Presentation given at a nutrition workshop. Focus is on medical nutrition therapy for diabetes mellitus.

1. 21 May 2010
Nutritional Issues
in the Outpatient Setting
Iris Thiele Isip Tan MD, FPCP, FPSEM
Clinical Associate Professor, UP College of Medicine
Section of Endocrinology, Diabetes & Metabolism, UP-PGH
http://www.endocrine-witch.info

2. 1 3
Low
Low CHO protein diet
vs low fat in kidney
diets Medical disease
2 Nutrition 4
Therapy
Glycemic
DIABETES Vegan diet
index/ & trace
glycemic minerals
load

3. What is the optimal CHO-to-fat ratio?
Recommendation
100
CHO 45-65%
Min 130 g/day
HIGH CHO
75
CHO ↑ glucose,
50 CHO insulin,
triglycerides
25 Fat Fat
LOW FAT
CHON CHON
0 ↓ energy intake
LFHC HFLC Reduce weight
Low fat = High CHO
Dietary CHO (Amount & Type) in the Prevention & Management of
Diabetes: American Diabetes Association Position Statement (2004)

4. Meta-analysis
CHO-to-fat ratio in Type 2 diabetes
Low-fat, high-CHO High-fat, low-CHO
CHO/Fat 58%/24%
vs CHO/Fat 40%/40%
Randomized trials (19; n=306)
Similar energy and CHON intake between groups
Measured FPG & insulin; >1 wk intervention
Parallel and cross-over designs
Studies excluded:
change in content/quality of CHO (↑ fiber/whole grains)
Kodama et al. Diabetes Care 2009;32:959-65

5. Meta-analysis
CHO-to-fat ratio in Type 2 diabetes
Kodama et al. Diabetes Care 2009;32:959-65
Low-fat, high-CHO High-fat, low-CHO
CHO/Fat 58%/24% vs CHO/Fat 40%/40%
↓ NS ↑
Fasting insulin
(p=0.02)
A1c, FPG,
HDL-C 2-h glucose &
(p<0.001) total chol and
LDL-C insulin (p<0.001)
Triglycerides*
(p<0.001)
* Insignificant when
energy intake restricted

6. Replace saturated fat with MUFA or CHO?
100
MUFA
75
High MUFA
CHO Mediterranean diet
50 Vegetables, fruits,
Fat whole grains, legumes,
25
nuts, olive oil
CHON
0
LFHC High MUFA
Replace saturated
fat with MUFA

7. Dietary Sources of MUFA
Vegetable
SFA MUFA PUFA
oils
g g g
(100 g)
Sunflower 9.7 83.6 3.8
Fruit SFA MUFA PUFA
Safflower 6.2 74.6 14.4 (100 g) g g g
Olive 13.5 73.7 8.4 Avocado 2.4 9.6 2.0
Canola 7.1 58.9 29.6 Olives 1.4 7.9 0.9
Nuts SFA MUFA PUFA
(100 g) g g g
SFA MUFA PUFA
Macademia 12.1 58.9 1.5 Animal products
g g g
Hazelnuts 4.5 45.7 7.9 Ground beef,
10.8 11.6 1.1
Pecans 6.2 40.8 21.6 regular, 100 g
Almonds 3.9 32.2 12.2 Fried eggs, 2 pcs 4.2 6.0 2.8
Cashews 9.2 27.3 7.8 Regular butter, 25 g 12.6 5.9 0.8
Peanuts 6.8 24.4 15.6 Fried bacon, 3 slices 3.3 4.5 1.1
Pistachios 5.4 23.3 13.4
Ros E. Am J Clin Nutr 2003;78(suppl):617S-25S

8. One-year data
High-MUFA vs high-CHO in Type 2 diabetes
Overweight/obese Weight loss
Type 2 diabetes Body fat
(n=124) P Waist circ
Diastolic BP
HDL-C
High-MUFA: A1c
45% CHO, 15% CHON Fasting glucose
& 40% fat (20% MUFA) & insulin
High-CHO: O
60% CHO, 15% CHON
& 25% fat RCT x 1 y
I 18 mos extension
M
Brehm et al. Diabetes Care 2009;32:215-20

