The Proposed Updates to the NICE Type 2 Diabetes Management Guidelines Do Not Address the Issues with their Dietary Advice
Dr Sean Wheatley, MSc, PhD; Science and Research Lead at X-PERT Health
Sean.Wheatley@xperthealth.org.uk
Background – Part 1: The Campaign
Earlier this year, we (X-PERT Health, the British Dietetic Association, and the Public Health Collaboration) wrote to the National Institute of Health and Care Excellence (NICE) imploring them to update their dietary advice for people with type 2 diabetes.
The letter we sent can be accessed here, and the key points were summarised in this blog post. Briefly though, the key factors we felt needed updating were that:
– Remission of type 2 diabetes should be promoted as a realistic goal.
– A range of dietary approaches should be supported.
– There should be a focus on helping patients to make informed choices that fit their own needs and preferences.
Background – Part 2: The Response
Encouragingly, we received a positive response from NICE. They not only acknowledged our concerns, but they also confirmed that they would be making some changes to the relevant guidelines to address them.
Their response was also outlined in one of our previous blogs, within which we described this news as “fantastic”, but with the caveat that “we will have to wait and see exactly what the updated recommendations look like”.
The Big Day, the Big Disappointment
On the 20th August 2025, NICE published the draft version of the updated guidelines. Based on their response to our letter, it was within this update that we were hoping to see some meaningful changes that addressed our concerns.
Disappointingly though, the amendments to the relevant sections of these guidelines were very limited. The existing dietary advice was retained, and the recommendations that were added or updated did little to address our concerns.
A Little Context…
Before proceeding, it is worth noting that this update was intended to focus on medicines. As such, a review of the lifestyle-related elements was outside of its original scope. This provides some justification for the lack of changes to the dietary advice section.
However, it is important to reiterate that NICE intimated in their response to our letter that revisions would be made to address our concerns as part of this update. It was not therefore unreasonable for us to expect some meaningful changes!
New Recommendations
Ignoring the sections related to the use of medicines (which, albeit important, are beyond our focus here), the most relevant new and/or updated recommendations were as follows:
1.4. For discussions about overweight and obesity, see the NICE guideline on overweight and obesity management.
3.4. For recommendations on low-energy and very-low-energy diets for the management of type 2 diabetes, see: the NICE guideline on overweight and obesity management, (and) the NHS Type 2 diabetes Path to Remission Programme
3.11 For recommendations on wellbeing advice, see the NICE guidelines on overweight and obesity management, physical activity and tobacco.
The Good
The only real positive, in the context of our initial campaign, is that they refer to the NICE guideline on overweight and obesity management (NG246).
The reason this is a positive is that the dietary recommendations in NG246 support the use of a range of dietary approaches (see recommendation 1.16.3) and promote the use of individualised, flexible approaches that fit the needs and preferences of the individual (see recommendation 1.16.1). They are therefore better aligned with the available evidence and the recommendations of other relevant national and international organisations. They are also (in our opinion) more likely to help people make lifestyle changes that they are able to stick to and that help them to meet their health-related goals.
The Bad
The first disappointment is the failure of any of the amendments to explicitly promote remission as a suitable goal for many people with type 2 diabetes.
Although an allusion to the NHS Type 2 diabetes Path to Remission Programme was added, this is inadequate on its own. For many patients, the very fact that remission may be possible is a significant source of hope, optimism and motivation. The failure to clearly reflect this within NICE guidance is a missed opportunity.
The Ugly
The main negative though is that the dietary advice in the draft guideline still overtly recommends a single, specific dietary approach, rather than supporting a range of options. As noted before, this advice is outdated, lacks flexibility, doesn’t support patient choice, doesn’t account for individual needs and preferences, and is contradictory to the guidelines of most other relevant national and international organisations.
Beyond this, by retaining the existing dietary advice, but referring to another NICE guideline that has different dietary advice (i.e., NG246), this update risks increasing confusion amongst healthcare professionals and people with diabetes. That many people with type 2 diabetes will also want to try to lose some weight makes this conflict particularly problematic. Indeed, losing weight will be the primary goal for many of them. For these people, which NICE guidance should they be following *?
