role of nutrition therapy in glycaemic control · role of medical nutrition therapy in glycaemic...

ROLE OF MEDICAL NUTRITION THERAPY IN GLYCAEMIC CONTROL

SP Chan

MBBS (Mal), FRCP (Edinburgh)

Consultant Endocrinologist

University of Malaya Medical Centre,

Subang Jaya Medical Centre

0.0 0.7

1.4

3.4 3.4

6.9

10.5

14.8

20.6

26.5

24.4

27.9

24.4

5.5 5.2

7.4 7.2

9.5 11.0 11.5

12.2 12.4 11.8

13.6

11.2 12.6

5.5 5.9

8.8 10.6

12.9

17.9

22.0

27.0

33.0

38.3 38.0 39.1

37.0

0

5

10

15

20

25

30

35

40

45

Pre

va

len

ce

(%

)

Known Undiagnosed Total Diabetes

Malaysia – Diabetes Prevalence (2015)

Houston (Oops. .. Malaysia!) … We have a PROBLEM

Dyslipidaemia 32.4 % 37.4 %

Hypertension 57.7 % 65.1 %

Diabetes 40.6 % 45.8 %

2009 (n=10,846)

2011-2013 (n=14,763) Cumulative No.

Co-Chairs (Original)

SIM Kui-Hian Robaayah Zambahari CV risk factors

Malaysian CVD database: Admissions for Acute Coronary Syndrome

Mortality 7.6 % - Inpatient 9.0 % - 30 days

AACE 2017

LIFESTYLE THERAPY

• "Cardiometabolic death" refers to death from heart disease, stroke, & T2D

• ~ half of all cardiometabolic deaths (ie, 318,656 of 702,308 such deaths) in US → associated with suboptimal intakes "of vegetables, fruits, nuts, seeds, & omega-3 fatty acids”

Micha et al. JAMA Mar 2017

Nutritionists / clinicians are concerned about blood glucose levels, obesity, diabetes, & other health implications they believe → “Sugar is the New Tobacco”

Sodium is another long-time concern, prevalent in processed foods

Pan A et al. Arch Int Med 2012;172:555-63

Follow-up 37,698 men + 83,644 women, health professionals, for up to 28 years

Participants did not have cardiovascular disease or cancer at baseline

→ Consumption of red meat ↑ risk for cardiovascular, cancer, and total mortality

• Medical nutrition therapy (MNT) has its greatest impact when a person is first diagnosed with diabetes

• MNT, the nutrition-based treatment provided by a registered dietitian nutritionist, includes a nutrition diagnosis as well as therapeutic and counselling services to help manage diabetes

Medical Nutrition Therapy

Registered

Dietitian

• Part of structured diabetes education program

• Set out SHORT-TERM & LONG-TERM Goals

• Effectiveness of diabetes MNT after 3 – 6 months Report HbA1c ↓ 0.25 – 2.9%

Medical Nutrition Therapy

Carb Count

Simplified Meal plans

Individual-ised Meal

planning

Healthy food

choices

Food Exchange

lists

Behaviour Strategies AB Evert et al. Nutrition Therapy Recommendations

for adults with diabetes. Diab Care 2013; 36:3821-42

Amount

Type

CHO exchanges

CHO counting Glycemic Index

or

Glycemic Load

1.

Type vs Amount?

Amount of carbs is main consideration

Amount of carbs intake can be monitored by using Carbs counting

Carbs exchange list

Hand measures

Grade A

Low GI : 55 Medium GI : 56 – 69 High GI : 70

2.

64

42

100

61

Strategies for people with Diabetes

• Portion control should be recommended for weight loss & maintenance

• Carbo-containing food & beverages + endogenous insulin production are the greatest determinants of post-meal glucose level;

• It is important to know what foods contain carbohydrates eg. Starchy vegies, whole grain, fruit, milk & milk products, & sugar

• When choosing carbo-containing foods – choose nutrient-dense, high fiber foods whenever possible ; instead of processed food with added sodium, fat & sugars. Nutrient-dense foods & beverages provide vitamins, minerals & other healthful substances with fewer calories

• Avoid sucrose-sweetened beverages (SSBs)

AB Evert et al. Nutrition Therapy Recommendations for adults with diabetes. Diab Care 2013; 36:3821-42

• Evidence suggests that there is no ideal % of calories from carbohydrate, protein, and fat (B)

• Macronutrient distribution should be based on

individualized assessment of current eating patterns, preferences, and metabolic goals (E)

Optimal Composition of Macronutrients

AB Evert et al. Nutrition Therapy Recommendations for adults with diabetes. Diab Care 2013; 36:3821-42

Breakfast –

the MOST IMPORTANT meal of the day

Skipping breakfast is associated with

significantly higher fasting & PPG levels

in T2DM1

Blo

od

glu

cose

(m

g/d

L)

Time (hours)

With breakfast

*p<0.0001

Without breakfast

Breakfast Lunch Dinner

Adapted from Jakubowicz et al. 2015.1

1. Jakubowicz D, et al. Diabetes Care 2015;38:1820–1826; 2. Jakubowicz D, et al. Diabetologia 2015;58;912–919; 3. Park YM, et al. J Nutr 2015;145:452–458.

