diet trends and diabetes: the state of the evidence · 2019. 11. 12. · diagnosed and undiagnosed...
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Diet Trends and Diabetes:
The State of the Evidence
Carmen Ramos, MS, RDN, CD
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THE WELLNESS BUS
Free Screenings
– Full lipid panel
– Blood glucose/A1C
– Blood pressure
– BMI
– Waist circumference
Free Nutrition Counseling
Other services:
Free dental exams
Food demonstrations
Free community and food resources
Vision: Equal access to
diabetes prevention for
a diabetes-free future.
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CONFLICT OF INTEREST
I have no actual or potential conflict of
interest in relation to this presentation.
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PRESENTATION OBJECTIVES
At the conclusion of this presentation,
participants will be able to:
• Describe historical dietary recommendations for
diabetes
• Describe the use and evidence of the ketogenic,
paleo, and intermittent fasting diets for diabetes
• Explain the importance of Hispanic food ways for
diabetes management
• Compare current diabetes dietary
recommendations with current food trends
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INCREASING PREVALENCE OF DIABETES OVER TIME
2015
Improvements in therapies and medical management over time are factored in
7-8% 11-12% 19-20%13-14% 17-18%
Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics
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INCREASING PREVALENCE OF DIABETES OVER TIMEImprovements in therapies and medical management over time are factored in
7-8% 11-12% 19-20%13-14% 17-18%
Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics
2020
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INCREASING PREVALENCE OF DIABETES OVER TIMEImprovements in therapies and medical management over time are factored in
7-8% 11-12% 19-20%13-14% 17-18%
Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics
2025
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INCREASING PREVALENCE OF DIABETES OVER TIMEImprovements in therapies and medical management over time are factored in
7-8% 11-12% 19-20%13-14% 17-18%
Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics
2030
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INCREASING ANNUAL COST OF DIABETES
<1 5-9 50-7010-14 30-49
Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* 1-4 20-29
*Constant 2015 Dollars
15-19
Total US $408 B
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; Dall, The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes, Diabetes Care 2014;37:3172-3179; CDC diabetes trends, US Census Bureau
2015
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INCREASING ANNUAL COST OF DIABETES
<1 5-9 50-7010-14 30-49
Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* 1-4 20-29
*Constant 2015 Dollars
15-19
Total US $491 B
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; Dall, The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes, Diabetes Care 2014;37:3172-3179; CDC diabetes trends, US Census Bureau
2020
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INCREASING ANNUAL COST OF DIABETES
<1 5-9 50-7010-14 30-49
Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* 1-4 20-29
*Constant 2015 Dollars
15-19
Total US $564 B
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; Dall, The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes, Diabetes Care 2014;37:3172-3179; CDC diabetes trends, US Census Bureau
2025
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INCREASING ANNUAL COST OF DIABETES
<1 5-9 50-7010-14 30-49
Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* 1-4 20-29
*Constant 2015 Dollars
15-19
Total US $622 B
Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; Dall, The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes, Diabetes Care 2014;37:3172-3179; CDC diabetes trends, US Census Bureau
2030
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
WHAT COULD WE DO WITH $622 BILLION?
• End world hunger for 21 years ($30 billion a
year)
• Provide universal healthcare for half of the
US population
• Provide 4 years of college tuition for 3
million students
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More than half of Hispanic/Latino American
adults are expected to develop type 2
diabetes in their lifetime. (CDC, 2019)
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
Historical Dietary
Recommendations for
Diabetes
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NUTRITION RECOMMENDATIONS UP TO 1900
h t t p : / / j o u r n a l . d i a b e t e s . o r g / d i a b e t e s s p e c t r u m / 0 0 v 1 3 n 3 / p g 1 1 6 . h t m
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7h t t p : / / j o u r n a l . d i a b e t e s . o r g / d i a b e t e s s p e c t r u m / 0 0 v 1 3 n 3 / p g 1 1 6 . h t m
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
Current Diabetes
Recommendations
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ADA STANDARDS OF MEDICAL CARE, 2019
EVIDENCE RATINGS
Level of Evidence Description
AClear evidence from well-conducted
randomized controlled trials
BSupportive evidence from well-
conducted cohort studies
CSupportive evidence from poorly
controlled or uncontrolled studies
E Expert consensus or clinical experience
Diabetes Care, 2019
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ADA STANDARDS OF MEDICAL CARE, NUTRITION
THERAPY 2019
Diabetes Care, 2019
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ADA STANDARDS OF MEDICAL CARE, NUTRITION
THERAPY 2019
Diabetes Care, 2019
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ADA STANDARDS OF MEDICAL CARE, NUTRITION
THERAPY 2019
Diabetes Care, 2019
“Research indicates that low-carbohydrate eating
plans may result in improved glycemia and have
the potential to reduce antihyperglycemic
medications for individuals with type 2 diabetes.”
