21 May 2010




    Nutritional Issues
in the Outpatient Setting
       Iris Thiele Isip Tan MD, FPCP, FPSEM
     Clinical...
1                        3
                          Low
Low CHO               protein diet
vs low fat             in kidn...
What is the optimal CHO-to-fat ratio?

                        Recommendation
 100
                        CHO 45-65%
    ...
Meta-analysis
CHO-to-fat ratio in Type 2 diabetes


      Low-fat, high-CHO             High-fat, low-CHO
      CHO/Fat 58...
Meta-analysis
CHO-to-fat ratio in Type 2 diabetes
                                     Kodama et al. Diabetes Care 2009;32...
Replace saturated fat with MUFA or CHO?


100
               MUFA

 75
                                 High MUFA
      CH...
Dietary Sources of MUFA
 Vegetable
             SFA    MUFA PUFA
    oils
              g      g     g
  (100 g)
Sunflower ...
One-year data
High-MUFA vs high-CHO in Type 2 diabetes


    Overweight/obese        Weight loss
    Type 2 diabetes      ...
One-year data
High-MUFA vs high-CHO in Type 2 diabetes


  Similar time        High-MUFA = High-CHO
     effects
    p<0.0...
One-year data
High-MUFA vs high-CHO in Type 2 diabetes


   Significant
                       High-MUFA = High-CHO
    ↑ H...
One-year data
High-MUFA vs high-CHO in Type 2 diabetes


  Similar time       High-MUFA = High-CHO
     effects
    p<0.01...
Replace saturated fat with MUFA or CHO?
                                 Brehm et al. Diabetes Care 2009;32:215-20




100...
1                        3
                          Low
Low CHO               protein diet
vs low fat             in kidn...
Glycemic Index (GI)

Definition
Increase in blood glucose (over
fasting level) in 2 h following
ingestion of 50 g CHO
  ___...
Glycemic CHO Availability in the GI tract

                   Available food carbohydrates

macronutrient                 ...
Issues with Glycemic Index

1                       3
  Only accounts for     GI for any particular
 CHO type (not total  ...
Glycemic Load (GL)

Definition                         GI 72 (50 g = 4 1/2 cups)
Quantitates the impact of a       1/2 cup ...
GI vs GL of Selected Foods

          Low GI      Interm GI  High GI
       Whole meal                Popcorn
          ce...
Cochrane Review
Low GI or low GL Diets for Diabetes

         Low GI or
        Low GL diet
                           vs ...
Cochrane Review
Low GI or low GL Diets for Diabetes

         Low GI or
                                  vs           Hig...
Canadian Trial of CHO in Diabetes
Low-GI diet for Type 2 diabetes on diet alone
 P        Type 2 diabetes on
          die...
Low GI
High GI
Low CHO


    Body wt
 NS
     HbA1c

 ↑        FBS


 ↓     2h post
     -load BG

                 Woleve...
Low GI
                          NS                   ↑                        ↓
High GI
                    Total chol   ...
Low GI                CRP 1.95 mg/L
High GI               CRP 2.75 mg/L         CRP (low-GI)
                             ...
Low GI vs ADA Dietary Education in Type 2 Diabetes

 P     Poorly-controlled
     Type 2 diabetes (n=40)

 I    Low GI vs ...
Low GI vs ADA Dietary Education in Type 2 Diabetes



          Low GI diet         vs         ADA diet


     ↓ LDL at 12...
1                        3
                          Low
Low CHO               protein diet
vs low fat             in kidn...
Meta-analysis
Low-protein diet for diabetic nephropathy

        Low-protein diet                  Normal
            (LPD...
Meta-analysis
Low-protein diet for diabetic nephropathy
                                             Yu Pan et al. Am J Cl...
Meta-analysis
Low-protein diet for diabetic nephropathy
                                           Yu Pan et al. Am J Clin...
Meta-analysis
Low-protein diet for diabetic nephropathy
                                           Yu Pan et al. Am J Clin...
Withdrawal of Red Meat from Usual Diet

P     Type 2 diabetes with
    macroalbuminuria (n=17)

I     Usual diet (UD) vs  ...
Withdrawal of Red Meat from Usual Diet


Usual diet (UD)

           vs
                                    ↓
 Chicken (CD...
1                        3
                          Low
Low CHO               protein diet
vs low fat             in kidn...
Low-fat Vegan Diet in Type 2 Diabetes

P    Free-living Type 2
      diabetics (n=99)

I    Low-fat vegan diet
           ...
Low-fat Vegan Diet in Type 2 Diabetes


      Low-fat
                            vs      ADA (2003) diet
     vegan diet
...
3


           2          Selenium                5


 1             Zinc    4                    Vanadium

Chromium      ...
1                        3
                          Low
Low CHO               protein diet
vs low fat             in kidn...
Thank You
http://www.endocrine-witch.info
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Nutritional Issues in the Outpatient Setting

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Presentation given at a nutrition workshop. Focus is on medical nutrition therapy for diabetes mellitus.

