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Fad Diets & Diabetes Management: What’s the Evidence?
MaureenChomko,RD,CDE
2019WADEAnnualConferenceApril25,2019
DisclosurestoParticipantsNoticeofRequirementsforSuccessfulCompletion:Forsuccessfulcompletion,participantsarerequiredtobeinattendanceinthefullactivityandcompletetheprogramevaluationattheconclusionoftheeducationalevent.PresenterConflictsofInterest/FinancialRelationshipsDisclosures:Noconflictsexist.DisclosureofRelevantFinancialRelationshipsandMechanismtoIdentifyandResolveConflictsofInterest:Noconflictsofinterest.Non-EndorsementofProducts:AccreditedstatusdoesnotimplyendorsementbyAADE,ANCC,ACPEorCDRofanycommercialproductsdisplayedinconjunctionwiththiseducationalactivity.Off-labelUse:ParticipantswillbenotifiedbyspeakerstoanyproductusedforapurposeotherthanthatforwhichitwasapprovedbytheFoodandDrugAdministration.
#1 Question to ADA consumer call center:
What Can I Eat?
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ADA:FoodandFitness->Food->WhatCanIEat
AADE:LivingwithDiabetes->AADE7Self-CareBehaviors->HealthyEating
EatingforDiabetes:Basics
• Effectiveplansbothreducecalorieintakeandincreasephysicalactivity
• Noclearpreferenceforanyspecificeatingplanormacronutrientdistribution
• Varietyofeatingplanswork• Totalenergyintakeappearsmoreimportantthansourceofenergy
FranzM,etal.JAcadofNutrandDietetics.2015Sep;115(9):1447-63.MacLeodJ,etal.JAcadofNutrandDietetics.2017Oct;117(10):1637-1658.
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Eating for Diabetes Isn’t Easy… “Isn’t there another way?”
EatingforDiabetes:FadDiets
• Whatistheindividualwillingtofollow?• Patient-centeredcounselingleadstodevelopingplansforfaddietswithindividuals
• Donoharm• Eatingplancannotputpersonwithdiabetesatgreaterhealthrisk
• Comparefaddietoutcomeswiththeindividual’sdesiredoutcomes
Joseph
• 68yoM;DM2x10years;mostrecentA1c8.4%aftermanagingA1c’s<7%
• Metformin1000mgBID;65unitsglargineand15-20unitsTIDaspart
• BMI36.Weightgainsinceretired2yearsago.
• HighlymotivatedtogetA1cbackdown• Social:retiredengineer,liveswithwife,whoisstillworkingasRN.
• Wifecooksallmeals,hehashaddifficultygettinghertochangethewayshecooks.
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WhicheatingplanwouldbethebestoptionforJoseph?
Joe’soldcoworkerhaslostweightthroughintermittentfasting,soJoehasbeenthinkingaboutthis.SonDavethinksheshouldtryaPaleoplanthatDavefollowsthroughhisCrossfitgym.HiswifehasreadabouttheDASHeatingplanforhermother’sbloodpressure,wantsJoetofollowitaswell.
WhicheatingplanwouldbethebestoptionforJoseph?
IntermittentFastingPaleo
DASH
Limited data to recommend Paleo for DM. Very small studies lasting only a few
weeks or months have been conducted to date.
More research is needed.
“Dietary Approaches to Stop Hypertension” Reduces BP & Framingham risk score for
CVD Published data conflicting for weight loss and
A1c Pitt CE. Aust Fam Physician. 2016 Jan-Feb;45(1):35-8.
IntermittentFasting:Definitions
• Eatingplancyclingbetweenperiodsofeatingandfasting.• Fastingperiodslongerthananormalovernightfastof8–12hours
• Severaltypesofintermittentfastingmethods:allofwhichsplitthedayorweekintoperiodsofeatingandperiodsoffasting
• DailyTime-RestrictedFeedingWindows• WeeklyEnergyRestrictionviaIntermittentFasting
• Noguidanceonwhatfoodstoeat,onlywhentoeat
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Time-RestrictedFeedingWindows
Limitingeatingperiodtoacertainnumberofhoursaday:Example:<10houreatingwindowduringdaytimewith>14hourfast
SuttonE,etal.CellMetabolism(27),2018:1212-1221.