“As research studies on some low-carbohydrate
eating plans generally indicate challenges with
long-term sustainability, it is important to reassess
and individualize meal plan guidance regularly for
those interested in this approach.”
“This meal plan is not recommended at this time for
women who are pregnant or lactating, people
with or at risk for disordered eating, or people who
have renal disease, and it should be used with
caution in patients taking sodium–glucose
cotransporter 2 (SGLT2) inhibitors due to the
potential risk of ketoacidosis.”
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ADA STANDARDS OF MEDICAL CARE,
NUTRITION THERAPY 2019
Low-carb eating plans
• Improved glycemia and lipid outcomes for up to 1
year
• Wide range of definitions for a low-carbohydrate
eating plan
• Most people with type 2 diabetes report carb
consumption 44-46% of kcals
“Efforts to modify habitual eating patterns are often
unsuccessful in the long term; people generally go
back to their usual macronutrient distribution.”
Diabetes Care, 2019
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ADA STANDARDS OF MEDICAL CARE, NUTRITION
THERAPY 2019
Diabetes Care, 2019
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
ADA STANDARDS OF MEDICAL CARE, NUTRITION
THERAPY 2019
Diabetes Care, 2019
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
ADA STANDARDS OF MEDICAL CARE, NUTRITION
THERAPY 2019
Diabetes Care, 2019
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
MACRONUTRIENT RECOMMENDATIONS
• No ideal percentage of calories from
carbohydrates, protein, & fat for all people
• Management should be individualized
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Historical
Dietary Trends
for Diabetes
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DIET TRENDS OVERVIEW
• Paleo diet
• Ketogenic diet
• Intermittent fasting
• Meal replacements
• Extreme liquid diets
• Alternative treatments
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DIABETIC COOKERY; RECIPES AND MENUSOPPENHEIMER, REBECCA 1917
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DIABETIC COOKERY; RECIPES
AND MENUSOPPENHEIMER, REBECCA
1917
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Paleo Diet
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PALEO DIET
• High protein, medium fat, low carbohydrate
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PALEO DIET AND DIABETES RESEARCH
• Small sample sizes (n<32)
• No long-term studies
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METABOLIC AND PHYSIOLOGIC EFFECTS FROM CONSUMING A
HUNTER-GATHERER (PALEOLITHIC)-TYPE DIET IN TYPE 2 DIABETES
• 24 participants
with Type 2
diabetes
• Two groups:
– Paleo diet
– ADA diet
European Journal of Clinical Nutrition (2015) 69, 944–948; doi:10.1038/ejcn.2015.39; published online 1
April 2015
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
METABOLIC AND PHYSIOLOGIC EFFECTS FROM CONSUMING A
HUNTER-GATHERER (PALEOLITHIC)-TYPE DIET IN TYPE 2 DIABETES
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A PALEOLITHIC DIET WITH AND WITHOUT COMBINED AEROBIC AND
RESISTANCE EXERCISE INCREASES FUNCTIONAL BRAIN RESPONSES AND
HIPPOCAMPAL VOLUME IN SUBJECTS WITH TYPE 2 DIABETES.
• 32 participants with Type 2
Diabetes
• Three groups:
– Control
– Paleo diet
– Paleo diet + exercise
• After 3 months:
– No difference between
intervention groups
– Increased functional brain
response
– Increased hippocampal volumeStomby A, Otten J, Ryberg M, Nyberg L, Olsson T and Boraxbekk C-J (2017) A Paleolithic Diet with and
without Combined Aerobic and Resistance Exercise Increases Functional Brain Responses and
Hippocampal Volume in Subjects with Type 2 Diabetes. Front. Aging Neurosci. 9:391. doi:
10.3389/fnagi.2017.00391
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Ketogenic
Diet
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KETOGENIC DIET
• High fat, medium protein, low
carbohydrate (< 50 grams, varies)
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AN ONLINE INTERVENTION COMPARING A VERY LOW-
CARBOHYDRATE KETOGENIC DIET AND LIFESTYLE
RECOMMENDATIONS VERSUS A PLATE METHOD DIET IN
OVERWEIGHT INDIVIDUALS WITH TYPE 2 DIABETES: A RANDOMIZED
CONTROLLED TRIAL
• Design: Randomized, controlled study
• Group 1: American Diabetes Associations’
“Create Your Plate” Diet (n=13)
• Group 2: Very Low-Carbohydrate Ketogenic Diet (VLKD) and Lifestyle
Recommendations (n=12)
• Duration: 6 months
Saslow LR, Journal of Medical Internet Research, 2017
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RESULTSSignificant ↓
• HbA1c
ADA: 16 weeks, -0.5%
32 weeks, -0.3%
VLKD:16 weeks, -0.9%
32 weeks, -0.8%
• Body weight
ADA: 16 weeks, -3.9 kg
32 weeks, -3.0 kg
VLKD: 16 weeks, -8.5 kg
32 weeks, -12.7 kg
• Triglycerides
ADA: 16 weeks, -17.4 mg/dL
32 weeks, -6.2 mg/dL*
VLKD: 16 weeks, -35.5 mg/dL
32 weeks, -60.1 mg/dLSaslow LR, Journal of Medical Internet Research, 2017
ADA vs VLKD
• No significant diff in
calories
• VLKD significantly less
carbohydrates and
sugar
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Intermittent
Fasting
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INTERMITTENT FASTING