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Nutritional Issues in the Outpatient Setting

  1. 1. 21 May 2010 Nutritional Issues in the Outpatient Setting Iris Thiele Isip Tan MD, FPCP, FPSEM Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism, UP-PGH http://www.endocrine-witch.info
  2. 2. 1 3 Low Low CHO protein diet vs low fat in kidney diets Medical disease 2 Nutrition 4 Therapy Glycemic DIABETES Vegan diet index/ & trace glycemic minerals load
  3. 3. What is the optimal CHO-to-fat ratio? Recommendation 100 CHO 45-65% Min 130 g/day HIGH CHO 75 CHO ↑ glucose, 50 CHO insulin, triglycerides 25 Fat Fat LOW FAT CHON CHON 0 ↓ energy intake LFHC HFLC Reduce weight Low fat = High CHO Dietary CHO (Amount & Type) in the Prevention & Management of Diabetes: American Diabetes Association Position Statement (2004)
  4. 4. Meta-analysis CHO-to-fat ratio in Type 2 diabetes Low-fat, high-CHO High-fat, low-CHO CHO/Fat 58%/24% vs CHO/Fat 40%/40% Randomized trials (19; n=306) Similar energy and CHON intake between groups Measured FPG & insulin; >1 wk intervention Parallel and cross-over designs Studies excluded: change in content/quality of CHO (↑ fiber/whole grains) Kodama et al. Diabetes Care 2009;32:959-65
  5. 5. Meta-analysis CHO-to-fat ratio in Type 2 diabetes Kodama et al. Diabetes Care 2009;32:959-65 Low-fat, high-CHO High-fat, low-CHO CHO/Fat 58%/24% vs CHO/Fat 40%/40% ↓ NS ↑ Fasting insulin (p=0.02) A1c, FPG, HDL-C 2-h glucose & (p<0.001) total chol and LDL-C insulin (p<0.001) Triglycerides* (p<0.001) * Insignificant when energy intake restricted
  6. 6. Replace saturated fat with MUFA or CHO? 100 MUFA 75 High MUFA CHO Mediterranean diet 50 Vegetables, fruits, Fat whole grains, legumes, 25 nuts, olive oil CHON 0 LFHC High MUFA Replace saturated fat with MUFA
  7. 7. Dietary Sources of MUFA Vegetable SFA MUFA PUFA oils g g g (100 g) Sunflower 9.7 83.6 3.8 Fruit SFA MUFA PUFA Safflower 6.2 74.6 14.4 (100 g) g g g Olive 13.5 73.7 8.4 Avocado 2.4 9.6 2.0 Canola 7.1 58.9 29.6 Olives 1.4 7.9 0.9 Nuts SFA MUFA PUFA (100 g) g g g SFA MUFA PUFA Macademia 12.1 58.9 1.5 Animal products g g g Hazelnuts 4.5 45.7 7.9 Ground beef, 10.8 11.6 1.1 Pecans 6.2 40.8 21.6 regular, 100 g Almonds 3.9 32.2 12.2 Fried eggs, 2 pcs 4.2 6.0 2.8 Cashews 9.2 27.3 7.8 Regular butter, 25 g 12.6 5.9 0.8 Peanuts 6.8 24.4 15.6 Fried bacon, 3 slices 3.3 4.5 1.1 Pistachios 5.4 23.3 13.4 Ros E. Am J Clin Nutr 2003;78(suppl):617S-25S
  8. 8. One-year data High-MUFA vs high-CHO in Type 2 diabetes Overweight/obese Weight loss Type 2 diabetes Body fat (n=124) P Waist circ Diastolic BP HDL-C High-MUFA: A1c 45% CHO, 15% CHON Fasting glucose & 40% fat (20% MUFA) & insulin High-CHO: O 60% CHO, 15% CHON & 25% fat RCT x 1 y I 18 mos extension M Brehm et al. Diabetes Care 2009;32:215-20
  9. 9. One-year data High-MUFA vs high-CHO in Type 2 diabetes Similar time High-MUFA = High-CHO effects p<0.01 High-CHO High-MUFA Baseline 12 months Baseline 12 months Body weight (kg) 102.1 + 2.0 98.3 + 2.0 103.7 + 2.8 99.7 + 3.0 Lean body mass (kg) 62.1 + 1.5 61.3 + 2.2 63.2 + 2.2 62.5 + 2.2 Body fat (kg) 38.9 + 1.0 37.1 + 1.1 38.8 + 1.3 36.9 + 1.4 130/77 + 129/73 + 132/78 + 130/73 + Blood pressure 2.0/1.6 2.3/1.4 2.3/1.4 2.4/1.5 Brehm et al. Diabetes Care 2009;32:215-20
