Learn how Plant Based Nutrition can radically change the risk and management of Diabetes. A presentation at PPOD- Conference in 2016.

1. Lab to Table: Plant Based
Medicine and Diabetes
Stephan Esser MD, USPTA
www.esserhealth.com
www.jaxstemcell.com

2. • Disclosures
• None

3. Statistics
• 2014 (CDC: National Diabetes Statistics Report)
– 9.3% of the population
– 29.1 million US citizens
– 21 mill. diagn. 8.1 mil. undia.
• 7th
Leading Cause of Death

4. Goals
• Review the basic pathophysiology of Diabetes
• Understand the relationship of key factors on Diabetes risk
• Briefly engage the literature related to plant-based
nutrition and diabetic management
• Identify five science-based diabetes prevention strategies
for patients.

5. Number of People with Diabetes in US by Year

6. 2 of 32 of 3

7. Overweight ↑ risk of DM2 by 3 fold
Obesity ↑ risk by 9 fold
Overweight ↑ risk of DM2 by 3 fold
Obesity ↑ risk by 9 fold

8. Age-adjusted Prevalence of Obesity and Diagnosed
Diabetes Among US Adults
Obesity (BMI ≥30 kg/m2
)
Diabetes
1994
1994
2000
2000
No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%
No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
2013
2013

10. Cost to the Nation
• Healthcare is 2-3 times that of those without DM(WHO)
• 2007: Total costs exceeded $174 billion dollars
• In 2007 projected costs by 2020 of $192 billion
• 2012:Cost =$ 245 billion dollars
• “Without preventive action, 1 in 3 children born in 2000
will develop diabetes in their lifetime.” (HHS)
• Perspective
• Diabetes care is 12 percent of the total health care
spending nationwide—roughly one of every eight dollars.

11. Complications
• Heart Disease: 2-6 ×’s higher
• Stroke: 2-6 ×’s higher
• Hypertension/Elevated Cholesterol
• #1 Cause:
– Blindness
– Kidney Failure
– Neuropathy
– Amputation (60%)
• Dental Disease
• ……..and on and on………….

12. Pathophysiology of Diabetes

13. Visceral Adiposity/Belly Fat/Apple Fat
•Reduce Belly Fat
•Enhance Receptor Function
•Improve Insulin Sensitivity
•Reduce Systemic Inflammation
•Reduce Belly Fat
•Enhance Receptor Function
•Improve Insulin Sensitivity
•Reduce Systemic Inflammation

14. • It’s about the Transporter

16. Glucose Transporters
Transporter Other Affinity Tissue
Glut1 High Erythrocytes
Blood/Brain,
Blood/Tests,
Blood/Retinal
Glut2 Low Liver, Pancreatic
Glut3 High Neuronal tissue,
Placenta, Testes
Glut4 Insulin Dependent
Exercise Induced
High Adipocytes,
Myocytes
Brain Tissue
Glut5 Fructose Transport Small Intestine,
Spermatazoa

18. Glut4 and Insulin
• Pathway
– Glut4 is sequestered in intracellular vesicles
– Insulin binds to it’s receptor on the cell membrane
– Glut4 translocates to the cell membrane
– Glucose is transported into the cell for use

19. Influencing the Transporter
• Insulin
• Exercise
• Fat
• Inflammation
• Meat

20. Insulin Effects
• Carbohydrate metabolism
– Increases the rate of glucose transport across the cell membrane in muscle and
adipose tissue by activating Glut4
– Stimulates glycogen synthesis in muscle, fat and liver tissue
– Inhibits glycogenolysis and gluconeogenesis in the liver
• Lipid metabolism
– Inhibits lipolysis
– Stimulates fatty acid and triacylglycerol synthesis
– Increases the rate of Low-density lipid (LDL) formation in the liver
– Increases the rate of triglyceride uptake from the bloodstream to muscle and
adipose tissue
– Decreases the rate of fatty acid oxidation in muscle and liver tissue
– Increases the rate of cholesterol synthesis in the liver
• Protein metabolism
– Increases the rate of amino acid transport into tissues from the bloodstream
– Increases the rate of protein synthesis in muscle, adipose and liver tissue
– Decreases the rate of protein degradation in muscle and other tissue

