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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
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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
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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
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AACE 2017
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LIFESTYLE THERAPY
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• "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
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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
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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
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• 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
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Registered
Dietitian
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• 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
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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
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Amount
Type
CHO exchanges
CHO counting Glycemic Index
or
Glycemic Load
1.
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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
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Low GI : 55 Medium GI : 56 – 69 High GI : 70
2.
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64
42
100
61
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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
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• 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
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Breakfast –
the MOST IMPORTANT meal of the day
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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
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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
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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
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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
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†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
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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
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If Weight Loss is DESIRED …
How to, what type of diet
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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
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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
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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
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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
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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
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• 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
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Khurana et al, 2012
Dietary Fibre & Weight Loss
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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
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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
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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!