• Feeding window of 1 to 8 hours
• Fasting window of 16 to 23 hours
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EFFECTS OF INTERMITTENT FASTING ON HEALTH MARKERS
IN THOSE WITH TYPE 2 DIABETES: A PILOT STUDY
• n=10
Arnason TG, Bowen MW, Mansell KD. Effects of intermittent fasting on health markers in those with
type 2 diabetes: A pilot study. World J Diabetes 2017; 8(4): 154-164 Available from: URL:
http://www.wjgnet.com/1948-9358/full/v8/i4/154.htm DOI: http://dx.doi.org/10.4239/wjd.v8.i4.154
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Arnason TG, Bowen MW, Mansell KD. Effects of intermittent fasting on health markers in those with
type 2 diabetes: A pilot study. World J Diabetes 2017; 8(4): 154-164 Available from: URL:
http://www.wjgnet.com/1948-9358/full/v8/i4/154.htm DOI: http://dx.doi.org/10.4239/wjd.v8.i4.154
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FASTING WITH DIABETES: A PROSPECTIVE
OBSERVATIONAL STUDY
• 150 participants with
type 2 diabetes
– Observing the fast of
Ramadan (11-20 hour
fast)
• Results: 1 in 10
participants experienced
hypoglycemia at least
once
Noon MJ, et al. BMJ Glob Health, 2016.
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Cultural Food Ways
and Diabetes
Management
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SOCIOCULTURAL CONSTRUCTION OF FOOD WAYS
IN LOW-INCOME MEXICAN-AMERICAN WOMEN
WITH DIABETES: A QUALITATIVE STUDY
Who:
12 low-income Hispanic
women with at least 10
years of having T2DM
Residents of Starr
County, TX
What has worked?
• Portion control
• The “fork” method
• Fluid food
categorizations
• Confidence and in-
tune with body cues
• Family involvement
Benavides-Vaello, S, 2016
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Benavides-Vaello, S, 2016
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Benavides-Vaello, S, 2016
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Benavides-Vaello, S, 2016
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SOCIOCULTURAL CONSTRUCTION OF FOOD WAYS
IN LOW-INCOME MEXICAN-AMERICAN WOMEN
WITH DIABETES: A QUALITATIVE STUDY
Benavides-Vaello, S, 2016
“Those with expertise make
changes in how they eat to
care for their diabetes, but
also continue to maintain
traditional food ways.”
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“CAN YOU KEEP IT REAL?” : PRACTICAL, AND CULTURALLY
TAILORED LIFESTYLE RECOMMENDATIONS BY MEXICAN AMERICAN
WOMEN DIAGNOSED WITH TYPE 2 DIABETES: A QUALITATIVE STUDY
Benavides-Vaello, S, 2017
Category Strategies
Environmental
Controls
• Make your own burgers and tacos
• Cook more at home
• Go to the grocery store alone
• Avoid aisles in the grocery store that have the
food items on sale that are bad for you
• Remove temptation from your home
• Not making tortillas helps because when you
buy, once the package is gone, they are gone
Table 1. Strategies Developed in Managing their Diabetes
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7Benavides-Vaello, S, 2017
Category Strategies
Avoid
Overeating/
Stress Eating
• Don’t let yourself get hungry
• Limit in between snacking
• Keep active, walk
• When you feel stressed or want to eat go for a
walk
• Drink more water
• Satisfy the craving from the beginning so that you
don’t keep eating foods you don’t really want
Cooking Tips
• Don’t drink regular coke-try lemonade with
Splenda or water
• Learn how to use the steamer, broiler, and oven
• Stick with natural foods
Table 1. Strategies Developed in Managing their Diabetes
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7Benavides-Vaello, S, 2017
Category Strategies
Lifestyle
Changes
• You can eat anything you want-even menudo-
just limit the amount
• Get into a routine
• The progress takes time, don’t do everything at
once, just step by step
• Make separate meals or smaller portions of the
foods you love
• Eat whole wheat flour tortillas
• Get away from processed foods
• Tortillas-flour, limit to once a week
• Eat earlier in the evening
Table 1. Strategies Developed in Managing their Diabetes
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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7Benavides-Vaello, S, 2017
Category Strategies
Family
• Put them (kids) first
• (Think) Your family is going to be healthier
• They may not like it at first, just keep trying, think of
what will happen to you
• Set the table and serve the food, no choices
• Put 2% or 1% milk in the whole milk container,
keep the same label, family thinks they are
drinking whole milk
Active Self-
Management
• Ask (health care providers and other staff) what
exactly you should eat to take care of your
diabetes
• See her doctor to make sure she is on the right
medicines
• See your dietitian
• Take medicines religiously
Table 1. Strategies Developed in Managing their Diabetes
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More…
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MEAL REPLACEMENTS
• Keogh J and Clifton PM: positive results
– A1C
– Weight loss
– HDL
– Blood Pressure
Considerations
• Sustainability
• Additives
Keogh J, Clifton PM. J Nutr Metabolism, 2012.