EarlyTimeRestrictedFeedingBenefits:• Decreasedfastinginsulinandinsulinlevelsat60&90minutespostprandial• Improvedinsulinsensitivity&responsiveness• Lowereddesiretoeatintheevening
Noweightlossinthisfive-weekstudyof15prediabeticmen.SuttonE,etal.CellMetabolism(27),2018:1212-1221.
“Manyofmypatientshavetimerestrictedfeedingwindows….theydon’teatbreakfastuntil2pm,andtheystopeatingat2am.”
• Feedingperiodsbeginningafter4PMledto:• Noresults,or• WorsepostprandialBGlevels,betacellresponsiveness,BPandlipidlevels
CarlsonO,etal.Metabolism.2007;56(12):1729-34.StoteKSetal.AmJClinNutr.2007;85(4):981-8.
TinsleyG&LaBountyP.NutritionReviews,.2015;73(10)661–674.
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WeeklyEnergyRestriction
1.“Fasting-mimicking”diets:significantlyreducedcaloriesfor5daysofthemonth
2.Restrictingenergyintakeon1–3daysperweek,andeatingfreelyonthenon-restrictiondays
• Example:5:2diet
3.Alternatedayfasting(ADF)• “fastday”(75%energyrestriction)alternatingwitha“feedday”
WeeklyEnergyRestrictionOutcomes• 54obeseadultswithDM2randomizedinto3groups:
(1)VLCDx5daysfollowedbyonly1day/wkofVLCDx15weeks(2)VLCDx5daysfollowedby5daysofVLCDevery5weeks.Consuming1500-1800caloriesonnon-fastingdays(3)Controlgroup:1500-1800calories/dayforlengthofstudy
• BothVLCDgroupslostsignificantlymoreweight• GroupTwomoresuccessfulthanGroup1(92%vs50%lost>5kg)• GroupTwomorelikelytoachievenormalA1c,independentofweightloss
• Shortstudy/nofollowup;Studydonein1998
Williams K, et al. Diabetes Care Jan 1998, 21 (1) 2-8.
WeeklyEnergyRestrictionOutcomes
• 63overweight/obeseadultswithDM:• GroupOne:2days/wkeating400-600kcal/day,thenhabitualeating5days/wk
• GroupTwo:dailyenergyrestrictionto1200-1550kcal/day
• After12weeks,bothgroupshadsimilarreductionsinA1c,bodyweight,meddoses,bodycomposition,andappetitereports
CarterSetal.DiabetesResClinPract.2016Dec;122:106-112.
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IntermittentFastingConcerns
• Variationsofdefinitionsmakeconsistentresearchfindingsdifficult
• Numberoffastingdaysvaryineachstudy• Amountofcaloriesvaryineachstudy
• Managinghungeronfastingdaysandappetiteonfeedingdays• Potentialfor“rebound”overeatingon“feeding”days
• Sociallife
DiabetesMedicationAdjustmentsforIntermittentFasting
• Riskofhypoglycemiain41%ofindividualsstudied• Hypoglycemiarisk2xgreateronfastingdays(despitemedadjustment&hypoeducation)
• Reducemedicationsonfastingdays:• Ifindividualseating<400calories,take1/2or1/3ofinsulindoses• Ifpossible,eliminateuseofhypoglycemicmedicationsonfastingdays
CorleyBT,etal.DiabeticMedicine.Vol35(5):2018.
Real World Strategies: Intermittent Fasting
Eatingdinnerearlier
EatingalighterdinnerTryeatingmorecaloriesforbreakfastandlunch
Avoidinglate-nightsnacking
MostAmericanseatbetweena12-15hourwindow.
Reduceby1-2hoursStopeatingafter6or8PM
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Marilyn
• 72yoF,BMI33;HTN,HLD,CADwithh/o3-VesselCABG
• Sinceretirement,hasgained30lbs.NewdxDM2;A1c6.8%.PCPwouldlikehertotrytoworkonherdietandbecomemoreactivebeforeinitiatingmetformin.
• Social:Retiredphysician,livesalone.• Usedtocookmuchmore;raised3childrenandisenjoyingretirement.Atetortillachips,avocadoandsalsafordinnerlastnight.
• Noregularexercisebut“doddersaround”inhergarden.
WhichwouldbethebesteatingplanforMarilyn?
