diet trends and diabetes: the state of the evidence · 2019. 11. 12. · diagnosed and undiagnosed...

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Diet Trends and Diabetes:

The State of the Evidence

Carmen Ramos, MS, RDN, CD

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

THE WELLNESS BUS

Free Screenings

– Full lipid panel

– Blood glucose/A1C

– Blood pressure

– BMI

– Waist circumference

Free Nutrition Counseling

Other services:

Free dental exams

Food demonstrations

Free community and food resources

Vision: Equal access to

diabetes prevention for

a diabetes-free future.

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

CONFLICT OF INTEREST

I have no actual or potential conflict of

interest in relation to this presentation.

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PRESENTATION OBJECTIVES

At the conclusion of this presentation,

participants will be able to:

• Describe historical dietary recommendations for

diabetes

• Describe the use and evidence of the ketogenic,

paleo, and intermittent fasting diets for diabetes

• Explain the importance of Hispanic food ways for

diabetes management

• Compare current diabetes dietary

recommendations with current food trends

INCREASING PREVALENCE OF DIABETES OVER TIME

2015

Improvements in therapies and medical management over time are factored in

7-8% 11-12% 19-20%13-14% 17-18%

Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%

Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics

INCREASING PREVALENCE OF DIABETES OVER TIMEImprovements in therapies and medical management over time are factored in

7-8% 11-12% 19-20%13-14% 17-18%

Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%

Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics

2020

INCREASING PREVALENCE OF DIABETES OVER TIMEImprovements in therapies and medical management over time are factored in

7-8% 11-12% 19-20%13-14% 17-18%

Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%

Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics

2025

INCREASING PREVALENCE OF DIABETES OVER TIMEImprovements in therapies and medical management over time are factored in

7-8% 11-12% 19-20%13-14% 17-18%

Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16%

Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics

2030

INCREASING ANNUAL COST OF DIABETES

<1 5-9 50-7010-14 30-49

Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* 1-4 20-29

*Constant 2015 Dollars

15-19

Total US $408 B

Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; Dall, The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes, Diabetes Care 2014;37:3172-3179; CDC diabetes trends, US Census Bureau

2015

INCREASING ANNUAL COST OF DIABETES

<1 5-9 50-7010-14 30-49

Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* 1-4 20-29

*Constant 2015 Dollars

15-19

Total US $491 B

Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; Dall, The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes, Diabetes Care 2014;37:3172-3179; CDC diabetes trends, US Census Bureau

2020

INCREASING ANNUAL COST OF DIABETES

<1 5-9 50-7010-14 30-49

Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* 1-4 20-29

*Constant 2015 Dollars

15-19

Total US $564 B

Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; Dall, The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes, Diabetes Care 2014;37:3172-3179; CDC diabetes trends, US Census Bureau

2025

INCREASING ANNUAL COST OF DIABETES

<1 5-9 50-7010-14 30-49

Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* 1-4 20-29

*Constant 2015 Dollars

15-19

Total US $622 B

Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; Dall, The Economic Burden of Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes, Diabetes Care 2014;37:3172-3179; CDC diabetes trends, US Census Bureau

2030

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WHAT COULD WE DO WITH $622 BILLION?

• End world hunger for 21 years ($30 billion a

year)

• Provide universal healthcare for half of the

US population

• Provide 4 years of college tuition for 3

million students

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More than half of Hispanic/Latino American

adults are expected to develop type 2

diabetes in their lifetime. (CDC, 2019)

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Historical Dietary

Recommendations for

Diabetes

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NUTRITION RECOMMENDATIONS UP TO 1900

h t t p : / / j o u r n a l . d i a b e t e s . o r g / d i a b e t e s s p e c t r u m / 0 0 v 1 3 n 3 / p g 1 1 6 . h t m

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7h t t p : / / j o u r n a l . d i a b e t e s . o r g / d i a b e t e s s p e c t r u m / 0 0 v 1 3 n 3 / p g 1 1 6 . h t m

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Current Diabetes

Recommendations

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ADA STANDARDS OF MEDICAL CARE, 2019

EVIDENCE RATINGS

Level of Evidence Description

AClear evidence from well-conducted

randomized controlled trials

BSupportive evidence from well-

conducted cohort studies

CSupportive evidence from poorly

controlled or uncontrolled studies

E Expert consensus or clinical experience

Diabetes Care, 2019

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ADA STANDARDS OF MEDICAL CARE, NUTRITION

THERAPY 2019

Diabetes Care, 2019

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ADA STANDARDS OF MEDICAL CARE, NUTRITION

THERAPY 2019

Diabetes Care, 2019

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ADA STANDARDS OF MEDICAL CARE, NUTRITION

THERAPY 2019

Diabetes Care, 2019

“Research indicates that low-carbohydrate eating

plans may result in improved glycemia and have

the potential to reduce antihyperglycemic

medications for individuals with type 2 diabetes.”