21. Insulin
• Increases Glut4 receptors in cell membrane
• Adipogenic: anabolic effects of insulin, appetite increases, and reduction of glycosuria
• Heller, S Weight gain during insulin therapy in patients with type 2 diabetes mellitus Diabetes Research and Clinical Practice, 2004
• Atherogenic: Uusitupa, M, 5-year incidence of atherosclerotic vascular disease in relation to general risk factors, insulin
level, and abnormalities in lipoprotein composition in non-insulin-dependent diabetic and nondiabetic subjects. Circulation, 1990

22. ’d Insulin
Secretion
Fat Causes Weight Gain
Increases Appetite
Causes Insulin Resistance

24. Exercise

25. Exercise
• Voluntary Muscle
– Increases Glucose Uptake
– Increases Glycogenolysis
– Enhances Insulin Sensitivity

26. Exercise
• Resistance Training
– Ishii et al Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal
oxygen uptake. Diabetes Care 1998 Aug; 21(8): 1353-1355.
– Ibanez, J. Twice-Weekly Progressive Resistance Training Decreases Abdominal Fat and Improves
Insulin Sensitivity in Older Men With Type 2 Diabetes Diabetes Care 2005 Mar; 28(3): 662-667.
• Cardiovascular Exercise
– Eriksson, J. et al Aerobic endurance exercise or circuit-type resistance training for individuals with
impaired glucose tolerance? Hormone and Metabolic Research 1998
– Albright, A American College of Sports Medicine position stand. Exercise and type 2 diabetes.
Medicine and Science in Sports 2000

28. Fat
• Increased Fat = Impaired Insulin Sensitivity
– Lee JS, Pinnamaneni SK, Eo SJ, Cho IH, Pyo JH, Kim CK, Sinclair AJ, Febbraio MA, Watt MJ. Saturated, but not n–6 polyunsaturated, fatty acids
induce insulin resistance: role of intramuscular accumulation of lipid metabolites. J Appl Physiol 100: 1467–1474, 2006.
– Leyton J, Drury PJ, Crawford MA. Differential oxidation of saturated and unsaturated fatty acids in vivo in the rat. Br J Nutr 57: 383–393,
1987.
– Lonnqvist F, Arner P, Nordfors L, Schalling M. Overexpression of the obese (ob) gene in adipose tissue of human obese subjects. Nat Med 1:
950 -953, 1995.
• Increased Fat Consumption = Impaired Insulin
Sensitivity
– Maron DJ, Fair JM, Haskell WL. Saturated fat intake and insulin resistance in men with coronary artery disease. The Stanford Coronary Risk
Intervention Project Investigators and Staff. Circulation 84: 2020–2027, 1991.
– Montell E, Turini M, Marotta M, Roberts M, Noe V, Ciudad CJ, Mace K, Gomez-Foix AM. DAG accumulation from saturated fatty acids
desensitizes insulin stimulation of glucose uptake in muscle cells. Am J Physiol Endocrinol Metab 280: E229–E237, 2001.
– Vessby, V et al. Substituting dietary saturated for monounsaturated fat impairs insulin sensitivity in healthy men and women: The KANWU
study, Diabetolopgia, 2001: 44: 3 (312-219))
– Mayer-Davis, EJ et al. Dietary fat and insulin sensitivity in a triethnic population: the role of obesity. The Insulin Resistance Atherosclerosis
Study (IRAS), AJCN, 1997 65: 1: 79-87.

30. Meat
• Meat consumption impairs Insulin Sensitivity
– Jung Hung et al Taiwanese vegetarians have higher insulin sensitivity than omnivores British Journal of Nutrition
2006
– Kuo et al. Insulin sensitivity in Chinese ovo-lactovegetarians compared with omnivores European Journal of Clinical
Nutrition 2004
• Meat Consumption increases risk of Type
Two Diabetes
– Fung et al Dietary Patterns, Meat Intake, and the Risk of Type 2 Diabetes in Women Arch Intern Med 2004
– Micha et al Red and Processed Meat Consumption and Risk of Incident Coronary Heart Disease, Stroke, and Diabetes
Mellitus A Systematic Review and Meta-Analysis Circulation, 2010
– Pan et al Red meat consumption and risk of type 2 diabetes: 3 cohorts of US adults and an updated meta-analysis
ACJN 2011
– Van Der Mann Dietary Fat and Meat Intake in Relation to Risk of Type 2 Diabetes in Men Diabetes Care 2002 Mar;
25(3): 417-424.
– Aune, D. et al. Meat consumption and the risk of type 2 diabetes: a systematic review and meta-analysis of cohort
studies Diabetologie November 2009, Volume 52, Issue 11, pp 2277-2287

