nutritional issues in the outpatient setting

Nutritional Issues in the Outpatient Setting

Iris Thiele Isip Tan MD, FPCP, FPSEMClinical Associate Professor, UP College of Medicine

Section of Endocrinology, Diabetes & Metabolism, UP-PGH

21 May 2010

http://www.endocrine-witch.info



Low CHO vs low fat

diets

1Low

protein diet in kidney disease

3

Glycemic index/

glycemic load

2

Vegan diet & trace minerals

4

Medical Nutrition

TherapyDIABETES

0

25

50

75

100

LFHC HFLC

CHON CHON

FatFat

CHOCHO

Low fat = High CHO

What is the optimal CHO-to-fat ratio?

LOW FAT↓ energy intake Reduce weight

HIGH CHO↑ glucose,

insulin, triglycerides

RecommendationCHO 45-65% Min 130 g/day

Dietary CHO (Amount & Type) in the Prevention & Management of Diabetes: American Diabetes Association Position Statement (2004)

Meta-analysis

CHO-to-fat ratio in Type 2 diabetes

Kodama et al. Diabetes Care 2009;32:959-65

Randomized trials (19; n=306)Similar energy and CHON intake between groups

Low-fat, high-CHOCHO/Fat 58%/24%

High-fat, low-CHOCHO/Fat 40%/40%vs

Measured FPG & insulin; >1 wk interventionParallel and cross-over designs

Studies excluded:change in content/quality of CHO (↑ fiber/whole grains)

Meta-analysis

CHO-to-fat ratio in Type 2 diabetes

↓ ↑NS

A1c, FPG, total chol and

LDL-C

Fasting insulin (p=0.02)

Triglycerides* (p<0.001)

2-h glucose & insulin (p<0.001)

HDL-C (p<0.001)

Low-fat, high-CHOCHO/Fat 58%/24%

High-fat, low-CHOCHO/Fat 40%/40%vs

Kodama et al. Diabetes Care 2009;32:959-65

* Insignificant when energy intake restricted

0

25

50

75

100

LFHC High MUFA

Replace saturated fat with MUFA or CHO?

High MUFA Mediterranean diet

Vegetables, fruits, whole grains, legumes, nuts, olive oil

CHON

Fat

CHO

Replace saturated fat with MUFA

MUFA

Dietary Sources of MUFA

Animal products SFAg

MUFAg

PUFAg

Ground beef, regular, 100 g

10.8 11.6 1.1

Fried eggs, 2 pcs 4.2 6.0 2.8

Regular butter, 25 g 12.6 5.9 0.8

Fried bacon, 3 slices 3.3 4.5 1.1

Nuts(100 g)

SFA g

MUFAg

PUFAg

Macademia 12.1 58.9 1.5

Hazelnuts 4.5 45.7 7.9

Pecans 6.2 40.8 21.6

Almonds 3.9 32.2 12.2

Cashews 9.2 27.3 7.8

Peanuts 6.8 24.4 15.6

Pistachios 5.4 23.3 13.4

Fruit (100 g)

SFAg

MUFAg

PUFAg

Avocado 2.4 9.6 2.0

Olives 1.4 7.9 0.9

Vegetable oils

(100 g)

SFAg

MUFAg

PUFAg

Sunflower 9.7 83.6 3.8

Safflower 6.2 74.6 14.4

Olive 13.5 73.7 8.4

Canola 7.1 58.9 29.6

Ros E. Am J Clin Nutr 2003;78(suppl):617S-25S

One-year data

High-MUFA vs high-CHO in Type 2 diabetes

RCT x 1 y18 mos extension M

Weight loss Body fat Waist circ Diastolic BP HDL-C A1c Fasting glucose & insulin O

Overweight/obese Type 2 diabetes (n=124) P

High-MUFA: 45% CHO, 15% CHON & 40% fat (20% MUFA)High-CHO: 60% CHO, 15% CHON & 25% fat I

