new developments in the dietary management of diabetes nicola guess.pdf · the look ahead research...

NEW DEVELOPMENTS IN THE

DIETARY MANAGEMENT OF

DIABETES

BACPR Annual Conference 6-7th October 2016

‘Applying Evidence to Practice’

Nicola Guess, RD MPH PhD

Lecturer in Nutrition & Dietetics, King’s College London

Honorary Researcher, Imperial College London

Slides by Dr Louise Goff, Senior Lecturer, KCL, except where noted.

Overview

Aims of dietary management of diabetes

Effectiveness of dietary management

Current guidelines – the evidence and the application

Current controversies

Aims of diabetes dietary management

Your average diabetes

patient…

- Type 2 diabetes

- Hyperlipidemia

- Hypertension

- Overweight

AIMS OF DIETARY MANAGEMENT

[1.] Optimise blood glucose control

[2.] Manage & minimise cardiovascular

risk factors

[3.] Prevent chronic complications

Diabetes dietary management is highly effective

Effects of dietetic counselling, n=2906 newly

diagnosed T2D

Monthly appointments, 3 months duration

Individualised advice, BDA guidelines

-4.61

kg

-2.03

%

-0.28

mmol

/l

-0.23

mmol

/l

-0.41

mmol

/l

Body weightHbA1cT-Cholesterol LDL-C Triglycerides

Manley SE et al. Diab Med 2000; 17: 518-523

RCT of 6 months intensive

individualised dietary advice

(EASD), n=93

8 dietitian appts in 6 mths


Coppell KJ et al. BMJ 2010; 341: c3337

-1.3

kg

-0.4

%

-0.5

kg/m2

-1.6

cm

Body weightHbA1cBMI Waist

Difference between

intervention and

control at 6 months

Effectiveness in a ‘real world’ setting

221 T2D patients, referred for nutrition education & counselling


Lemon CC et al. J Am Diet Assoc 2004; 104: 1805-1815.

Weight

Glycaemic control

Cardiovascular

risk factors

Current guidelines for dietary advice

What type?How much?

- sugar-free, ‘diabetic foods’

- low carbohydrate

- 50% carbohydrate

A SHIFT

IN FOCUS

Obesity is responsible for 80% of the population attributable risk for

diabetes (Laaksonen MA et al. 2010. Eur J Epidemiol)

7-fold greater risk of diabetes in obesity (BMI ≥30 kg/m2) and 3-fold

in overweight (BMI >25 and ≤30 kg/m2) (Abdullah A et al. 2010. Diab Res Clin

Prac)

4.5-9% relative increase in T2D risk for every 1 kg weight gain(Mokdad et al. 2000 Diabetes Care 23(9);1278-83)

60% to 90% of T2D appears related to weight gain (Anderson et al.

2003 AJCN 22(5);331-339)


Weight loss of 10% of initial body weight dramatically improves glycaemic control and reduces lipids and BP

BMI <25 kg/m2 is recommended for persons with T2D

Effects of weight loss with very low energy diets on fasting plasma glucose

values for obese persons with type 2 diabetes.

Mean values from 10 studies (see text) including 152 subjects.

Anderson et al. (2003) Importance of weight management in Type 2

Diabetes: Review with Meta-Analysis of Clinical Studies. J Am Coll Nutr

22(5);331-339.


Shifting the focus to weight loss

The Look AHEAD study

…‘provide a definitive assessment of the long-term health consequences of intentional weight loss’

5,145 overweight men and women with type 2 diabetes

16 US centres

Standard care vs intensive lifestyle

12 years follow-up

Outcome: cardiovascular morbidity &

mortality

Management of Diabetes

Intensive lifestyle intervention goals:

1. Achieve mean weight loss of 7% of initial weight

2. Increase physical activity to ≥ 175 minutes a week


Intensive lifestyle intervention goals:

1. Achieve mean weight loss of 7% of initial weight

2. Increase physical activity to ≥ 175 minutes a week


Frequency Format of sessions Weight loss goal Activity goal

PHASE I

Months 1-6

Months 7-12

Weekly

3 per month

3 group, 1 individual

2 group, 1 individual

Lose ≥ 10% of initial weight

Continued loss or weight

maintenance

Exercise ≥ 175 min/wk by mo. 6

Increase min/wk; 10,000

steps/day goal

PHASE II

Years 2-4 Min. 1 per

month

1 individual + min. 1

contact by phone/email

Weight maintenance, reverse

weight gain as it occurs

Maintain high levels of physical

activity

PHASE III

Year 5+ Monthly Individual Prevention of weight gain Prevention of inactivity


Group Education:

-cost effective

-social support

-healthy competitiveness

Individual Counselling:

-individual tailoring e.g. culture, ethnicity

-creates a stronger bond, share more personal details

-safety net for participants who stop group attendance

-continuity of care

Dietary Intervention:

-energy prescription

-portion control

-meal replacements

-low fat, low saturated fat

Physical Activity:

-walking

-steadily increase

-lifestyle activity e.g. stairs

rather than escalators

-supervised activity classes

Behaviour Modification:

-recording food intake &

activity

-weight measurements

-education

-homework assignments

FORMAT

CONTENT

The Look AHEAD Research Group. Obesity. 2006 May; 14(5): 737-752


The Look AHEAD Research Group. N Engl J Med

2013; 369: 145-54

• 8.6% weight loss in the intervention

group vs 0.7% in the control at 1 year

• 6.0 vs 3.5% weight loss at trial end


Usual care Intensive dietary interventionIntensive dietary intervention

+ increased physical activity

593 newly diagnosed type 2

diabetes patients

vs vs

5-10% weight loss & maintenance

Reduced calories, fat & glycaemic index

Individual goal setting & motivational interviewing

Individual appts with dietitian every 3 months, nurse appts every 6 wks

Standard diet & exercise

advice

Doctor and nurse reviews at 6

& 12 months

30 mins brisk walking, 5

days/wk + pedometer


Between group differences at 6

months (95% CI)

p Between group differences at 12

months (95% CI)

p

Weight (kg)

Diet vs usual care -2.28 (-3.08 to -1.48) <0.001 -2.41 (-3.49 to -1.32) <0.001

Diet & activity vs usual care -2.21 (-3.01 to -1.40) <0.001 -2.25 (-3.35 to -1.16) <0.001

Diet & activity vs diet 0.08 (-0.53 to 0.68) 0.81 0.15 (-0.65 to 0.95) 0.71


Between group differences at 6

months (95% CI)

p Between group differences at 12

months (95% CI)

p

HbA1c (%)

Diet vs usual care -0.28 (-0.46 to -0.10) 0.0049 -0.26 (-0.44 to -0.08) 0.005

Diet & activity vs usual care -0.33 (-0.51 to -0.14) 0.0009 -0.21 (-0.39 to -0.02) 0.027

Diet & activity vs diet -0.05 (-0.18 to 0.09) 0.51 0.06 (-0.08 to 0.19) 0.43

Baseline HbA1c 6.7%

How to achieve weight loss in diabetes

Low

carbohydrate

diets

Very low carbohydrate

diets

Meal

replacement

diets

Commercial diet

groups

Very low calorie

diets

How to achieve weight loss in diabetes

Low

carbohydrate

diets


diets

Meal

replacement

diets

Commercial diet

groups

Very low calorie

diets

THEY ARE ALL

EFFECTIVE BUT NOT

FOR EVERYONE

Low-Carbohydrate Diets

Definition? Covers a diverse range of diets, with food choices

changing as degree of CHO restriction changes

Rationale? CHO is the only nutrient that has direct effect on blood

glucose concentrations – reducing it will improve blood glucose control

Food choices? grains, starch, sugar and fat and protein

Effective? Can be effective in short-term studies (<6mo) but as

degree of restriction increases, adherence declines

Evidence? Meta-analyses suggest “superiority” of LCHO over low-fat

over 1 year: BUT mean difference modest; drop-outs high.

Larsen RN et al. Diabetologia 2011;54: 731-740. Krebs JD et al. Diabetologia 2012;55: 905-914. Mansoor N,

Vinknes KJ et al. Br J Nutr. 2016;115(3):466-79.

Low-Carbohydrate Diets in Practice

Very Low Carbohydrate Diets

Definition? <50g/d CHO (250-300g/d in average diet)

Rationale? CHO affect blood glucose AND CHO weight

Food choices? NO grains, starch, sugar and fat & protein

Effective? Significant weight loss (12kg in 24 wks), BP, LDL-C and

glucose improvements but not different to low-fat diet. Significantly

better improvements in TG, HDL and HbA1c in low-CHO diet.

Independent of weight loss: Improvement in TG, HDL and HbA1c

Tay J. et al. Diabetes Care 2014; 169: 344-351. Mansoor N. et al. Br J Nutr. 2016;115(12):2264-6. Nuttal FQ. et

al. Nutr Metab. 2012;9(1):43. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a

randomized trial. Tay J et al. Am J Clin Nutr. 2015;102(4):780-90.