Marilynrememberslearningaboutlowfatdietsforweightlosswhenshewasinresidency,hasbeenconsideringthis.ShehasreadarticlesaboutMediterranean-styleeating,shehasalwaysenjoyedMiddleEasternfood.HerdaughterisontheketogenicdietandinsiststhiswillworkforMarilyn’snewdiagnosisdiabetes.
WhichwouldbethebesteatingplanforMarilyn?
LowFatMediterraneanKetogenic
Concern due to high CVD
risk
LOOK AHEAD trial: lowering total fat intake did not consistently improve
glycemic control in patients with DM2.
LookAHEADResearchGroup.NEnglJMed2013;369:145-154
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WhatisMediterraneanStyleEating?
“Fillyourplatewithfreshfruitsandvegetables,healthyfats,wholegrains,legumesandfishandenjoymoderate
amountsofredwine”
MEDEatingPlan:DMStudyOutcomes
• Whencomparedtohighcarbohydrate-lowfat,small&shortstudiesfind:
• NodifferenceinA1corweight• SignificantloweringofVLDL&TG• MixedresultswithHDLchange
Rodriguez-VillarC.DiabetMed.2004Feb;21(2):142-9.GargA.etal.DiabetesCare.1992Nov;15(11):1572-80.GargA.etal.JAMA.1994May11;271(18):1421-8.MonlezunDJ,etal.DiabetesResClinPract.2015Aug;109(2):420-6.
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Mixed Results in Larger DM Mediterranean Studies
• A1c&BMIloweredwhenMEDcombinedwith:PA+stressmgmt+smokingcessation
• Whencomparedtolowerfat-highercarb,MEDresultedinlowerweight,improvedglycemiccontrol,insulinsensitivity,HDL,TGandBP,lessDMmedicationuseandlongertimetoDMmedicationsinMEDgroup.àAt4years,weightandbloodpressuresimilarbetweengroups• LessinsulinresistanceinMEDgroupvslowfatgroup.WhenMED
comparedtolowercarbgroup,A1clowestinlowcarbgroup
ToobertDJ,etal.DiabetesCare.2003Aug;26(8):2288-93.EspositoK,etal.DiabetesCareJul2014,37(7)1824-183.
ShaiI,etal.NEnglJMed2008;359:229-241
• Priority:reducingCVDrisk• IncidenceofmajorCVDeventslowerforthoseconsumingMediterraneandietvscontrolgroup(advisedtoreducefatintake)
• GlycemiccontrolvsMortalityReduction• Cardiovasculardiseaseremainsthemostprevalentcauseofmorbidityandmortalityindiabeticpatients
MediterraneanEatingPlan:Barriers• HigheradherencetoMEDeatingassociatedwithgreaterspendingonfood
• CostmuchmorelikelytodecreaseadherencetoMEDeatingplaninthoseoflowersocioeconomicstatus
• MEDeatingassociatedwithlowerCVDriskinthosewithgreaterincomeorgreatereducationlevel
• NorelationshipfoundforlowerCVDriskinthosewithlowereducation/incomelevel,despitesimilarMEDadherencescores
G.AlbuquerqueG,etal.PortoBiomedicalJournal.(2017)2,115-119BonaccioM,etal.IntrJEpi,Vol46,(5),2017,1478–1487.
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MediterraneanEatingPlan:Barriers
• Time/MealPreparation• Few“convenience”MEDfoods• Requireshigher-levelcookingskills
• Starkdifferencefromotherculturaleatingpatterns• ~93%oftheworldisnotMediterranean
MooreSE,etal.JHumNutrDiet.(2018);31:451-462.Tong,etal.BritishJournalofNutrition(2018),119,685–694
MediterraneanEatingPlan:Solutions• Notallnutrient-densefoodscostmore,itcouldbepossibletoconstructaMED-styleplanusinglowercostoptionsineachfoodcategory
• Lessspendingonredmeat&sweetscouldbeusedforvegetables,fruitsandfish
• Providingshoppinglists,mealplanners,andrecipescanhelpassistindividualsfollowingMED-styleeatingplan
G.AlbuquerqueG,etal.PortoBiomedicalJournal.(2017)2,115-119.