Brehm et al. Diabetes Care 2009;32:215-20

One-year data


High-CHO High-MUFABaseline 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

Blood pressure130/77 + 2.0/1.6

129/73 + 2.3/1.4

132/78 + 2.3/1.4

130/73 + 2.4/1.5

Similar time effectsp<0.01

High-MUFA = High-CHO


One-year data


mg/dLHigh-CHO High-MUFA

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

Significant ↑ HDL-C p<0.01



One-year data


High-CHO High-MUFABaseline 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



Similar time effectsp<0.01

0

25

50

75

100

LFHC High MUFA

Replace saturated fat with MUFA or CHO?

High MUFA good alternative

Comparable beneficial effects on body weight, body composition, CV risk factors & glycemic controlCHON

Fat

CHO

MUFA

Replace saturated fat with MUFA


Low CHO vs low fat

diets

1Low


3

Glycemic index/

glycemic load

2


4

Medical Nutrition

TherapyDIABETES

Glycemic Index (GI)

DefinitionIncrease in blood glucose (over fasting level) in 2 h following ingestion of 50 g CHO

_______Test food______ Reference food

Low GI0-55

High GI>70

Intermediate56-69

Llona A. Nutr Hosp 2006;21:53-59

Glycemic CHO Availability in the GI tract

Available food carbohydrates

Stomach

Small intestine

Portal circulation

Gastric emptying

Disruption/digestion

(Rate limiting)

(Rate limiting)

macronutrient compositionfiber contentviscosityvolume & structure of the food

Riccardi et al. Am J Clin Nutr 2008;87(suppl):269S-74S

Issues with Glycemic Index

Dietary CHO (Amount & Type) in the Prevention & Management of Diabetes: American Diabetes Association Position Statement (2004)

Only accounts for CHO type (not total

amount)

1

GI for any particular food item highly

variable

3

Measures response to individual food

consumed in isolation

2Inaccurate predictor

of postprandial response in diabetes

4

Glycemic Load (GL)

DefinitionQuantitates the impact of a usual portion of a food with known GI

GL = GI x CHO net content per portion (g) / 100

Low GL<10

High GL>20

Intermediate11-19


GI 72 (50 g = 4 1/2 cups)1/2 cup = 5.75 g CHOGL = (5.75 x 72)/100 = ~4

Low GI Interm GI High GI

Low GL

Whole meal cerealsPeanut

Strawberries

PineappleMelon

PopcornWatermelonWhole wheat

bread

Interm GL

BananaFettucine

White bread

Refined cerealsSweet

potatoesWhole rice

CherriesToasted flour

High GLNoodlesMacaroniSpaghetti

CouscousRefined

rice

PotatoesCornflakes

GI vs GL of Selected Foods


Randomized controlled trials (11; n=402)Intervention 4-52 wks; Follow-up 12 mos

Low GI or Low GL diet

Higher GI dietvs

Glycemic control: HbA1c & fructosamineAdverse events: hypo-/hyperglycemia

Parallel and cross-over studiesTwo studies involved children

Cochrane Review

Low GI or low GL Diets for Diabetes

Thomas & Eliott. Cochrane Database of Systematic Reviews 2009

Cochrane Review

Low GI or low GL Diets for Diabetes

Low GI or Low GL diet

Higher GI dietvs

Thomas & Eliott. Cochrane Database of Systematic Reviews 2009

HbA1c reductionParallel trialsWMD -0.5% (95% CI -0.9,-0.1) p=0.02

Crossover trialsWMD -0.5% (95% CI -1.0,-0.1) p=0.03

Fewer episodes of

hypoglycemia(1 trial)

Difference -0.8 episodes/patient/month (p<0.01)

NO STUDYreported on mortality,

morbidity or costs

Canadian Trial of CHO in Diabetes

Low-GI diet for Type 2 diabetes on diet alone

Wolever et al. Am J Clin Nutr 2008;87:114-25

Randomized controlled trial x 12 mos

M

Type 2 diabetes on diet alone (n=162)