  10. 10. One-year data High-MUFA vs high-CHO in Type 2 diabetes Significant High-MUFA = High-CHO ↑ HDL-C p<0.01 High-CHO High-MUFA mg/dL Baseline 12 months Baseline 12 months Total cholesterol 178 + 4.9 180 + 5.2 179 + 7.2 184 + 6.5 Triglycerides 182 + 17.9 177 + 17.4 202 + 17.3 201 + 20.0 LDL-C 100 + 4.6 97 + 4.9 104 + 7.0 101 + 6.1 HDL-C 43 + 1.4 48 + 1.4 42 + 1.2 47 + 1.3 Brehm et al. Diabetes Care 2009;32:215-20
  11. 11. One-year data High-MUFA vs high-CHO in Type 2 diabetes Similar time High-MUFA = High-CHO effects p<0.01 High-CHO High-MUFA Baseline 12 months Baseline 12 months A1c (%) 7.2 + 0.1 7.2 + 0.2 7.4 + 0.1 7.5 + 0.3 Glucose (mg/dL) 135 + 4.7 127 + 5.5 150 + 7.0 142 + 8.1 Insulin (pmol/L) 314 + 37.1 287 + 26.7 309 + 25.4 251 + 23.6 HOMA-IR 7.6 + 0.6 7.6 + 0.8 9.2 + 0.8 7.8 + 1.0 Brehm et al. Diabetes Care 2009;32:215-20
  12. 12. Replace saturated fat with MUFA or CHO? Brehm et al. Diabetes Care 2009;32:215-20 100 MUFA High MUFA 75 good alternative CHO Comparable beneficial 50 effects on body weight, Fat body composition, CV 25 risk factors & glycemic CHON control 0 LFHC High MUFA Replace saturated fat with MUFA
  13. 13. 1 3 Low Low CHO protein diet vs low fat in kidney diets Medical disease 2 Nutrition 4 Therapy Glycemic DIABETES Vegan diet index/ & trace glycemic minerals load
  14. 14. Glycemic Index (GI) Definition Increase in blood glucose (over fasting level) in 2 h following ingestion of 50 g CHO _______Test food______ Reference food Low GI Intermediate High GI 0-55 56-69 >70 Llona A. Nutr Hosp 2006;21:53-59
  15. 15. Glycemic CHO Availability in the GI tract Available food carbohydrates macronutrient Stomach Gastric composition emptying (Rate limiting) fiber content viscosity Small volume & intestine structure of the Disruption food /digestion (Rate limiting) Portal circulation Riccardi et al. Am J Clin Nutr 2008;87(suppl):269S-74S
  16. 16. Issues with Glycemic Index 1 3 Only accounts for GI for any particular CHO type (not total food item highly amount) variable 2 4 Measures response to Inaccurate predictor individual food of postprandial consumed in isolation response in diabetes Dietary CHO (Amount & Type) in the Prevention & Management of Diabetes: American Diabetes Association Position Statement (2004)
  17. 17. Glycemic Load (GL) Definition GI 72 (50 g = 4 1/2 cups) Quantitates the impact of a 1/2 cup = 5.75 g CHO usual portion of a food with GL = (5.75 x 72)/100 = ~4 known GI GL = GI x CHO net content per portion (g) / 100 Low GL Intermediate High GL <10 11-19 >20 Llona A. Nutr Hosp 2006;21:53-59
  18. 18. GI vs GL of Selected Foods Low GI Interm GI High GI Whole meal Popcorn cereals Pineapple Watermelon Low GL Peanut Melon Whole wheat Strawberries bread Refined Banana cereals Interm Cherries Fettucine Sweet GL Toasted flour White bread potatoes Whole rice Noodles Couscous Potatoes High GL Macaroni Refined Cornflakes Spaghetti rice Llona A. Nutr Hosp 2006;21:53-59
  19. 19. Cochrane Review Low GI or low GL Diets for Diabetes Low GI or Low GL diet vs Higher GI diet Randomized controlled trials (11; n=402) Intervention 4-52 wks; Follow-up 12 mos Glycemic control: HbA1c & fructosamine Adverse events: hypo-/hyperglycemia Parallel and cross-over studies Two studies involved children Thomas & Eliott. Cochrane Database of Systematic Reviews 2009