9. One-year data
High-MUFA vs high-CHO in Type 2 diabetes
Similar time High-MUFA = High-CHO
effects
p<0.01
High-CHO High-MUFA
Baseline 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
130/77 + 129/73 + 132/78 + 130/73 +
Blood pressure 2.0/1.6 2.3/1.4 2.3/1.4 2.4/1.5
Brehm et al. Diabetes Care 2009;32:215-20

10. One-year data
High-MUFA vs high-CHO in Type 2 diabetes
Significant
High-MUFA = High-CHO
↑ HDL-C
p<0.01
High-CHO High-MUFA
mg/dL 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
Brehm et al. Diabetes Care 2009;32:215-20

11. One-year data
High-MUFA vs high-CHO in Type 2 diabetes
Similar time High-MUFA = High-CHO
effects
p<0.01
High-CHO High-MUFA
Baseline 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
Brehm et al. Diabetes Care 2009;32:215-20

12. Replace saturated fat with MUFA or CHO?
Brehm et al. Diabetes Care 2009;32:215-20
100
MUFA
High MUFA
75 good alternative
CHO Comparable beneficial
50
effects on body weight,
Fat body composition, CV
25
risk factors & glycemic
CHON control
0
LFHC High MUFA
Replace saturated
fat with MUFA

13. 1 3
Low
Low CHO protein diet
vs low fat in kidney
diets Medical disease
2 Nutrition 4
Therapy
Glycemic
DIABETES Vegan diet
index/ & trace
glycemic minerals
load

14. Glycemic Index (GI)
Definition
Increase in blood glucose (over
fasting level) in 2 h following
ingestion of 50 g CHO
_______Test food______
Reference food
Low GI Intermediate High GI
0-55 56-69 >70
Llona A. Nutr Hosp 2006;21:53-59

15. Glycemic CHO Availability in the GI tract
Available food carbohydrates
macronutrient Stomach
Gastric
composition
emptying (Rate limiting)
fiber content
viscosity Small
volume & intestine
structure of the Disruption
food /digestion (Rate limiting)
Portal
circulation
Riccardi et al. Am J Clin Nutr 2008;87(suppl):269S-74S

16. Issues with Glycemic Index
1 3
Only accounts for GI for any particular
CHO type (not total food item highly
amount) variable
2 4
Measures response to Inaccurate predictor
individual food of postprandial
consumed in isolation response in diabetes
Dietary CHO (Amount & Type) in the Prevention & Management of
Diabetes: American Diabetes Association Position Statement (2004)

17. Glycemic Load (GL)
Definition GI 72 (50 g = 4 1/2 cups)
Quantitates the impact of a 1/2 cup = 5.75 g CHO
usual portion of a food with GL = (5.75 x 72)/100 = ~4
known GI
GL = GI x CHO net content
per portion (g) / 100
Low GL Intermediate High GL
<10 11-19 >20
Llona A. Nutr Hosp 2006;21:53-59

18. GI vs GL of Selected Foods
Low GI Interm GI High GI
Whole meal Popcorn
cereals Pineapple Watermelon
Low GL
Peanut Melon Whole wheat
Strawberries bread
Refined
Banana cereals
Interm Cherries
Fettucine Sweet
GL Toasted flour
White bread potatoes
Whole rice
Noodles Couscous
Potatoes
High GL Macaroni Refined
Cornflakes
Spaghetti rice
Llona A. Nutr Hosp 2006;21:53-59

19. Cochrane Review
Low GI or low GL Diets for Diabetes
Low GI or
Low GL diet
vs Higher GI diet
Randomized controlled trials (11; n=402)
Intervention 4-52 wks; Follow-up 12 mos
Glycemic control: HbA1c & fructosamine
Adverse events: hypo-/hyperglycemia
Parallel and cross-over studies
Two studies involved children
Thomas & Eliott. Cochrane Database of Systematic Reviews 2009