“As research studies on some low-carbohydrate

eating plans generally indicate challenges with

long-term sustainability, it is important to reassess

and individualize meal plan guidance regularly for

those interested in this approach.”

“This meal plan is not recommended at this time for

women who are pregnant or lactating, people

with or at risk for disordered eating, or people who

have renal disease, and it should be used with

caution in patients taking sodium–glucose

cotransporter 2 (SGLT2) inhibitors due to the

potential risk of ketoacidosis.”

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ADA STANDARDS OF MEDICAL CARE,

NUTRITION THERAPY 2019

Low-carb eating plans

• Improved glycemia and lipid outcomes for up to 1

year

• Wide range of definitions for a low-carbohydrate

eating plan

• Most people with type 2 diabetes report carb

consumption 44-46% of kcals

“Efforts to modify habitual eating patterns are often

unsuccessful in the long term; people generally go

back to their usual macronutrient distribution.”

Diabetes Care, 2019

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ADA STANDARDS OF MEDICAL CARE, NUTRITION

THERAPY 2019

Diabetes Care, 2019

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ADA STANDARDS OF MEDICAL CARE, NUTRITION

THERAPY 2019

Diabetes Care, 2019

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ADA STANDARDS OF MEDICAL CARE, NUTRITION

THERAPY 2019

Diabetes Care, 2019

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MACRONUTRIENT RECOMMENDATIONS

• No ideal percentage of calories from

carbohydrates, protein, & fat for all people

• Management should be individualized

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Historical

Dietary Trends

for Diabetes

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DIET TRENDS OVERVIEW

• Paleo diet

• Ketogenic diet

• Intermittent fasting

• Meal replacements

• Extreme liquid diets

• Alternative treatments

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DIABETIC COOKERY; RECIPES AND MENUSOPPENHEIMER, REBECCA 1917

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DIABETIC COOKERY; RECIPES

AND MENUSOPPENHEIMER, REBECCA

1917

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Paleo Diet

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PALEO DIET

• High protein, medium fat, low carbohydrate

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PALEO DIET AND DIABETES RESEARCH

• Small sample sizes (n<32)

• No long-term studies

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METABOLIC AND PHYSIOLOGIC EFFECTS FROM CONSUMING A

HUNTER-GATHERER (PALEOLITHIC)-TYPE DIET IN TYPE 2 DIABETES

• 24 participants

with Type 2

diabetes

• Two groups:

– Paleo diet

– ADA diet

European Journal of Clinical Nutrition (2015) 69, 944–948; doi:10.1038/ejcn.2015.39; published online 1

April 2015

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METABOLIC AND PHYSIOLOGIC EFFECTS FROM CONSUMING A

HUNTER-GATHERER (PALEOLITHIC)-TYPE DIET IN TYPE 2 DIABETES

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A PALEOLITHIC DIET WITH AND WITHOUT COMBINED AEROBIC AND

RESISTANCE EXERCISE INCREASES FUNCTIONAL BRAIN RESPONSES AND

HIPPOCAMPAL VOLUME IN SUBJECTS WITH TYPE 2 DIABETES.

• 32 participants with Type 2

Diabetes

• Three groups:

– Control

– Paleo diet

– Paleo diet + exercise

• After 3 months:

– No difference between

intervention groups

– Increased functional brain

response

– Increased hippocampal volumeStomby A, Otten J, Ryberg M, Nyberg L, Olsson T and Boraxbekk C-J (2017) A Paleolithic Diet with and

without Combined Aerobic and Resistance Exercise Increases Functional Brain Responses and

Hippocampal Volume in Subjects with Type 2 Diabetes. Front. Aging Neurosci. 9:391. doi:

10.3389/fnagi.2017.00391

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Ketogenic

Diet

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KETOGENIC DIET

• High fat, medium protein, low

carbohydrate (< 50 grams, varies)

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AN ONLINE INTERVENTION COMPARING A VERY LOW-

CARBOHYDRATE KETOGENIC DIET AND LIFESTYLE

RECOMMENDATIONS VERSUS A PLATE METHOD DIET IN

OVERWEIGHT INDIVIDUALS WITH TYPE 2 DIABETES: A RANDOMIZED

CONTROLLED TRIAL

• Design: Randomized, controlled study

• Group 1: American Diabetes Associations’

“Create Your Plate” Diet (n=13)

• Group 2: Very Low-Carbohydrate Ketogenic Diet (VLKD) and Lifestyle

Recommendations (n=12)