P

High-GI vs low-GI vs low-CHO diets

I

0

25

50

75

100

High-GI Low-GI low-CHO

GI 63 GI 55 GI 59

Fat

CHO

OHbA1c, FPG, OGTT Body weightBlood pressureLipids & CRP


FBS↑

Body wtHbA1c

NS

Low GI

High GI

Low CHO

↓ 2h post-load BG


0 3 6 129 0 3 6 129Time in study (mos)

Total cholesterol Triglycerides

LDL-C HDL-C

Low GI

High GI

Low CHOTriglycerides12% vs low-CHO

↑Total chol

LDL-C

NS ↓HDL-C

4% vs low-CHO


were only !1/3 of the differences at 3 mo. In addition, triacyl-glycerol and HDL may not be the most relevant markers of CVDrisk. Therapy of dyslipidemia to reduce CVD risk is based ontargets for LDL cholesterol and total:HDL cholesterol (62). Al-though we found no effect on LDL cholesterol, there was asignificant time " diet interaction for total:HDL cholesterol.There was a difference of !10% in total:HDL cholesterol at 3mo, which is consistent with the results of short-term studies (44,63), but this difference was not present at 6, 9, and 12 mo.Because the effects of high-CHO diets on triacylglycerol andHDL-cholesterol concentrations appear to be similar in subjectswith (16) and without (63) diabetes, our results may apply tomore than subjects with diabetes treated with diet alone. We haveno data to explain long-term adaptation, but it may be due tochanges in colonic fermentation (64) or insulin sensitivity sec-ondary to changes in body composition (65). However, reducedadherence to the dietary treatments is not a likely explanation.The key-food diaries and 3-d food records show no change incompliance or dietary composition across the study. In addition,

the significant or nearly significant time " diet interactions forseveral variables (eg, FPG, 2-h post-OGTT glucose, and CRP),in which the differences among diets increase at the end of thestudy, are not consistent with reduced dietary adherence.

Our most novel finding was the larger, more sustained reduc-tion in CRP with the low-GI diet than with the high-GI diet. The29% difference is greater than that elicited by pravastatin inT2DM patients, ie, 13% (9), and similar to the differences elicitedby atorvastatin, ie, !25% (10), and rosiglitazone, ie, !25% (11).These findings are consistent with a prospective study showingthat CRP concentrations in diabetic women were inversely re-lated to diet GI but not to diet GL (66). Hyperglycemia inducesthe release of inflammatory cytokines from monocytes (67).Although differences in HbA1c cannot explain the differences inCRP that we observed, differences in glucose fluctuations maybe involved. Exposing endothelial cells to fluctuating glucoseconcentrations, rather than to the same average but constantconcentration, increased oxidative stress and apoptosis (68), andthose increases, in turn, may trigger proinflammatory responsesand greater release of CRP (69). Thus, the reduction in CRP thatwe observed may be related to the lower postprandial glucoseincrements seen with the low-GI diet than with the other diets. Inthis context, it is of interest that the treatment of T2DM patientswith repaglinide induced larger reductions in postprandial glu-cose and serum CRP than did treatment with glyburide, despiteno difference in HbA1c, and that this treatment also was associ-ated with greater regression of carotid artery atherosclerosis (70).

We conclude that, in T2DM patients treated with diet alonewho have optimal glycemic control, long-term HbA1c was notaffected by altering the source or the amount of dietary carbo-hydrat. The deleterious effects of the high-CHO diets on total:HDL cholesterol had disappeared by 6 mo. The low-GI dietelicited sustained reductions in postprandial glucose and CRP,and, for these reasons, it may be preferred for the dietary man-agement of T2DM.