20. Cochrane Review
Low GI or low GL Diets for Diabetes
Low GI or
vs Higher GI diet
Low GL diet
NO STUDY
HbA1c reduction
Fewer reported on mortality,
Parallel trials
episodes of morbidity or costs
WMD -0.5%
(95% CI -0.9,-0.1) p=0.02 hypoglycemia
Crossover trials (1 trial)
WMD -0.5% Difference -0.8
(95% CI -1.0,-0.1) p=0.03 episodes/patient/
month (p<0.01)
Thomas & Eliott. Cochrane Database of Systematic Reviews 2009

21. Canadian Trial of CHO in Diabetes
Low-GI diet for Type 2 diabetes on diet alone
P Type 2 diabetes on
diet alone (n=162)
I High-GI vs low-GI
vs low-CHO diets
O
HbA1c, FPG, OGTT
100
GI 63 GI 55 GI 59 Body weight
75 Blood pressure
Fat
50 Lipids & CRP
25 CHO
Randomized controlled
0
High-GI Low-GI low-CHO trial x 12 mos
M
Wolever et al. Am J Clin Nutr 2008;87:114-25

22. Low GI
High GI
Low CHO
Body wt
NS
HbA1c
↑ FBS
↓ 2h post
-load BG
Wolever et al. Am J Clin Nutr 2008;87:114-25

23. Low GI
NS ↑ ↓
High GI
Total chol Triglycerides HDL-C
4% vs low-CHO
Low CHO LDL-C 12% vs low-CHO
Total cholesterol Triglycerides
LDL-C HDL-C
0 3 6 9 12 0 3 6 9 12
Time in study (mos)
Wolever et al. Am J Clin Nutr 2008;87:114-25

24. Low GI CRP 1.95 mg/L
High GI CRP 2.75 mg/L CRP (low-GI)
less than
Low CHO CRP 2.35 mg/L
CRP (high-GI)
LOW-GI VS LOW-CARBOHYDRATE DIET IN DIA
by 30%
(p=0.0078) the significant or nea
several variables (eg,
in which the differen
study, are not consist
Our most novel fin
tion in CRP with the
29% difference is g
T2DM patients, ie, 13
by atorvastatin, ie, 2
These findings are co
that CRP concentrati
lated to diet GI but n
the release of inflam
Although differences
CRP that we observe
FIGURE 5. Mean (and 95% CI) serum C-reactive protein (CRP) con- be involved. Exposin
centrations in subjects receiving the high-glycemic-index (F; n 43), low- concentrations, rathe
glycemic-index (E; n 48), and low-carbohydrate (Œ; nWolever et al. Am J Clinconcentration, increa
50) diets. Values Nutr 2008;87:114-25

25. Low GI vs ADA Dietary Education in Type 2 Diabetes
P Poorly-controlled
Type 2 diabetes (n=40)
I Low GI vs ADA diet O
8 educational sessions Baseline, mos. 6 & 12
(monthly x 6 mos then Diet, physical activity,
at mos. 8 & 10) psychosocial factors,
diabetes medication use,
weight, A1c, lipids
Randomized controlled
trial x 12 mos
M
Yunsheng et al. Nutrition 2008;24(1):45-56

26. Low GI vs ADA Dietary Education in Type 2 Diabetes
Low GI diet vs ADA diet
↓ LDL at 12 mos Similar↓ HbA1c &
(p=0.03) total cholesterol
↓ DBP at 6 mos Unchanged HDL &
(p=0.03)
triglycerides for both
↓ switch to new
drug or increase Weight loss NS for
dose (OR 0.26, p=0.01) both
Yunsheng et al. Nutrition 2008;24(1):45-56

27. 1 3
Low
Low CHO protein diet
vs low fat in kidney
diets Medical disease
2 Nutrition 4
Therapy
Glycemic
DIABETES Vegan diet
index/ & trace
glycemic minerals
load