MooreSE,etal.JHumNutrDiet.(2018);31:451-462.Tong,etal.BritishJournalofNutrition(2018),119,685–694
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Real World Strategies: Mediterranean Eating Plan
Nutsasasnack(inmoderation)
Moreplant-basedfats:Avocado,nuts,seeds,olives
Cookingathomemore
Trymoremeatlessmeals,ordecreasingredmeatintake
Rosalba
• 39yoF,pre-DM.BMI36.• A1c6.3%,fastingBG117• Herhusbandhasdiabetes,shewouldliketopreventitifshecan
• Social:homewithkidsduringtheday,worksnightsatanactivejob
• Lost10lbslastyearwhensheatelesstortillas&rice;shethenstoppedlosing.Shebecamediscouragedandreturnedtohernormaleatinghabits.
WhicheatingplanwouldbethebestoptionforRosalba?
Rosalba’shusbandhasbeentellinghertoeatlikehedoesforyears.He’sbeenfollowingalow-fatplansincehisheartattack.Shecoulddothis,butdoesn’twanttoadmithe’sright.Shehasheardaboutlow-carb,butisworriedthateverythingsheeatsisacarbohydrate.Herbosstoldheraboutintermittentfastingandhowitcuredhisfather’sdiabetes.Shewantsmoreinformationonhowthisworks.
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WhicheatingplanwouldbethebestforRosalba?
Low-fatLow-carbohydrateIntermittentFasting
Meta-analysis of 11 cohort studies showed a low-carbohydrate pattern did not have a lower
risk of developing DM2 than a high-carbohydrate pattern.
Need more research on IF for DM prevention
NotoH,etal.JofGenandFamMed.Vol17(1);2016.
Whatislow-fateating?
Typically20-30%(orless)ofcaloriesfromfat
2000caloriediet=40-60gramsfat/day
Low-fatEatingforDiabetesPrevention
• FinnishDiabetesPreventionStudy:<30%calsfromfatPLUS30minofdailymoderateactivityresultedin:
• Moreparticipantsachieving>5%weightloss• Riskfortype2diabeteswasreducedby58%
• USDiabetesPreventionProgram(DPP):~25%ofcalsfromfatPLUS150minPA/wkresultedin:
• 58%reducedincidenceofdevelopmentofDM2,DESPITEonly38%meetingthe7%weightlossgoal
Tuomilehto J. N Engl J Med 2001; 344:1343-1350.
Studiesbothcombinedwithphysicalactivity–difficulttoseparatetheindividual
effectsonDMprevention
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LowFatEatingPlan:Concerns
• Reductioninfatusuallyreplacedbyincreaseincarbohydrate
• Mediterraneandietshowsusthathigher(plant)fatcanbecardioprotective
• Low-fatmealsmayresultinlowersatiety
LowFatDiet:Solutions• Reducefatandincreasefiber(offerideas!)
• Provideeducationonhealthyfatchoices
• Managesatietyviaincreasedfiberorpost-mealhungermanagement
Real World Strategies: Low Fat
Decreasingintakeofhigh-fatdairy
Cookinghighfatmeatslessfrequently
Lessfastfoodordifferentchoicesatfastfood
Replacinghighfatsnackswithhighfibersnacks
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Kevin
• 29yoM,DMx4years.BMI37;A1c8.8%• Metformin1000unitsBID;glipizide2mgBID
• Social:Workssecurityforprosportsteam• HeandfiancéehavedoneWhole30&Paleodietsasmonthlychallengeswitheachotheroverthepastyear.Worksforamonth,thentheygobacktoregulareating.
• Wantstolose40lbsbeforeweddingin3months
WhatisthebesteatingplanforKevin?
HehastriedPaleobefore,andcouldseehimselfdoingthisdietagain,helikedtheamountofmeatinvolved.Hisfiancéehasbeenwantingtodoavegetarian/veganchallengewithhim,buthe’sbeenputtingitoffformonths.TheFacebookgroupheisamemberofhasbeentalkingabouttheketogenicdiet,andtheamountofweighttheyhavelosthasbeenappealingtohim.
Insufficient data that these eating plans result in
significant weight loss in those with DM
WhatisthebesteatingplanforKevin?
PaleoVegetarian/VeganLowcarb/Ketogenic
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Whatisalow-carbohydrateeatingplan?