The 2nd-meal Phenomenon: Breakfast improves glucose

control throughout the day

A high-protein breakfast offers greater glycaemic control than a high-carbohydrate breakfast

•PPG is lower

•Postprandial insulin response is lower

•GLP-1 response at lunch is higher

Adapted from Park YM et al. 2015.

Park YM, et al. J Nutr 2015;145:452–458.

Blo

od

glu

cose

(m

g/d

L)

Time (min)

Protein

Carbohydrate

When meals were consumed

Protein – Key to the 2nd-meal Phenomenon

Efficacy and Tolerance of a Diabetes Specific Formula in Patients

with Type 2 Diabetes Mellitus:

an Open Label, Randomized, Crossover Study

SEEMA GULATI1,2,3, ANOOP MISRA1,2,3,4,5, RAVINDRA M. PANDEY6, KRITI NANDA1,2,3,

VIVEK GARG7, SANJEEV GANGULY7, LORENA CHEUNG8 1. Diabetes Foundation (India), SDA, New Delhi, India, 2. National Diabetes, Obesity and Cholesterol Diseases Foundation

(N-DOC), SDA, New Delhi, India, 3. Center of Nutrition & Metabolic Research (C-NET), SDA, New Delhi, India, 4. Fortis C-

DOC Center for Excellence for Diabetes, Metabolic Disease and Endocrinology, New Delhi, India, 5. Fortis Flt. Lt. Rajan Dhall

Hospital, Center for Internal Medicine, New Delhi, India, 6. All India Institute of Medical Sciences (AIIMS), 7. Nestlé India

Limited, 8. Nestlé Health Science, AOA region.

Poster presented at American Diabetes Association’s 73rd Scientific Sessions, June 21-25, 2013 in Chicago, Illinois. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 2015;9:252-7

PRE-TREATMENT PHASE TREATMENT PHASE

Visit 0 Visit 1 Visit 2 Visit 3

Screening Day-14 to Day-7

Run In Day-7 to Day-1

Period 1 Day 1

Wash Out Day 2-7

Period 2 Day 8

Follow-up Day 9-10

Group A Nutren Diabetes

Group B Isocaloric Diet

Group B Nutren Diabetes

Group A Isocaloric Diet

NUTREN® DIABETES vs Isocaloric diet

S Gulati et al. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 9 (2015) 252–257

†Isocaloric breakfast constituted cornflakes and milk. PPG, postprandial glucose. Gulati S, et al. Diabetes Metab Syndr Clin Res Rev 2015;9:252–257.

Time (in minutes)

NUTREN® Diabetes

Isocaloric breakfast†

*p ≤0.0026

**p ≤0.001

Blo

od

glo

cose

leve

ls (

mg/

dL)

*

**

**

**

214.7

180.1

191.9

170.6

168.3

153.1 127

121.6

134.9

135.9

NUTREN® DIABETES –

Low GI & Lowers postprandial glucose vs isocaloric diet

35

Whey Proteins: High Digestibility & Better Absorbed

Type of Protein Biological value* NPU*

Whey 100 92%

Casein 80 76%

Soy protein concentrate 75 61%

*Biological value: amino acids profile meets or exceeds requirements for essential & non–essential amino acids

*Net Protein Utilization: amount of nitrogen absorbed and retained by the body

Protein Quality Evaluation. Report of the Joint FAO/WHO Consultation, 1990. Protein Quality Evaluation. Report of the Joint FAO/WHO Consultation, 1991.

Nutren® Diabetes – Protein 50 % made up of Whey protein

If Weight Loss is DESIRED …

How to, what type of diet

2008

2013

Type 2 Type 2

Age (Yrs) (n=1655) 57.5 (10.7) 57.8 (11.0)

Sex (M/F) (n=1667) (%) 45.7/51.3 46.5/53.5

BMI (Kg/m2) (n=1643) 27.8 (4.5) 29.0 (4.0)

Age at onset (yrs) (n=1561) 44.1 (11.7) 44.9 (10.0)

Malaysia – DiabCare 2013

Mafauzy M,… SP Chan. Med J M’sia 2016; 71 (4): 177-85

Design: 20 RCTs (N= 3073) lasting ≥6 months, comparing low CHO, low GI, high fiber, Mediterranean, & high-protein diets vs control diets including low-fat, high-GI, ADA, EASD, and low-protein diets.

O Ajala et al . Am J Clin Nutr 2013;97:505–16.

