Medical Nutrition Therapy for Diabetes

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Medical Nutrition Therapy

for Diabetes

Marion J. Franz, MS, RD, CDE

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• Objectives:

– Discuss expected outcomes and when to

evaluate effectiveness of MNT

– Review macronutrient questions

– Select effective nutrition therapy

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Is Diabetes Nutrition Therapy Effective?

• Pre-diabetes outcomes

– MNT along with physical activity

↓ risk of type

2 diabetes by 58%; maintained up to 14 yrs

• Diabetes MNT goals and outcomes

– MNT provided by RD: ave.

↓ in A1C 1% to 2%

(ranging from 0.5 to 2.6%) depending on type,

duration, and level of control of db

– LDL-C

↓ by 15-25 mg/dl or by up to 16%

– SBP and DBP

↓ on average by ~5 mmHg

– Outcomes known by 6 weeks to 3 months

AmDbAssoc. Diabetes Care 2012:35(suppl 1):S11; Franz et al. J Am Diet Assoc 2008;108:S52; Van Horn et al. J Am Diet Assoc 2008;108:287; Appel et al. JAMA 2004; 289:2083

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United Kingdom Prospective Diabetes Study:

A1C (pts newly diagnosed)

6 7 8 9 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 YEARS GL Y C OH E M OGLOB IN ( H bA 1 c , % ) INTENSIVE GROUP CONVENTIONAL GROUP

UKPDST. Lancet 1998; 352: 837-853

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Lessons from the UKPDS

• “Interestingly, the greatest HbA1c reduction was

the fall of >2% during the first 3 months with

intensive diet and 5% weight loss.”

• Initial glucose response more related to

decreased energy intake than to weight loss;

decrease in body weight was a secondary

response

• “The real problem is the progressive decrease in

beta cell function…we are now duty-bound to

explain this to our patients at the onset…and not

to castigate them because they failed to diet.”

R. Holman, Oxford UK. Diabetes Care. 2000;23:1016

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Early ACTID (Early Activity in Diabetes)

• Newly diagnosed type 2 db (n=593) in

England, usual care vs intensive nutrition

intervention or latter with physical activity

program

– Baseline A1C: 6.7%, 6.6%, 6.7%

– 6 mo maintained to 12 mo: no improvement in

usual care, intervention groups A1C -0.3%

(p<0.001), even with use of fewer diabetes

drugs

– Addition of physical activity: no added benefit

Andrews et al. Lancet 378:129, 2011

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Effectiveness of medical nutrition therapy provided

by dietitians in the management of type 2 diabetes: a

randomized, controlled clinical trial

6.6 6.8 7.0 7.2 7.4 7.6 7.8 8.0 8.2 8.4

Initial 6 Week 3 Month 6 Month

No Educ. 1 RD visit 3 RD visits

Franz et al. J Am Diet Assoc. 1995;95:1015

A1C ↓ 0.9% 4-yr duration of diabetes

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Lifestyle Over and Above Drugs in Diabetes

(LOADD) Study

• RCT in 93 pts type 2 db hyperglycemic (A1C>7%)

despite optimized drug therapy

• Intensive MNT according to international nutrition

management guidelines vs control

– Ave duration of db: ~9 yrs

– Intensive MNT—6 sessions with dietitian

– A1C ↓ 0.4% vs control (P=0.007); comparable to

adding new drug to conventional agents; cost-effective

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What Nutrition Therapy Interventions Are Effective?

• A variety of nutrition therapy interventions, such

as reduced energy/fat intake, carbohydrate

counting, simplified meal plans, healthy food

choices, individualized meal planning

strategies, exchange lists,

insulin-to-carbohydrate ratios, physical activity, and

behavioral strategies

– Type 2 db: reduced energy intake

– Type 1 db: matching insulin to CHO intake

• A number of initial individual or group sessions

and follow-up encounters were implemented

Acad Nutr Diet. www.adaevidencelibrary.com/topic.cfm?=3252

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100 200 150 300 250 350

-10 -5 0 5 10 15 20 25 30 0 100 200 50 150 *Postprandial glucose Fasting glucose Insulin resistance Insulin level Years At risk for

diabetes β-cell dysfunction

250 Glucose (mg/dL) % Relative to Normal

Type 2 Diabetes: A Progressive Disease

* Post Prandial = 1-2 h ppg

Bergenstal RM et al. Management of Type 2 Diabetes in Endocrinology. 4th Edition; Philadelphia, 2001