• Duration: 6 months

Saslow LR, Journal of Medical Internet Research, 2017

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RESULTSSignificant ↓

• HbA1c

ADA: 16 weeks, -0.5%

32 weeks, -0.3%

VLKD:16 weeks, -0.9%

32 weeks, -0.8%

• Body weight

ADA: 16 weeks, -3.9 kg

32 weeks, -3.0 kg

VLKD: 16 weeks, -8.5 kg

32 weeks, -12.7 kg

• Triglycerides

ADA: 16 weeks, -17.4 mg/dL

32 weeks, -6.2 mg/dL*

VLKD: 16 weeks, -35.5 mg/dL

32 weeks, -60.1 mg/dLSaslow LR, Journal of Medical Internet Research, 2017

ADA vs VLKD

• No significant diff in

calories

• VLKD significantly less

carbohydrates and

sugar

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Intermittent

Fasting

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INTERMITTENT FASTING

• Feeding window of 1 to 8 hours

• Fasting window of 16 to 23 hours

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EFFECTS OF INTERMITTENT FASTING ON HEALTH MARKERS

IN THOSE WITH TYPE 2 DIABETES: A PILOT STUDY

• n=10

Arnason TG, Bowen MW, Mansell KD. Effects of intermittent fasting on health markers in those with

type 2 diabetes: A pilot study. World J Diabetes 2017; 8(4): 154-164 Available from: URL:

http://www.wjgnet.com/1948-9358/full/v8/i4/154.htm DOI: http://dx.doi.org/10.4239/wjd.v8.i4.154

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Arnason TG, Bowen MW, Mansell KD. Effects of intermittent fasting on health markers in those with

type 2 diabetes: A pilot study. World J Diabetes 2017; 8(4): 154-164 Available from: URL:

http://www.wjgnet.com/1948-9358/full/v8/i4/154.htm DOI: http://dx.doi.org/10.4239/wjd.v8.i4.154

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FASTING WITH DIABETES: A PROSPECTIVE

OBSERVATIONAL STUDY

• 150 participants with

type 2 diabetes

– Observing the fast of

Ramadan (11-20 hour

fast)

• Results: 1 in 10

participants experienced

hypoglycemia at least

once

Noon MJ, et al. BMJ Glob Health, 2016.

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Cultural Food Ways

and Diabetes

Management

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SOCIOCULTURAL CONSTRUCTION OF FOOD WAYS

IN LOW-INCOME MEXICAN-AMERICAN WOMEN

WITH DIABETES: A QUALITATIVE STUDY

Who:

12 low-income Hispanic

women with at least 10

years of having T2DM

Residents of Starr

County, TX

What has worked?

• Portion control

• The “fork” method

• Fluid food

categorizations

• Confidence and in-

tune with body cues

• Family involvement

Benavides-Vaello, S, 2016

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Benavides-Vaello, S, 2016

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Benavides-Vaello, S, 2016

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Benavides-Vaello, S, 2016

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SOCIOCULTURAL CONSTRUCTION OF FOOD WAYS

IN LOW-INCOME MEXICAN-AMERICAN WOMEN

WITH DIABETES: A QUALITATIVE STUDY

Benavides-Vaello, S, 2016

“Those with expertise make

changes in how they eat to

care for their diabetes, but

also continue to maintain

traditional food ways.”