No “ONE-SIZE-FITS ALL” Eating Pattern for people with T2D

Compared to Control diet (WMD)

Low CHO Low GI Mediterranean High protein

HbA1c ↓ - 0.12 %

(p = 0.04) ↓ -0.14% (p = 0.008)

↓ -0.47% (p < 0.00001)

↓ -0.28% (p = 0.0001)

Weight loss -0.69 kg (p = 0.21)

+ 1.39 kg (p = 0.36)

↓ -1.84 kg (p < 0.00001)

+ 0.44 kg (p = 0.54)

Systematic review & Meta-analysis of different dietary approaches to management of T2DM

Conclusion: Low-CHO, low-GI, Mediterranean, and high protein diets are effective in improving HbA1c in T2DM and should be considered in the overall strategy of diabetes management

Soluble components

pectic substances, some hemicelluloses, gums & mucilages and are completely fermented by the bacterial flora

Insoluble components

cellulose, some hemicelluloses, waxes, & lignin primarily in plant cell walls as well as resistant starch are only slightly fermented

Adults & elderly

14 g / 1000 kcal

A minimum of 20 g/d (American Dietetic Association)

20–30 g / day (Europ Soc for Clin Nutrition & Metab)

DAILY RECOMMENDATION

Affects palatability

Reduces caloric density (all)

Slows gastric emptying (Soluble fiber)

Delays digestion & absorption (Soluble fiber)

May trap micronutrients (all)

Improves stool consistency

Regulates stool production (all)

Stimulates bacterial growth

& fermentation (Soluble fiber, esp. prebiotic fiber)

Action is dependent on

type of fiber & amount

Behavior of fiber in the intestine Dietary Fibre – Behavior in Intestine

• Supplemented fiber intake ranged from 4.5 – 20 g/day

• Predominantly insoluble form but guar gum or glucomannan were used in several studies

• Weight loss achieved with fiber supplements administered as an adjunct to an energy restricted diet → modestly greater than

weight loss achieved with placebo

Anderson et al. (2009) Nutrition Reviews Vol. 67(4):188–205

Dietary Fibre & Weight Loss

Wt loss with fiber-supplemented diets vs control diets

p = 0.0063

p = 0.0088

Khurana et al, 2012

Dietary Fibre & Weight Loss

ADA, American Diabetes Association; MUFA, monounsaturated fatty acid; PUFA, polyunsaturated fatty acid; SFA, saturated fatty acid; TEI, total energy intake.

1. Bantle JP, et al. Diabetes Care 2008;31(Suppl 1):S61–78; 2. Gulati S, et al. Diabetes Metab Syndr Clin Res Rev 2015;9:252–257; 3. NUTREN® Diabetes product

information. Data on File.

Nutrients ADA recommended targets1 NUTREN® Diabetes (Energy: 253 kCal)2,3

Carbohydrates Individualised (Average 45% TEI)

43% Complex

carbohydrate

Protein Individualised

(Average 16–18% TEI) 18%

50%

whey protein

Fat Individualised, fat quality

is more important than quantity

(Average 36–40% TEI)

39%

High in MUFA

MUFAs MUFA-rich pattern is recommended 72%

SFAs <10% TEI 3.56%

PUFAs Individualised 6.0%

Fibre ≥14g/1000 kCal 20g/1000 kCal

Glycaemic

index Low glycaemic index

(Glycaemic index <55 is considered low)

Low glycaemic

index (28)

NUTREN® Diabetes meets Recommended Nutritional Targets

Choose a breakfast that will give you

slow-release energy.

Choose a snack that will keep your blood glucose

levels even between meals. Be careful of

high-fat or sugary snacks.

Choose a combination of protein, carbohydrates

and fresh vegetables for a

balanced meal.

Choose a snack that will keep your blood glucose

levels even between meals. Be careful of

high-fat or sugary snacks.

Choose a combination of protein, carbohydrates

and fresh vegetables for a

balanced meal.

Choose a snack that will keep your blood glucose

levels even between meals. Be careful of

high-fat or sugary snacks.

Choose one: Choose one: Choose one: Choose one: Choose one: Choose one:

1 glass of NUTREN® Diabetes (7 scoops + 210 mL water)

½ cup blueberries + ½ cup low-fat yogurt

2 Vietnamese rice paper rolls filled with vegetables + prawns

1 glass of NUTREN® Diabetes (4 scoops + 150 mL water)

Tofu or lean meat with vegetables

hotpot + ½ cup brown rice

1 glass of NUTREN® Diabetes (4 scoops + 150 mL water)

OR OR OR OR OR OR 2 egg omelettes (1

egg yolk removed) + grilled mushrooms

1 small peach and 6 rice crackers

Medium bowl sliced fish with bee hoon

soup

½ cup unshelled edamame + ½ cup

sliced mango

½ cup brown rice with 150g chicken (no skin) + stir-fried vegetables

1 banana + ½ cup low-fat custard

OR OR OR OR OR OR

½ cup brown rice + 100g chicken congee

with herbs

Small sashimi + miso soup

Thai beef salad (150g beef + fresh

salad greens + herbs + light dressing)

1 cup Indian spiced popcorn + 1 clementine

Sliced fish with vegetables stir fry +

2/3 cup whole grain noodles

1 Asian fruit salad (lychees + pineapple

+ papaya) + ½ cup sugar-free pandan

jelly

Potential Ways to Incorporate NUTREN® Diabetes into meal plan

Medical Nutrition Therapy

• Essential for every phase of management of T2DM

• Healthy choice / Portion-sizes

• Optimally done as part of a multidisciplinary team

• As part of weight reduction / maintenance (for patients with ↑ BMI) use of low calorie / high fibre options to substitute • No ONE-SIZE-FITS ALL … as in everything, INDIVIDUALISE!