Very Low Carbohydrate Diets in Practice

Very Low Carbohydrate Diet (<50g/d) – 1500 kcals/d,

<10% saturated fat

High Carbohydrate Diet (~200g/d) – 1500 kcals/d,

<10% saturated fat

30g high fibre cereal 40g high fibre cereal

1 crispbread e.g. Ryvita 5 crispbread e.g. Ryvita

250g lean meat ½ cup cooked pasta/rice/potato

40g almonds and 20g pecans 2 slices wholegrain bread

3 cups of low-starch vegetables 80g lean meat, 80g fish

200ml skimmed milk 80g legumes

100g diet yoghurt 3 cups vegetables

20g cheese 400g fruit

30g margarine/oil of monounsaturated variety 250ml semi-skimmed milk

150g reduced fat yoghurt

20g cheese

25g margarine/oil of monounsaturated variety

Meal Replacement Diets

Definition? calorie-controlled, pre-packaged product in the form of a bar

or beverage (ready to drink or powder), that replaces a regular meal

Rationale? Restrict food choice, portion & calorie control

Food choices? Commercially available products to replace meals

Effective? Greater weight loss than reduced energy diets over the short

term

Weight loss = 7-8%

2.54 kg (P<0.01) and 2.43 kg (P=0.14) greater weight loss in the meal

replacement group for the 3-month and 1-y periods, respectively.

Heymsfield SB et al. 2003. Int J Obes Relat Metab Disord; 27(5):537-49

Meal Replacement Diets in Practice

Commercial Weight Loss Programmes

Definition? A range of commercially available weight loss

programmes – provide education & behaviour change techniques e.g.

group support, goal setting, motivational interviewing

Rationale? Support individual behaviour change relating to weight

management

Food choices? Range of approaches aiming to restrict calories, fat

and sugar

Effective? Achieve significantly greater weight loss than

control/education but not evaluated specifically in diabetes

Gudzane KA et al. Ann Intern Med 2015; 162(7): 501-512

Commercial Weight Loss Programmes in Practice

Very Low Calorie Diets

Definition? <800 kcals/d (400-800 kcals), provided in fortified liquid meals as sole source of nutrition for 12 weeks

Rationale? Significant, rapid weight loss has been shown to normalise blood glucose concentrations – ‘diabetes remission’

Food choices? NONE!

Effective? Significantly greater weight

loss than low calorie regimens BUT

not always maintained

NB: requires clinical supervision

Very Low Calorie Diets in Practice

Lighter Life

8 weeks plus 12 weeks

food reintroduction

£66/wk inc. supplements,

counsellors and group

support meetings

Cambridge Plan

Optifast

Which Diet?

Low

carbohydrate

diets


diets

Meal

replacement

diets

Commercial diet

groups

Very low calorie

diets

Which Diet?

Low

carbohydrate

diets


diets

Meal

replacement

diets

Commercial diet

groups

Very low calorie

diets

THE ONE THAT THE

PATIENT LIKES &

WILL STICK TO!

Summary – diet & diabetes management

Current Controversies

SATURATED FAT - should it be restricted or does it not matter?

Diabetes guidelines focus on restricting SF due to increased

cardiovascular risk in diabetes patients

Evidence for the role of saturated fat in cardiovascular disease has

been brought into question

Alongside this activists have focused on carbohydrate as the main

culprit in diabetes

low carbohydrate, high (saturated) fat diets

Low Carbohydrate, High (Saturated) Fat Diets

The evidence:

Saturated fats should continue to be restricted, and replaced with

monounsaturated fats for the reduction of cardiovascular risk

Low carbohydrate diets, that are not high in fat or saturated fat, are

effective for weight loss

There is no evidence upon which to recommend high fat, high

saturated fat diets in diabetes

Diabetes UK and British Dietetic Association’s Diabetes Specialist Group Policy Statement, 2015

My Views

Some evidence that in ketogenic diet, SFA does not increase LDL-C.

BUT, above a certain amount of CHO, increase in LDL-C is a concern.

Therefore delivering public health advice challenging.

Need to understand more about what people eat “low-carb”.

BUT – even in ketogenic diet, CVD risk factors IMPROVE more with

foods rich in MUFAs and PUFAs than SFAs.

Tay J et al. Am J Clin Nutr. 2015;102(4):780-90. Fuehrlein BS et al. J Clin Endocrinol Metab. 2004;89(4):1641-5. Volek JS,

et al. 2008;47(5):307-18.

Summary

Dietetic management is first line therapy in the management of

diabetes

It should focus on optimising glycaemic control, reducing cardiovascular

risk and minimising long-term diabetes complications

The primary goal should be weight management

A number of weight management options are available

Low carbohydrate diets are one option for diabetes management –

they are recommended for weight loss and should not promote

increased fat and saturated fat intakes

new developments in the dietary management of diabetes nicola guess.pdf · the look ahead research...

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