The authors’ responsibilities were as follows—TMSW: had full access toall of the data in the study and takes responsibility for the integrity of the dataand the accuracy of the data analysis; TMSW, ALG, CM, J-LC, PWC, RGJ,LAL, PM, RR-L, NWR, and EAR: study design and concept; TMSW, CM,J-LC, PM, RR-L, NWR, and EAR: acquisition of data; TMSW and ALG:analysis and interpretation of data; TMSW: drafting of the manuscript;TMSW, ALG, CM, J-LC, PWC, RGJ, LAL, PM, RR-L, NWR, and EAR:

FIGURE 5. Mean (and 95% CI) serum C-reactive protein (CRP) con-centrations in subjects receiving the high-glycemic-index (F; n # 43), low-glycemic-index (E; n # 48), and low-carbohydrate (Œ; n # 50) diets. Valuesare the residuals of a regression model that included the baseline value andBMI (the only other significant confounding variable). The statistical anal-ysis was performed on the natural logarithms of the CRP concentrations,which are shown here as percentage changes from baseline. Main effect ofdiet, P # 0.0078.

TABLE 5Composition of breakfast test meals at baseline and after 1 y1

Diet Energy Fat Protein Carbohydrate Dietary fiber GI GL

kcal g g g g % gHigh-GI (n # 31)

Baseline 511 $ 18 13 $ 0.5 14 $ 0.5 84 $ 3 2.6 $ 0.1 65 $ 0.1 54 $ 21 y 511 $ 18 13 $ 0.5 14 $ 0.5 84 $ 3 2.6 $ 0.1 65 $ 0.1 54 $ 2

Low-GI (n # 14)Baseline 441 $ 30 11 $ 0.8 12 $ 0.8 72 $ 5 2.2 $ 0.1 65 $ 0.3 47 $ 31 y 456 $ 33 13 $ 1.5 16 $ 1.2 70 $ 5 21.9 $ 1.6 50 $ 0.2 35 $ 2

Low-CHO (n # 16)Baseline 503 $ 30 13 $ 0.7 14 $ 0.8 82 $ 5 2.6 $ 0.2 65 $ 0.3 53 $ 31 y 515 $ 29 23 $ 1.3 15 $ 0.9 62 $ 4 2.9 $ 0.2 65 $ 0.1 40 $ 2

1 All values are x! $ SEM. GI, glycemic index; GL, glycemic load; CHO, carbohydrate. At baseline, all subjects received a high-CHO, high-GI breakfast.At 1 y, subjects received a breakfast that represented the study diet to which they had been randomly assigned; thus, subjects randomly assigned to the high-GIdiet received identical test meals at baseline and after 1 y, and subjects randomly assigned to the low-GI or low-CHO diet received low-GI or low-CHO breakfasttest meals at 1 y.

LOW-GI VS LOW-CARBOHYDRATE DIET IN DIABETES 123

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10

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nlo

ad

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from

Low GI

High GI

Low CHO

CRP 1.95 mg/L

CRP 2.35 mg/L

CRP 2.75 mg/L CRP (low-GI) less than

CRP (high-GI) by 30%

(p=0.0078)

Low GI vs ADA Dietary Education in Type 2 Diabetes

Yunsheng et al. Nutrition 2008;24(1):45-56

Randomized controlled trial x 12 mos

M

Baseline, mos. 6 & 12Diet, physical activity, psychosocial factors,

diabetes medication use, weight, A1c, lipids

O

Poorly-controlled Type 2 diabetes (n=40)

P

Low GI vs ADA diet8 educational sessions (monthly x 6 mos then

at mos. 8 & 10)

I

Low GI diet ADA dietvs

Low GI vs ADA Dietary Education in Type 2 Diabetes

Yunsheng et al. Nutrition 2008;24(1):45-56

↓ LDL at 12 mos (p=0.03)

↓ DBP at 6 mos (p=0.03)

↓ switch to new drug or increase dose (OR 0.26, p=0.01)

Similar↓ HbA1c & total cholesterolUnchanged HDL & triglycerides for bothWeight loss NS for both