The failure to bring the dietary advice in the type 2 diabetes management guidelines in line with other contemporary guidelines (including other NICE guidelines) is another missed opportunity.
What we would have liked to happen
Ultimately, we (X-PERT Health) would have been satisfied if the relevant recommendations from the NICE overweight and obesity management guidelines (NG246) had have been used as direct replacements for the corresponding recommendations in the type 2 diabetes management guidelines (NG28) **.
For example, replacing recommendation 1.3.3 in NG28 (“Encourage adults with type 2 diabetes to follow the same healthy eating advice as the general population…”) with recommendation 1.16.1 from NG246 (“Use a flexible and individualised approach to tailor dietary interventions …”) would go a long way to addressing some of the existing issues!
As the evidence review used in the development of the NICE overweight and obesity management guidelines included studies in people with type 2 diabetes, and was carried out much more recently than the last review of evidence to inform possible updates to the dietary advice in the NICE type 2 diabetes management guidelines ***, we feel this would have been entirely justified without the need for a separate review of evidence.
Beyond this, the addition of recommendations making it clear that remission is a suitable treatment target for many people with type 2 diabetes, alongside guidance on how to support people to achieve this, is desired.
Next Steps – Part 1: The Consultation Period
All NICE draft guidelines have a consultation period, during which stakeholders can comment on any proposed changes.
During these consultations, comments on anything outside of the original scope are usually disregarded, and the original scope of this update was to focus solely on medicines. You can however comment on any new or amended recommendations, even where they are outside of the initial scope. As such, the changes that were made to some of the recommendations within the dietary advice section (like those outlined previously) provide a valid avenue through which we can (and will) register our ongoing concerns as part of this consultation.
It is, unfortunately, probably unlikely that any comments made as part of this consultation will have a significant impact on what the guidelines look like once this update is finalised. It is important to keep these items on the agenda though, and doing so may help with what happens afterwards…
Next Steps – Part 2: After the Consultation
Although any further delays to addressing the issues with the existing guidelines is frustrating, there is some cause for optimism.
When we submitted our letter, we also submitted an online form to the NICE surveillance team that outlined our concerns. The response to this form was also, superficially at least, positive, as it confirmed that a surveillance review of the relevant evidence would be being carried out, with a view to considering whether further updates were required.
As well as reviewing the evidence we had highlighted in our previous submissions, this review will also consider relevant comments made as part of the ongoing consultation (hence the suggestion above that reiterating our concerns during this consultation may help further down the line).
The timeline for this review is unclear (their response simply stated that they will be “…concluding the surveillance review of dietary interventions after the consultation on the update to NG28 has completed”), but the fact a review is being carried out at all suggests that the door is not closed on the updates we believe are necessary.
So, what’s the bottom line?
After NICE’s positive response to our open letter asking them to review their dietary advice for people with type 2 diabetes, we were hopeful that meaningful changes were on the horizon. The draft guidance failed to deliver these though, and may even increase confusion amongst healthcare professionals and members of the public.
There is cause for hope though, with, for example, a surveillance review of the available evidence due to be completed after the current consultation period ends. Whatever happens next, we will continue to encourage NICE to update their recommendations in order to support improved care for people with type 2 diabetes.
* Although I have somewhat facetiously presented this as a conflict, until the dietary advice in the NICE type 2 diabetes management guidelines is updated the choice is actually clear. In people with type 2 diabetes who also have overweight or obesity, the logical option is to prioritise weight loss, and to use the more up-to-date (and flexible) NICE overweight and obesity management guidelines as the basis from which to try and achieve this.
** With some minor adjustments to the wording in some cases, e.g., to remove the reference to type 1 diabetes that is part of recommendation 1.16.1 in NG246.
*** Shockingly, it is almost 20 years since the last time NICE carried out an evidence review for the specific purpose of considering possible updates to the dietary advice section of NG28.