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“CAN YOU KEEP IT REAL?” : PRACTICAL, AND CULTURALLY

TAILORED LIFESTYLE RECOMMENDATIONS BY MEXICAN AMERICAN

WOMEN DIAGNOSED WITH TYPE 2 DIABETES: A QUALITATIVE STUDY

Benavides-Vaello, S, 2017

Category Strategies

Environmental

Controls

• Make your own burgers and tacos

• Cook more at home

• Go to the grocery store alone

• Avoid aisles in the grocery store that have the

food items on sale that are bad for you

• Remove temptation from your home

• Not making tortillas helps because when you

buy, once the package is gone, they are gone

Table 1. Strategies Developed in Managing their Diabetes

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7Benavides-Vaello, S, 2017

Category Strategies

Avoid

Overeating/

Stress Eating

• Don’t let yourself get hungry

• Limit in between snacking

• Keep active, walk

• When you feel stressed or want to eat go for a

walk

• Drink more water

• Satisfy the craving from the beginning so that you

don’t keep eating foods you don’t really want

Cooking Tips

• Don’t drink regular coke-try lemonade with

Splenda or water

• Learn how to use the steamer, broiler, and oven

• Stick with natural foods

Table 1. Strategies Developed in Managing their Diabetes

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7Benavides-Vaello, S, 2017

Category Strategies

Lifestyle

Changes

• You can eat anything you want-even menudo-

just limit the amount

• Get into a routine

• The progress takes time, don’t do everything at

once, just step by step

• Make separate meals or smaller portions of the

foods you love

• Eat whole wheat flour tortillas

• Get away from processed foods

• Tortillas-flour, limit to once a week

• Eat earlier in the evening

Table 1. Strategies Developed in Managing their Diabetes

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7Benavides-Vaello, S, 2017

Category Strategies

Family

• Put them (kids) first

• (Think) Your family is going to be healthier

• They may not like it at first, just keep trying, think of

what will happen to you

• Set the table and serve the food, no choices

• Put 2% or 1% milk in the whole milk container,

keep the same label, family thinks they are

drinking whole milk

Active Self-

Management

• Ask (health care providers and other staff) what

exactly you should eat to take care of your

diabetes

• See her doctor to make sure she is on the right

medicines

• See your dietitian

• Take medicines religiously

Table 1. Strategies Developed in Managing their Diabetes

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More…

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MEAL REPLACEMENTS

• Keogh J and Clifton PM: positive results

– A1C

– Weight loss

– HDL

– Blood Pressure

Considerations

• Sustainability

• Additives

Keogh J, Clifton PM. J Nutr Metabolism, 2012.

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ALTERNATIVE TREATMENTS

Herbs and Supplements

• Aloe Vera

• Alpha-Lipoic Acid

• Chromium

• Cinnamon

• Garlic

• Ginseng

Relaxation Techniques

• Aromatherapy

• Meditation

• Acupuncture

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ADA STANDARDS OF MEDICAL CARE, NUTRITION

THERAPY 2019

Diabetes Care, 2019

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OTHER EMERGING TRENDS

• Artificial sweeteners

• Fiber

– Fruit, vegetables, whole grains

– Legumes (lentils)

• Fish

• Eggs

• Low-fat dairy

• Social drinking

• Multifaceted interventions/regular contact/ digital

coaching

• Fast-paced walking

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OTHER EMERGING TRENDS

• Coffee

• Regular/excessive alcohol

• Full-fat dairy

• Mindful eating

• Lifestyle advice alone

• Food insecurity

• Stress

• Slow walking (compared to fast paced walking)

• Free food at work/ office vending machines

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ONE OF THE BIGGEST DIFFERENCES BETWEEN

RECOMMENDATIONS AND TRENDS?

Food trends tend to not individualized

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QUESTIONS?

Carmen Ramos, MS, RDN

Carmen.ramos@hsc.utah.edu

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REFERENCES

ADA. Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42:S46-S60.

Arnason TG, Bowen MW, Mansell KD. Effects of intermittent fasting on health markers

in those with type 2 diabetes: A pilot study. World J Diabetes 2017;8(4):154-164.

Benavides-Vaello S, Brown SA. Sociocultural construction of food ways in low-income Mexican-American women with diabetes: a qualitative study. Journal of Clinical

Nursing 2016;25,2367–2377.

Benavides-Vaello S, Brown SA, Vandermause R. “Can you keep it real?”: Practical,

and culturally tailored lifestyle recommendations by Mexican American women

diagnosed with type 2 diabetes: A qualitative study. BMC Nursing 2017;16:36.

CDC. National Diabetes Statistics Report, 2014; Dall, The Economic Burden of

Elevated Blood Glucose Levels in 2012: Diagnosed and Undiagnosed Diabetes,

Gestational Diabetes Mellitus, and Prediabetes. Diabetes Care 2014;37:3172-3179.

CDC. Hispanic/Latino Americans and Type 2 Diabetes.

https://www.cdc.gov/diabetes/library/features/hispanic-diabetes.html; 2019.

Keogh KB, Clifton PM. Meal Replacements for Weight Loss in Type 2 Diabetes in a

Community Setting. J Nutr Metab 2012; 918571.

Masharani, U et al. Metabolic and physiologic effects from consuming a hunter-

gatherer (Paleolithic)-type diet in type 2 diabetes. European Journal of Clinical

Nutrition 2015;69:944–948.

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REFERENCES

Noon MJ, et al. Fasting with Diabetes: A Prospective Observational Study. BMJ Glob

Health 2016;1:2.

Oppenheimer, R. Diabetic Cookery, Recipes and Menus. 1917.

Saslow LR, Mason AE, Kim S, Goldman V, Ploutz-Snyder R, Bayandorian H, Daubenmier J, Hecht FM, Moskowitz JT. An Online Intervention Comparing a Very

Low-Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate

Method Diet in Overweight Individuals With Type 2 Diabetes: A Randomized

Controlled Trial. J Med Internet Res 2017;19(2):e36.

Stomby, A et al. A Paleolithic Diet with and without Combined Aerobic and

Resistance Exercise Increases Functional Brain Responses and Hippocampal Volume

in Subjects with Type 2 Diabetes. Front Aging Neurosci 2017;9:391.

Wheeler, M. Cycles: Diabetes Nutrition Recommendations—Past, Present, and

Future. Diabetes Spectrum 2000;13:116.