Low CHO vs low fat

diets

1Low


3

Glycemic index/

glycemic load

2


4

Medical Nutrition

TherapyDIABETES

Meta-analysis

Low-protein diet for diabetic nephropathy

Yu Pan et al. Am J Clin Nutr 2008;88:660-6

Randomized controlled trials (8; n=519)Duration >6 mos

Low-protein diet (LPD)

Normal protein dietvs

Rate of Δ GFRΔ urinary CHON excretion & serum albumin

Excluded cross-over studiesType 1 and Type 2 diabetic nephropathy


Meta-analysis


Treatment Low-protein diet

Control Normal proteinvs

Δ GFR in patients with type 1 or type 2 diabetes mellitus

Change in WMD of GFR not significantly associated with LPD


Meta-analysis


Δ in proteinuria (type 1 or type 2 diabetes mellitus)

Significant benefit of LPD on proteinuria (p=0.003) but data

heterogeneous

Meta-analysis

Low-protein diet for diabetic nephropathyYu 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

(95%CI -1.33, 1.03 g/L)Authors’ ConclusionLPD was not associated with a significant improvement of renal function in patients with either type 1 or type 2 diabetes.

Withdrawal of Red Meat from Usual Diet

de Mello et al. Am J Nutr 2006;83:1032-8

Randomized crossover (q 4 wks)

controlled trial M

GFR, UAER, serum fatty acid, lipid profile, glycemic

control, anthropometric indices, blood pressure

O

Type 2 diabetes with macroalbuminuria (n=17)

P

Usual diet (UD) vs with chicken (CD) vs lactovegetarian low-

protein diet (LPD)

I

Withdrawal of Red Meat from Usual Diet

de Mello et al. Am J Nutr 2006;83:1032-8

Usual diet (UD)

vs

Chicken (CD)

Lactovegan low-protein diet (LPD)

↓Urine albumin excretion rationon-HDL-C

↑Serum PUFA

UD CD LPD pUAER (ug/min)

312.8 (223.7-1223.7)

269.4 (111-1128)

229.3 (76.6-999.3)

<0.001

GFR (ml/min/1.73 m)

81.8 + 22.2 83.3 + 26.1 81.9 + 25.3 0.860

Low CHO vs low fat

diets

1Low


3

Glycemic index/

glycemic load

2


4

Medical Nutrition

TherapyDIABETES

Low-fat Vegan Diet in Type 2 Diabetes

Barnard et al. Am J Clin Nutr 2009;89(suppl):1588S-96S

Randomized controlled trial x 74 weeksM

HbA1c & lipids (wks 0, 11, 22, 35, 48, 61 & 74)

Weight (wks 0, 22 &74)

O

Free-living Type 2 diabetics (n=99)

P

Low-fat vegan diet vs ADA diet

I

Avoid animal products and fatty foods

Favor low-GI foods

BOTH diets reduced weight

and lipids .

Low-fat vegan diet

ADA (2003) dietvs

Better reductionHbA1c (p=0.03)Total chol (p=0.01)non-HDL-C (p=0.02)LDL-C (p=0.03)

Data analysis controlled for medications

Significant weight loss within each group but NS between groups

(-4.4 kg vegan vs -3.0 kg ADA diet, p=0.25)

Low-fat Vegan Diet in Type 2 Diabetes

Barnard et al. Am J Clin Nutr 2009;89(suppl):1588S-96S

TraceMinerals

Chromium

1

Selenium

3

Zinc

2

Vanadium

5

Calcium

4

Except for calcium, NO EVIDENCE of benefit for

supplementation in diabetics without underlying deficiencies

Chehade et al. Diabetes Spectrum 2009;22:214-217

Low CHO vs low fat

diets

1Low


3

Glycemic index/

glycemic load

2


4

Medical Nutrition

TherapyDIABETES

Thank Youhttp://www.endocrine-witch.info



nutritional issues in the outpatient setting

Health & Medicine