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ALTERNATIVE TREATMENTS
Herbs and Supplements
• Aloe Vera
• Alpha-Lipoic Acid
• Chromium
• Cinnamon
• Garlic
• Ginseng
Relaxation Techniques
• Aromatherapy
• Meditation
• Acupuncture
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ADA STANDARDS OF MEDICAL CARE, NUTRITION
THERAPY 2019
Diabetes Care, 2019
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OTHER EMERGING TRENDS
• Artificial sweeteners
• Fiber
– Fruit, vegetables, whole grains
– Legumes (lentils)
• Fish
• Eggs
• Low-fat dairy
• Social drinking
• Multifaceted interventions/regular contact/ digital
coaching
• Fast-paced walking
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OTHER EMERGING TRENDS
• Coffee
• Regular/excessive alcohol
• Full-fat dairy
• Mindful eating
• Lifestyle advice alone
• Food insecurity
• Stress
• Slow walking (compared to fast paced walking)
• Free food at work/ office vending machines
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ONE OF THE BIGGEST DIFFERENCES BETWEEN
RECOMMENDATIONS AND TRENDS?
Food trends tend to not individualized
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QUESTIONS?
Carmen Ramos, MS, RDN
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REFERENCES
ADA. Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42:S46-S60.
Arnason TG, Bowen MW, Mansell KD. Effects of intermittent fasting on health markers
in those with type 2 diabetes: A pilot study. World J Diabetes 2017;8(4):154-164.
Benavides-Vaello S, Brown SA. Sociocultural construction of food ways in low-income Mexican-American women with diabetes: a qualitative study. Journal of Clinical
Nursing 2016;25,2367–2377.
Benavides-Vaello S, Brown SA, Vandermause R. “Can you keep it real?”: Practical,
and culturally tailored lifestyle recommendations by Mexican American women
diagnosed with type 2 diabetes: A qualitative study. BMC Nursing 2017;16:36.
CDC. National Diabetes Statistics Report, 2014; Dall, The Economic Burden of
Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes,
Gestational Diabetes Mellitus, and Prediabetes. Diabetes Care 2014;37:3172-3179.
CDC. Hispanic/Latino Americans and Type 2 Diabetes.
https://www.cdc.gov/diabetes/library/features/hispanic-diabetes.html; 2019.
Keogh KB, Clifton PM. Meal Replacements for Weight Loss in Type 2 Diabetes in a
Community Setting. J Nutr Metab 2012; 918571.
Masharani, U et al. Metabolic and physiologic effects from consuming a hunter-
gatherer (Paleolithic)-type diet in type 2 diabetes. European Journal of Clinical
Nutrition 2015;69:944–948.
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REFERENCES
Noon MJ, et al. Fasting with Diabetes: A Prospective Observational Study. BMJ Glob
Health 2016;1:2.
Oppenheimer, R. Diabetic Cookery, Recipes and Menus. 1917.
Saslow LR, Mason AE, Kim S, Goldman V, Ploutz-Snyder R, Bayandorian H, Daubenmier J, Hecht FM, Moskowitz JT. An Online Intervention Comparing a Very
Low-Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate
Method Diet in Overweight Individuals With Type 2 Diabetes: A Randomized
Controlled Trial. J Med Internet Res 2017;19(2):e36.
Stomby, A et al. A Paleolithic Diet with and without Combined Aerobic and
Resistance Exercise Increases Functional Brain Responses and Hippocampal Volume
in Subjects with Type 2 Diabetes. Front Aging Neurosci 2017;9:391.
Wheeler, M. Cycles: Diabetes Nutrition Recommendations—Past, Present, and
Future. Diabetes Spectrum 2000;13:116.