31. Meat
• Dietary Protein Intake and Risk of Type 2
Diabetes in US Men and Women Am. J. Epidemiol,
March 2016
• Investigated the associations between total, animal, and vegetable protein and
incident T2D in 72,992 women from the Nurses' Health Study (1984–2008), 92,088
women from Nurses' Health Study II (1991–2009) and 40,722 men from the Health
Professionals Follow-up Study (1986–2008).
• “Substituting 5% of energy intake from vegetable protein for animal
protein was associated with a 23% (95% CI: 16, 30) reduced risk of
T2D. In conclusion, higher intake of animal protein was associated with an
increased risk of T2D, while higher intake of vegetable protein was associated with
a modestly reduced risk.”

32. Meat
• Low Carbohydrate–Diet Scores and Long-
term Risk of Type 2 Diabetes Among Women
With a History of Gestational Diabetes
Mellitus: A Prospective Cohort Study Diabetes Care
January 2016 vol. 39 no. 1 43-49
– Among women with a history of GDM, a low-carbohydrate dietary pattern,
particularly with high protein and fat intake mainly from animal-source foods, is
associated with higher T2DM risk, whereas a low-carbohydrate dietary pattern with
high protein an fat intake from plant-source foods is not significantly associated
with risk of T2DM.

33. Meat
• The Less meat consumed the lower the risk
of Type 2 Diabetes
– Type of Vegetarian Diet, Body Weight, and Prevalence of Type 2 Diabetes
Tonsted, S et al Adventist Health Study Diabetes Care May 2009 vol. 32 no. 5
791-796
• vegans (OR 0.51 [95% CI 0.40–0.66])
• lacto-ovo vegetarians (0.54 [0.49–0.60])
• pesco-vegetarians (0.70 [0.61–0.80])
• semi-vegetarians (0.76 [0.65–0.90])
• As compared to nonvegetarians.

35. Inflammation and Insulin resistance
• Elevated Levels of Pro-inflammatory Cytokines
Impair Insulin Sensitivity
– Olson NC et al. Circulating levels of TNF-α are associated with impaired glucose tolerance, increased
insulin resistance, and ethnicity: The insulin resistance atherosclerosis study. J Clin Endocrin Metab.
2012.
– Bradley JR. TNF-mediated inflammatory disease. J Pathol. 2008; 214:149-160.39.
– Cawthorn WP, Sethi JK. TNF-α and adipocyte biology. FEBS Lett. 2008; 582:117-131.40. Moller DE.
Potential role of TNF-α in the pathogenesis of insulin resistance and type 2 diabetes. Trends
Endocrinol Metab. 2000; 11:212-217.
• Fruit and Vegetable Intake reduce levels of Pro-
Inflammatory Cytokines
– Root, M et al. Combined Fruit and Vegetable Intake Is Correlated with Improved Inflammatory and
Oxidant Status from a Cross-Sectional Study in a Community Setting Nutrients 2012, 4(1), 29-41

36. Influencing the Transporter
• Insulin
• Exercise
• Fat
• Meat
• Inflammation

37. Clinical Application in Review

38. Diabetes
• Does a vegetarian diet reduce the occurrence of
diabetes? American Journal of Public Health, Vol. 75, Issue 5 507-512
– 25,698 adult White Seventh-dayAdventists identified in 1960 followed for 21 years
– vegetarians had a substantiallylower risk than non-vegetarians of diabetes as an
underlyingor contributing cause of death
• Fruit and Vegetable Consumption and Diabetes
Mellitus Incidence among U.S. Adults Preventive Medicine Vol 32 Iss
1 January 2001. Pages 33-39
– Appr. 10, 000 participants, highest fruit and vegetable consumption = lowest risk of
T2D
• Dietary Patterns and the Incidence of Type 2
Diabetes Am. J. Epidemiol. (2005) 161 (3): 219-227.
– 4,000 Finnish men and women, followed 23 years
– Highest consumption of fruits/vegetables in prudent diet resulted in decreased risk

39. Diet and Exercise in the Treatment of NIDDM:
The need for early emphasis
Diabetes Care December 1994 vol. 17 no. 12 1469-1472
• 652 with NIDDM
• 3-week intensive dietary modification
program
• 71% of 197 on oral hypoglycemic agents and
39% of 212 on insulin were able to
discontinue their medication with normalized
BS’s