28. Meta-analysis
Low-protein diet for diabetic nephropathy
Low-protein diet Normal
(LPD)
vs protein diet
Randomized controlled trials (8; n=519)
Duration >6 mos
Rate of Δ GFR
Δ urinary CHON excretion & serum albumin
Excluded cross-over studies
Type 1 and Type 2 diabetic nephropathy
Yu Pan et al. Am J Clin Nutr 2008;88:660-6

29. Meta-analysis
Low-protein diet for diabetic nephropathy
Yu Pan et al. Am J Clin Nutr 2008;88:660-6
Treatment Control
Low-protein diet vs Normal protein
Δ GFR in patients with type 1 or type 2 diabetes mellitus
Change in WMD of
GFR not significantly
associated with LPD

30. Meta-analysis
Low-protein diet for diabetic nephropathy
Yu Pan et al. Am J Clin Nutr 2008;88:660-6
Δ in proteinuria (type 1 or type 2 diabetes mellitus)
Significant benefit of
LPD on proteinuria
(p=0.003) but data
heterogeneous

31. Meta-analysis
Low-protein diet for diabetic nephropathy
Yu 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
Authors’ Conclusion
(95%CI -1.33, 1.03 g/L)
LPD was not associated with a
significant improvement of
renal function in patients with
either type 1 or type 2 diabetes.

32. Withdrawal of Red Meat from Usual Diet
P Type 2 diabetes with
macroalbuminuria (n=17)
I Usual diet (UD) vs O
with chicken (CD) vs GFR, UAER, serum fatty
lactovegetarian low- acid, lipid profile, glycemic
protein diet (LPD) control, anthropometric
indices, blood pressure
Randomized
crossover (q 4 wks)
controlled trial
M
de Mello et al. Am J Nutr 2006;83:1032-8

33. Withdrawal of Red Meat from Usual Diet
Usual diet (UD)
vs
↓
Chicken (CD) Urine albumin ↑
excretion ratio
Lactovegan low- Serum PUFA
non-HDL-C
protein diet (LPD)
UD CD LPD p
UAER 312.8 269.4 229.3
<0.001
(ug/min) (223.7-1223.7) (111-1128) (76.6-999.3)
GFR 81.8 + 22.2 83.3 + 26.1 81.9 + 25.3 0.860
(ml/min/1.73 m)
de Mello et al. Am J Nutr 2006;83:1032-8

34. 1 3
Low
Low CHO protein diet
vs low fat in kidney
diets Medical disease
2 Nutrition 4
Therapy
Glycemic
DIABETES Vegan diet
index/ & trace
glycemic minerals
load

35. Low-fat Vegan Diet in Type 2 Diabetes
P Free-living Type 2
diabetics (n=99)
I Low-fat vegan diet
O
vs ADA diet
HbA1c & lipids
(wks 0, 11, 22, 35, 48, 61 & 74)
Avoid animal products Weight
and fatty foods (wks 0, 22 &74)
Favor low-GI foods
Randomized controlled
trial x 74 weeks
M
Barnard et al. Am J Clin Nutr 2009;89(suppl):1588S-96S

36. Low-fat Vegan Diet in Type 2 Diabetes
Low-fat
vs ADA (2003) diet
vegan diet
Better reduction Significant weight loss within each
HbA1c (p=0.03) group but NS between groups
Total chol (p=0.01) (-4.4 kg vegan vs -3.0 kg ADA diet,
non-HDL-C (p=0.02) p=0.25)
LDL-C (p=0.03)
Data analysis BOTH diets
controlled for reduced weight
medications and lipids .
Barnard et al. Am J Clin Nutr 2009;89(suppl):1588S-96S

37. 3
2 Selenium 5
1 Zinc 4 Vanadium
Chromium Calcium
Trace
Minerals Except for calcium, NO
EVIDENCE of benefit for
supplementation in diabetics
without underlying deficiencies
Chehade et al. Diabetes Spectrum 2009;22:214-217

38. 1 3
Low
Low CHO protein diet
vs low fat in kidney
diets Medical disease
2 Nutrition 4
Therapy
Glycemic
DIABETES Vegan diet
index/ & trace
glycemic minerals
load

39. Thank You
http://www.endocrine-witch.info