Whatislow-carbohydrateoftendefinedas? <45%fromcarbohydrate
Whatishigh-carbohydrateoftendefinedas? >45%fromcarbohydrate
Firstproblemwithlow-carbohydrateresearch:
• Analysisof36RCT’s(lowCHOvslowFAT):lowCHOimprovesA1cmorethanlowfatinthosewithdiabetes
• NodifferencewhenfollowedouttotwoyearsVanZuuren,E,etal.AmerJourofClinNutr,Vol108(2),2018.
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LowCarbOutcomes• Analysisof25RCT’s(lowCHOvshighCHO):greaterA1creductionswhen<20%ofcaloriesarefromcarbohydrate
• Lowerthecarbohydrate=greaterbloodglucoselowering
• Significantreductionsat3and6months• Nosignificantdifferencebetweenlow-carbandmoderatecarbohydratewhenfollowedoutto12+months
SnorgaardO,etal.BMJOpenDiabetesResearchandCare2017.Sato,etal.PLOSOne,Dec4;12(12):2017.
Ex)2000caloriediet:100gCHOperdayorless
Ex)1200caloriediet:60gCHOperdayorless
Whatisaketogeniceatingplan?
• Highfat:65-80%oftotalcalories
• Moderateprotein:0.8-1.2g/kg[ideal]bodyweight
• Verylowcarb:<50-60g/day5-15%ofcalories
KetogenicEating:Outcomes
• 34adultsw/DM/pre-DM:16onketovs18onlow-fat
• KetoreducedA1c(6.6%to6.1%)morethanlow-fat(6.9%to6.7%)
• Ketoreducedweight(-7.9kg)morethanlow-fat(-1.7kg)
• Largerreductionsinuseofsulfonylureas&DPP4sinketogroup
Limitations:• Only12monthstudy• Participantsattended19classesover12months
Saslow,etal.NutritionandDiabetes.(2017)Vol7:304-309.
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KetogenicEating:Outcomes
• 349adultsw/DM2:262chosetofollowketogeniceatingplanplusbehaviorchangecoachingwhile87incontrolgroupchosetocontinueusualcare
• Ketogenicgroup:at12months:A1c(7.6%à6.3%),weight(-13.8kg),TG,LDL,BPandmedicationrequirementslower
• Studynotrandomized• Notjustketogenic:Individualizedhealthcoaching,on-siteorweb-basedclasses,onlinecommunitysupport,andremotecareteamprovidingmonitoring,education,andcommunicationviaphoneapp
HallbergS,etal.DiabetesTher(2018)9:583-612.
KetogenicEating:Concerns• NutrientQuality
• LowerinvitaminsD,A,K,C,folate,calcium,potassium&fiber• Constipation• Hydration
• Dividebodyweight(lbs)inhalfforfluidgoal240lbs/2=120ouncesor~15cups/day
• Keto“flu”• Cost
KetogenicEating:Concerns• Kidneydisease:Ketonotrecommended
• NostudiesdoneonketogeniceatinginindividualswithCKD+DM
• Cardiovascularoutcomes:• Saturatedfatintaketypicallyincreasesandfiberintakedecreases• Nolong-termstudiesevaluatingriskforCVDeventswhenfollowingketoeatingplan
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CarbohydrateIntakeDistribution&Mortality
• 1999–2010NHANESdata;N=24,825• Lowcarbintake:
• 32%morelikelytodieprematurelyfromanycause
• 51%morelikelytodiefromcoronaryheartdisease
• 50%morelikelytodiefromcerebrovasculardisease
• 35%morelikelytodieofcancer
SeidelmannSB,etal.TheLancetPublicHealth(2018).
MedicationAdjustmentsforKetogenicEating
• AvoidSGLT2-Imedications
• PossibleincreasedriskofeuglycemicDKA
• Reducedosesofinsulin&sulfonylureas
Real World Strategies: Lower-Carbohydrate Eating
Focusonliquidsourcesofcarbohydrate
Identifyingsourcesofaddedsugars/labelreading
Reducingportionsizesofhigh-carbohydratefoods
Increasingfiberandplant-basedfatintake
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Sidebar: SSB & ASB
SSB=SugarSweetenedBeveragesASB=ArtificiallySweetenedBeverages
SugarSweetenedBeverages&Juices
• EatYourFood–Don’tDrinkIt!
• “Don’tbeapassiveparticipantinthedigestiveprocess”MichaelPollan• “Howmuchworkdoesittaketosucksomethingdownwithastraw?”AlisonEvert
Artificial Sweeteners
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Mossavar-Rahmani, et al. Stroke; 2019.