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Type 2 Diabetes: A Progressive Disease

Lifestyle Interventions Medical Nutrition Therapy Alone or with Medications

Medical Nutrition Therapy Medications

Insulin

Lifestyle

Meds

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Carbohydrate And Diabetes

• Most widely held assumption: sugars because they are small molecule are absorbed into the blood stream

more rapidly than starches

• Over 20 studies: when a variety of starches and sugars are selected, the glycemic response is identical, if total amount of carbohydrate is kept constant

• Sucrose does not increase glycemia more than

isocaloric amounts of starch and does not need to be restricted because of concern about aggravating

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Sucrose In The Diet Of Persons With Diabetes:

Just Another Carbohydrate?

• 12 type 1; 11 type 2; 6 weeks

• 54% CHO, similar in both diets; all starch or 45 g starch replaced with 45 g of sucrose (18% of calories)

• No differences: day-long glucose levels, HbA1c, lipids in type 1 and type 2 diabetes; insulin profiles in type 2

Peterson DB et al. Diabetologia 1986;29:216

Mean Plasma Glucose* (mmol/L)

Sucrose diet, type 2 Starch diet, type 2

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• Diet books define GI as measure of

how rapidly a food raises blood glucose after eating

• Claims made by diet books:

– “Foods that are broken down and

absorbed into the blood stream quickly require a lot of insulin…

– High levels of insulin cause blood

glucose to drop so low that it triggers new cravings for food.”

• No evidence given for these claims

• This is NOT the correct definition of the

GI

Agatston A. The South Beach Diet, 2005

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80 90 100 110 120 130 140 150 160 170 0 15 30 45 60 75 90 120

Bread Med GI Glucose

Bread Low GI Bread High GI

Time (min) G lu c o s e m g /d L )

Glycemic Index: The GI Does Not Measure How

Rapidly BG Increases!

The GI is the relative area under the postprandial glucose curve (AUC) comparing 50 g of digestible carbohydrate from a test food to 50 g of carbohydrate of glucose

Brand-Miller et al. Am J Clin Nutr 2009;89:97

80 90 100 110 120 130 140 150 160 170 0 15 30 45 60 75 90 105 120

Glucose Fruit Juice Fruit

“No statistical difference in the glucose response curve from different foods…Low GI foods do not produce a slower rise in BG nor do they produce an extended, sustained glucose response.”

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Low GI Meals vs High GI Meals: The Glucose and

Insulin Responses Are Parallel to Usual Responses

• Usual diet GI: 53; low GI: modest improvements in FPG, HbA1c; insulin secretion and sensitivity and body weight unchanged

• Plasma glucose (A) and insulin (B) before and after 4-wk

dietary periods: HGI (Δ,▲) and LGI (○, ●)

Rizkalla et al. Diabetes Care 27:1866, 2004

Low GI, baseline Low GI, 4 wks

High GI, baseline High GI, 4 wks

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Problems with the Glycemic Index

• Based on 50 g CHO portions not actual amounts

of CHO in a typical serving; combining foods in a

meal changes the GI

• Considerable variability exists

– 50 g CHO from bread

– n=23: GI 78± 73 (CV 94%); second test; n=14: GI 78 ± 39 (CV 50%)

– Range of GI: 44-132

• No

t be the best indicator of healthy food choices;

soft drinks, candies, sugars and high fat foods

have low to moderate GIs; GI

↓ by adding or

substituting sugars, especially fructose or sugar

alcohols, and fat

Vega-Lopez. Diabetes Care 30:1412, 2007, Pi-Sunyer. Am J Clin Nutr 87:3, 2008 Franz. Diabetes Care 26:2466, 2003

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•85+33 •Cornflakes •47+27 •Spaghetti •52 •Banana •58 •Coke •58 •Oatmeal •71+38 •Rice, long grain

•78 •Sports drink

•32 •Milk, skim

•37

•Premium ice cream

•38 •Apple •28 •Kidney beans •99 •Glucose •55 •Snickers Bar •73+36 •Bread, white •GI •Food Am J Cl Nutr 2002;76:5

Glycemic Index

(GI)