  20. 20. Cochrane Review Low GI or low GL Diets for Diabetes Low GI or vs Higher GI diet Low GL diet NO STUDY HbA1c reduction Fewer reported on mortality, Parallel trials episodes of morbidity or costs WMD -0.5% (95% CI -0.9,-0.1) p=0.02 hypoglycemia Crossover trials (1 trial) WMD -0.5% Difference -0.8 (95% CI -1.0,-0.1) p=0.03 episodes/patient/ month (p<0.01) Thomas & Eliott. Cochrane Database of Systematic Reviews 2009
  21. 21. Canadian Trial of CHO in Diabetes Low-GI diet for Type 2 diabetes on diet alone P Type 2 diabetes on diet alone (n=162) I High-GI vs low-GI vs low-CHO diets O HbA1c, FPG, OGTT 100 GI 63 GI 55 GI 59 Body weight 75 Blood pressure Fat 50 Lipids & CRP 25 CHO Randomized controlled 0 High-GI Low-GI low-CHO trial x 12 mos M Wolever et al. Am J Clin Nutr 2008;87:114-25
  22. 22. Low GI High GI Low CHO Body wt NS HbA1c ↑ FBS ↓ 2h post -load BG Wolever et al. Am J Clin Nutr 2008;87:114-25
  23. 23. Low GI NS ↑ ↓ High GI Total chol Triglycerides HDL-C 4% vs low-CHO Low CHO LDL-C 12% vs low-CHO Total cholesterol Triglycerides LDL-C HDL-C 0 3 6 9 12 0 3 6 9 12 Time in study (mos) Wolever et al. Am J Clin Nutr 2008;87:114-25
  24. 24. Low GI CRP 1.95 mg/L High GI CRP 2.75 mg/L CRP (low-GI) less than Low CHO CRP 2.35 mg/L CRP (high-GI) LOW-GI VS LOW-CARBOHYDRATE DIET IN DIA by 30% (p=0.0078) the significant or nea several variables (eg, in which the differen study, are not consist Our most novel fin tion in CRP with the 29% difference is g T2DM patients, ie, 13 by atorvastatin, ie, 2 These findings are co that CRP concentrati lated to diet GI but n the release of inflam Although differences CRP that we observe FIGURE 5. Mean (and 95% CI) serum C-reactive protein (CRP) con- be involved. Exposin centrations in subjects receiving the high-glycemic-index (F; n 43), low- concentrations, rathe glycemic-index (E; n 48), and low-carbohydrate (Œ; nWolever et al. Am J Clinconcentration, increa 50) diets. Values Nutr 2008;87:114-25
  25. 25. Low GI vs ADA Dietary Education in Type 2 Diabetes P Poorly-controlled Type 2 diabetes (n=40) I Low GI vs ADA diet O 8 educational sessions Baseline, mos. 6 & 12 (monthly x 6 mos then Diet, physical activity, at mos. 8 & 10) psychosocial factors, diabetes medication use, weight, A1c, lipids Randomized controlled trial x 12 mos M Yunsheng et al. Nutrition 2008;24(1):45-56
  26. 26. Low GI vs ADA Dietary Education in Type 2 Diabetes Low GI diet vs ADA diet ↓ LDL at 12 mos Similar↓ HbA1c & (p=0.03) total cholesterol ↓ DBP at 6 mos Unchanged HDL & (p=0.03) triglycerides for both ↓ switch to new drug or increase Weight loss NS for dose (OR 0.26, p=0.01) both Yunsheng et al. Nutrition 2008;24(1):45-56
  27. 27. 1 3 Low Low CHO protein diet vs low fat in kidney diets Medical disease 2 Nutrition 4 Therapy Glycemic DIABETES Vegan diet index/ & trace glycemic minerals load
  28. 28. Meta-analysis Low-protein diet for diabetic nephropathy Low-protein diet Normal (LPD) vs protein diet Randomized controlled trials (8; n=519) Duration >6 mos Rate of Δ GFR Δ urinary CHON excretion & serum albumin Excluded cross-over studies Type 1 and Type 2 diabetic nephropathy Yu Pan et al. Am J Clin Nutr 2008;88:660-6