40. Pritikin Program
• Pritikin et al Long-Term Use of a High-Complex-Carbohydrate,
High-Fiber, Low-Fat Diet and Exercise in the Treatment of NIDDM
Patients Diabetes Care 1983
– 26 day inpatient stay, 77% off Oral Hypoglycemics, 25%  in TC
• Effect of Short-Term Pritikin Diet Therapy on the Metabolic
Syndrome Journal of Cardio-Metabolic Disease 2006
– 12-15 day stays, BMI 3%, SBP, SG, LDL  10-15%
– 37% no longer met criteria for Metabolic Syndrome

41. Toward Improved Management of NIDDM: A
Randomized, Controlled, Pilot Intervention
Using a Low-fat, Vegetarian Diet
Preventive Medicine, Volume 29, Number 2, August 1999 , pp. 87-91(5)
Over 12 weeks, 28% mean reduction in fasting serum
glucose of the experimental group, from 10.7 to 7.75
mmol/L (195 to 141 mg/dl), was significantly greater
than the 12% decrease, from 9.86 to 8.64 mmol/L
(179 to 157 mg/dl), for the control group (P < 0.05).
The mean weight loss was 7.2 kg in the experimental
group, compared to 3.8 kg for the control group (P <
0.005).

42. Regression of Diabetic Neuropathy with Total
Vegetarian (Vegan) Diet
• 21 pts with T2D and SDPN average age of 64
• Low fat (10–15% of cal), high fiber, total vegetarian diet (TVD) of
unrefined foods and conditioning exercise
• 17/21 (81%) had complete relief of the SDPN pain in 4 to 16 days.
• Weight loss averaged 4-9 ± 2-6 kg during the 25 days.
• By the 14th day, the fasting blood glucose level averaged 35% lower
• 5 got off hypoglycemic agents
• Serum triglyceride and total cholesterol had decreased by 25-0 ±
23% and 13 ± 15% respectively (p <0-01) in 2 weeks.
• Follow-up studies of 17 of the 21 patients for 1-4 years indicated that
71% had remained on the diet and exercise program as advised in
nearly every item.
Journal of Environmental and Nutritional Medicine 1994, Vol. 4, No. 4 , Pages 431-439

43. Multi-System Benefit
A Low-Fat Vegan Diet Improves Glycemic Control and
Cardiovascular Risk Factors in a Randomized Clinical
Trial in Individuals With Type 2 Diabetes
Diabetes Care August 2006 vol. 29 no. 8 1777-1783
– 100 people randomized vegan vs ADA diet
22 weeks
– 43% VG 26% ADA reduced diabetes
medications.
– HbA1c (A1C)  0.96 points VG 0.56 points
in the ADA group
– Excluding those who changed medications,
A1C fell 1.23 points in the vegan group
compared with 0.38 points in the ADA
group
– Body weight  6.5 kg VG and 3.1 kg ADA
– LDL cholesterol  21.2% in the vegan
group and 10.7% in the ADA group (P =
0.02).
– urinary albumin reductions 15.9 mg/24h
VG than in the ADA group 10.9 mg/24 h
• A low-fat vegan diet and a conventional diabetes diet in the
treatment of type 2 diabetes: a randomized, controlled, 74-
wk clinical trial
Clin Nutr May 2009 vol. 89 no. 5 1588S-1596S
• Weight loss was significant within each diet group but not
significantly different between groups (−4.4 kg in the vegan
group and −3.0 kg in the conventional diet group, P = 0.25)
and related significantly to Hb A1c changes (r = 0.50, P =
0.001). Hb A1c changes from baseline to 74 wk or last
available values were −0.34 and −0.14 for vegan and
conventional diets, respectively (P = 0.43). Hb A1c changes
from baseline to last available value or last value before any
medication adjustment were −0.40 and 0.01 for vegan and
conventional diets, respectively (P = 0.03). In analyses before
alterations in lipid-lowering medications, total cholesterol
decreased by 20.4 and 6.8 mg/dL in the vegan and
conventional diet groups, respectively (P = 0.01); LDL
cholesterol decreased by 13.5 and 3.4 mg/dL in the vegan
and conventional groups, respectively (P = 0.03).Conclusions:
Both diets were associated with sustained reductions in
weight and plasma lipid concentrations. In an analysis
controlling for medication changes, a low-fat vegan diet
appeared to improve glycemia and plasma lipids more than
did conventional diabetes diet recommendations. Whether
the observed differences provide clinical benefit for the
macro- or microvascular complications of diabetes remains
to be established.