A difficulty of use is its variability Australian potatoes: 87-101 Canadian potatoes: 59-70 US potatoes: 56-77 Boiled rice: 45-112 Bananas: 30-70 Spaghetti: 45-65 All-Bran Australia: 30 All-Bran Canada: 51

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Two 1-Year RCT of Low GI Diets: No

Differences in A1C

• Canadian Trial of Carbohydrates in Diabetes

– 162 subjects with type 2 db randomized to

high-CHO/high GI; high-GI/low GI; low-high-CHO/high MUFA

– No significant differences in A1C, lipids or body weight; low GI small drop within the normal range for CRP

• Low GI vs ADA dietary education

– 40 subjects with type 2 db randomized to low-GI or ADA diet

– Similar reductions in A1C at 6 and 12 mo – No association between GI and CRP

Wolever et al. Am J Clin Nutr. 2008;87:114; Ma et al. Nutrition. 2008;24:45

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GI Summary

• American Diabetes Association:

– In general, there is little difference in glycemic control and CVD risk factors between low GI and high GI or other diets. Slight improvement in glycemia from lower GI diets confounded by higher fiber intake.

– Monitoring total grams of carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control

– Deleted statement that use of the GI may provide a

modest additional benefit over that observed when total CHO is considered alone

Wheeler et al. Diabetes Care 2012;35:434; American Diabetes Association. Diabetes Care. 2012;35(Suppl 1):S13

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GI Summary

• Academy of Nutrition and Dietetics:

– GI complicated by differing definitions of “high GI” or “low GI” diets or quartiles

– Conflicting evidence on effectiveness; studies

comparing high vs low GI diets report mixed effects on A1C

– A low glycemic index diet is not recommended for weight loss or weight maintenance as part of a

comprehensive weight management program; it has not been shown to be effective in these areas.

AmDbAssoc. Diabetes Care. 2009;32(Suppl 1):S23

AmDietAssoc. www.adaevidencelibrary.com/topic.cfm?format_tables=0&cat=3252

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Carbohydrate: What’s Important?

• Foods containing carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk are important

sources of vitamins and minerals and provide glucose for the brain

• “Several different macronutrient distributions may lead to improvement in glycemic and/or CVD risk factors…”; total energy more important than CHO amount

• As carbohydrate decreases, total and saturated fats increase

• Monitoring total intake of carbohydrate is key strategy for achieving glycemic control

• Negotiate with patients; advise healthful nutrient-dense carbohydrate choices in appropriate amounts and portion sizes

ADA. Diabetes Care 2008;31(suppl 1):S61; Wheeler et al. Diabetes Care 35:434-445, 2012; AmDietAssoc. www.adaevidencelibrary.com/topic.cfm?=3252

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• In animal and observational studies, higher intakes of total dietary fat, regardless of the fat type, produce greater

insulin resistance

• In clinical trials saturated and trans fats shown to cause insulin resistance, whereas mono- and polyunsaturated and omega-3 fatty acids do not have an adverse effect • High fat meals interfere with indexes of insulin signaling

which results in a transient increase in insulin resistance

Louheranta, 2000; Riccardi, 2000; Denkins, 2002; Lovejoy, 2002; Trichopoulou, 2005

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Protein and Diabetes

• In persons with type 2 diabetes, ingested protein can increase insulin response without increasing plasma glucose concentrations

– Therefore, protein should not be used to treat acute or to prevent nighttime hypoglycemia

• In persons with normal renal function, usual protein intake (15-20%) does not need to be changed

– Although protein has an acute effect on insulin

secretion, usual protein intake in longer term studies has minimal effects on glucose, lipids, and insulin

American Diabetes Association, Diabetes Care 35(suppl 1): S11, 2012; Acad Nutr Diet. J Am Diet Assoc 110;1852, 2010

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Glucose and Insulin Response to 50 g Glucose,

50 g Protein, or Combination in Type 2 Diabetes

• Glucose response stable with protein alone

• Glucose peak response the same when protein given with glucose

• Insulin response double when protein combined with glucose

Nuttall et al. Diabetes Care 7:465, 1984

50 g protein 50 g glucose

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Glucose Appearance and Insulin Response to 50 g Protein or Water in Type 2 Diabetes

• 50 g protein (very lean beef) or water at 8 am and followed for 8 hrs

• Protein deaminated, ~20-23 g (changed into glucose in the liver)

• Amount of glucose appearing in circulation, >2 g • Protein ingestion increased insulin levels