  29. 29. Meta-analysis Low-protein diet for diabetic nephropathy Yu Pan et al. Am J Clin Nutr 2008;88:660-6 Treatment Control Low-protein diet vs Normal protein Δ GFR in patients with type 1 or type 2 diabetes mellitus Change in WMD of GFR not significantly associated with LPD
  30. 30. Meta-analysis Low-protein diet for diabetic nephropathy Yu Pan et al. Am J Clin Nutr 2008;88:660-6 Δ in proteinuria (type 1 or type 2 diabetes mellitus) Significant benefit of LPD on proteinuria (p=0.003) but data heterogeneous
  31. 31. Meta-analysis Low-protein diet for diabetic nephropathy Yu Pan et al. Am J Clin Nutr 2008;88:660-6 Δ in serum albumin (type 1 or type 2 diabetes mellitus) LPD ↓ serum albumin WMD 1.18 g/L Authors’ Conclusion (95%CI -1.33, 1.03 g/L) LPD was not associated with a significant improvement of renal function in patients with either type 1 or type 2 diabetes.
  32. 32. Withdrawal of Red Meat from Usual Diet P Type 2 diabetes with macroalbuminuria (n=17) I Usual diet (UD) vs O with chicken (CD) vs GFR, UAER, serum fatty lactovegetarian low- acid, lipid profile, glycemic protein diet (LPD) control, anthropometric indices, blood pressure Randomized crossover (q 4 wks) controlled trial M de Mello et al. Am J Nutr 2006;83:1032-8
  33. 33. Withdrawal of Red Meat from Usual Diet Usual diet (UD) vs ↓ Chicken (CD) Urine albumin ↑ excretion ratio Lactovegan low- Serum PUFA non-HDL-C protein diet (LPD) UD CD LPD p UAER 312.8 269.4 229.3 <0.001 (ug/min) (223.7-1223.7) (111-1128) (76.6-999.3) GFR 81.8 + 22.2 83.3 + 26.1 81.9 + 25.3 0.860 (ml/min/1.73 m) de Mello et al. Am J Nutr 2006;83:1032-8
  34. 34. 1 3 Low Low CHO protein diet vs low fat in kidney diets Medical disease 2 Nutrition 4 Therapy Glycemic DIABETES Vegan diet index/ & trace glycemic minerals load
  35. 35. Low-fat Vegan Diet in Type 2 Diabetes P Free-living Type 2 diabetics (n=99) I Low-fat vegan diet O vs ADA diet HbA1c & lipids (wks 0, 11, 22, 35, 48, 61 & 74) Avoid animal products Weight and fatty foods (wks 0, 22 &74) Favor low-GI foods Randomized controlled trial x 74 weeks M Barnard et al. Am J Clin Nutr 2009;89(suppl):1588S-96S
  36. 36. Low-fat Vegan Diet in Type 2 Diabetes Low-fat vs ADA (2003) diet vegan diet Better reduction Significant weight loss within each HbA1c (p=0.03) group but NS between groups Total chol (p=0.01) (-4.4 kg vegan vs -3.0 kg ADA diet, non-HDL-C (p=0.02) p=0.25) LDL-C (p=0.03) Data analysis BOTH diets controlled for reduced weight medications and lipids . Barnard et al. Am J Clin Nutr 2009;89(suppl):1588S-96S
  37. 37. 3 2 Selenium 5 1 Zinc 4 Vanadium Chromium Calcium Trace Minerals Except for calcium, NO EVIDENCE of benefit for supplementation in diabetics without underlying deficiencies Chehade et al. Diabetes Spectrum 2009;22:214-217
  38. 38. 1 3 Low Low CHO protein diet vs low fat in kidney diets Medical disease 2 Nutrition 4 Therapy Glycemic DIABETES Vegan diet index/ & trace glycemic minerals load
  39. 39. Thank You http://www.endocrine-witch.info

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