ASB and Stroke
• IncreasedriskofischemicstrokeamongfrequentASBconsumersobservedamongblackwomenbutnotwhitewomen
• FrequentASBconsumptionwasassociatedwithincreasedincidenceofstrokeonlyamongtheobese
• Increasedriskofcoronaryheartdiseaseinwhitepostmenopausalwomen,butnotblackwomen.
• AllcausemortalityincreasedamongnormalweightoroverweightfreqASBconsumers,butnotdefinitelyamongthosewhowereobese.
• CausalnatureoftheseASBandstrokeassociationisunclear• Thosewhodrank>2ASBperdayweremorelikelytobeoverweightorobese,havelowerlevelsofexercise,higherenergyintakeandlowerdietquality,morehistoryofDM,MIorstroke
Artificial Sweeteners: Debate
• ASB=increasedsugarcravings/appetitestimulation?• ASBconsumption=caloriccompensation?• Weightgain?
• Shorttermhumantrialsshowpromotionofweightloss• Observationalstudies&rodentstudiesresultsyieldinconsistentresults
• Glucoseintolerance?• Reversecausality–ASBconsumptionoftenoccursinlaterlife,possiblyduetoanalreadyincreasedriskofvasculardisease
• Gutmicrobiotachanges?
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Artificially Sweetened Beverages
Trevor
• 24yoM;DM1x9years.• BMI28.Interestedinweightloss.• A1c’sconsistently7-8%• Glargine38unitsandSSIaspartTID• Inactivesincegraduatingfromhighschool
• Worksasgeneralmanagerforrestaurant,typically60+hourweeks
WhatisthebesteatingplanforTrevor?
• LimitedornoresearchonDM1and:• Mediterranean• Vegetarian/Vegan• DASH• Paleo• Low-Fat• Low-carbohydrate(26-45%ofcaloriesfromcarbohydrates)
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LowCarbResearchinDM1Population• 10adultswithDM1;47gcarb/day;1weekstudy.
• VLChadlessglycemicvariability,moretimeineuglycemiaandrequiredlessinsulinwhencomparedtohighcarbdiet(>250gcarb/day).
• 48adultswithDM1;<75gcarb/day;f/uat3monthsand4years.
• 3months:weight,A1candTGreduced.HDLincreased.• 4years:weightandTGreturnedtobaseline;A1cremainedlower,HDLhigherthanbaseline
• Adherencerate48%• Nocomparisonorcontrolgroup
RanjanA,etal.DiabetesObesMetab.2017;19(10):1479-1484.
Nielsen J, et al. Diabetology & Metabolic Syndrome. 2012; 4(23).
EatingPlansforType1Diabetes:Summary
• Inadequateresearch• Verylow-carbohydrateeatingmayhavepotentialforimprovedglucosecontrol• Nolongterm(>2years)RCT’sconductedforanydietarypatternintype1diabetes
EatingPlansforType2Diabetes:Summary
• Low-carbohydrateeating,especiallyverylow-carbohydrateeating,mayreduceA1candneedfordiabetesmedicationswhencomparedtohighercarbohydratediets
• Difficultymaintainingpast12months
• Limitedevidencetorecommendlow-fateatingtomanagetype2diabetes
• Mixedeffectsseenin:Mediterranean,vegetarian ,DASH,orintermittentfasting
• Fewlongtermtrials(>2years)havebeenconductedinanydietarypattern
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EatingPlansforPrediabetes:Summary• Bestchoicesappeartobelow-fat,Mediterranean,orvery-low-carbohydrate
• Norandomizedcontrolledtrialhascomparedtheseagainsteachother• LowfatPLUSphysicalactivitystrongestevidence10-15yearsout
• EpidemiologicalstudiessuggestMediterranean,vegetarian,andDASHeatingpatternsresultinlowerriskofdevelopingtype2diabetes
• Mediterraneaneatingassociatedwith20%lowerriskofdevelopingtype2diabetes
• IncreasedplantproteinanddecreasedmeatproteinreducedriskforDMby23-35%
EspositoK.Endocrine.2014Sep;47(1):107-16.VasantiSetal,AmerJourEpi,183(8)2016,715–728
LeeY,etal.Nutrients2017,9(6),603
Thankyou!MaureenChomko,RD,CDE