44. Retrospective Cohort Study
Outcomes: Incidence of CVD events
379,0003 Diabetics to 9 Million non-DM2
Diabetics four times more likely to have CVD
“Diabetes confers an
equivalent risk to
ageing 15 years!”

45. Identify five science-based diabetes prevention
strategies for patients.

46. Finnish Diabetes Prevention Trial
Total 522: 172M 350W
Av. age 55
Av. BMI 31
Randomized to standard of care or
individualized lifestyle counseling
Av. f/u 3.2 yrs
Risk of
Diabetes ↓ 58 %
(P<0.001)
N Engl J Med 2001;344:1343-50
“The reduction in the incidence of diabetes was
directly associated with changes in lifestyle”

47. Weight
• Achieve > 5% of total weight loss

48. Associated Pathology
• CVD:
– Hypertension
– Congestive Heart Failure
– PVD
– Impotence
– Claudication
• Endocrine:
– Diabetes
– PCOS
– Hypothyroidism
– Infertility
• Orthopedics:
– Osteoarthritis
– AVN
• Hepatic:
– #1 cause of liver dz in US
• Obstetrics:
– Gestational DM
– Macrosomia
– Inc. C Section rate
– Inc. Perinatal Morbidity
– Inc. Pre/Eclampsia
• Cancer:
– Prostate
– Colon
– Breast
– Endometrial
– Renal Cell
– Gallbladder
– Esophageal Adeno.
• Other:
• Hyperuricemia, Pancreatitis,
Gallstones, Sleep Apnea, Alzheimer’s,
Dyslipidemia, Metabolic Syndrome

49. Fat Intake
• Total fat < 30% of daily calories

50. Fat Intake
• Ornish < 10% from fat
• Esselstyne < 10% from fat
• Mcdougall < 10% from fat
• Pritikin < 10% from fat
• Rice Diet 2% from fat
• China Study <15% from fat

51. Fat Intake
• Goals?
– “Pretty Good” Health
– Prevention
– Reversal
– “Excellent” Health

52. Saturated Fat
• < 10% of total Calories

53. Fiber Intake
• > 15g per 1000 kcal

54. Fiber Intake
• 16g /day: USDA 2014

55. 8% from Fruits
and Vegetables
8% from Fruits
and Vegetables
≈ 50% from Added
fat/oil and
processed flour
≈ 50% from Added
fat/oil and
processed flour

61. • Physical activity > 30 min per day

62. Exercise
• Leisure time Exercise: organized sports,
running, gym activities, rehabilitation etc.
• Lifestyle Exercise: activity incorporated into our
daily pattern of life
– eg: parking in the distant portion of the parking lot rather then the first
bumper, taking the stairs instead of the elevator etc.

63. Types of Physical Activity
• Cardiovascular
• Strength/Resistance Training
• Core Stability/Balance
• Flexibility/Coordination

64. Present Recommendations
• Cardiovascular:
– 150 minutes of moderate-intensity exercise per
week.

65. Present Recommendations
• Resistance Training:
– 2-3 days per week
– All major muscle groups
– 2-4 sets of each exercise
– 48 hours in between sessions
http://www.acsm.org/about-acsm/media-room/news-releases/2011/08/01/acsm-issues-new-
recommendations-on-quantity-and-quality-of-exercise

66. Present Recommendations
• Flexibility:
– 2-3 days/week to improve range of motion
• Balance:
– 2-3 days/week
– Eg: Tai Chi, Yoga

67. Which is best?
• Cardiovascular
• Resistance Training
• Both
Whatever they are
willing to do?
Whatever they are
willing to do?

68. Outline
• Eat MORE plants
• Eat less/no animal based and refined foods
• Move

69. Stages of Change (Prochaska and DiClemente)
1: Pre-contemplation
2: Contemplation
3: Preparation/planning
4: Action
5: Maintenance
6: Permanent Maintenance (Termination)

70. Examples
• Seek Opportunity
– Fear of Death/Amputation
– Cost of Care
– Loss of Function
– Side effects of Drugs
– Image/Sexual function
– Performance

71. Examples
• Practice and Enhance Marketing

72. Conclusion
• Scientific Evidence is clear/incontrovertible
• Plant Based nutrition can prevent and reverse
Type 2 Diabetes
• The greater the changes, the more rapid and
significant the changes
• Readiness for change and “marketing” of the
product influence clinical success

73. Thank You!