pre and post interventions implementing a liberalized
diet; but even within these studies data was incomplete for
primary outcomes. However, the authors are confident that
this review contains the most relevant literature on this topic,
sourced from an extensive database search without narrowing
key word terms so as not to limit findings. The inclusion
criteria were limited only so far as to ensure the studies were
relevant to the research question and were extended to also
include papers not in English. In conclusion, the consensus
findings driving a change in food service, do not address the
complex nutritional needs of this heterogeneous group of
which <25% may be frail [5] and at risk of weight loss and
malnutrition, but the remaining <75% older adults with
diabetes may be better suited to a less relaxed approach
which promotes optimal glycaemia. The evidence base on
which change in practice is currently occurring is lacking and
inconsistent in delivery across institutions. Guidelines rec-
ommend individualized eating plans for residents but in
reality the structure of the menu need to be first standardized
from which to accommodate preferences in addition to
meeting the needs of well-nourished and frail residents.
Ideally further research in optimal dietary management of
diabetes and menu design for the aged care facility resident
would be beneficial within a more rigorous study design. Such
evidence could provide a stronger base for future revisions of
diabetes food service management guidelines until then it
may be prudent to examine residents’ diabetes and nutritional
status before implementing menu changes based on the
literature available.
Conflict of interest statement
The authors declare that they have no conflict of interest.
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