Practical Approach

to Popular Diets

in

Diabetes and

ObesityDiabetes Update 2020

Wendy Graham RD CDE

Objectives

Discuss the pros and cons of various popular diets in the management of people with diabetes and obesity

Popular Diets

MediterraneanIntermittent Fasting

Ketogenic DietLow Carbohydrate

8 hr

Popular Diets

Risks

Hypoglycemia

Hypotension

Dehydration

Protein Malnutrition

Vitamin and Mineral deficiencies

Potential complications

Assess/Advice

Medication adjustment

Blood Glucose monitoring

Monitoring blood pressure

Hydration

Nutrition

Protein

Vitamin & Minerals supplements

Monitoring blood work

Intermittent Fasting

16 : 8 Fasting : Feasting

Time restricted Feeding

5 : 2 Days regular intake: fasting less than 500 calories

Alternate day fasting

8 hr

Intermittent Fasting

• Two fold risk of hypoglycemia on fasting days, despite medication reduction

• Improvement in Weight, A1c and Fasting glucose

• Education, weekly follow-up

12 months, follow-up 24 months

• Similar i weight, i A1c & imedication

• 24 months weight loss was maintained (-3.9 kg)

• A1c increased at FU (0.3%)

• Intermittent(IF) and calorie restriction

equally effective in weight reduction

• IF more effective at retention of lean mass Carter et al. Diabetes Research and Clin Practice 2019:152:11-19.

Corley BT et al. Diabet Med. 2018:35(5):588-94.

Varady KA. Obes Rev 2011:12(7):593-601.

Intermittent Fasting

Hypoglycemia

Hypotension

Dehydration

Protein Malnutrition

Vitamin and Mineral deficiency

8 hr

Risks

Grajower M et al. Nutrients 2019:11: 873-93

Intermittent Fasting

Hypoglycemia

8 hr

Assess/Advice

Medication Class Dose adjustment Comment

Sulfonylureas Omit dose on fast day

**take half dose on fast days

** education required on

hypoglycemiaMeglitinides Omit if no carbohydrate consumed

SGLT2 Inhibitors Omit on day of fast or if concerns of dehydration

Alpha glucosidase inhibitors Omit if no carbohydrate consumed

Basal insulin

(NPH, glargine, basaglar, determir)

-one third of usual dose if blood glucose at

target

-half dose if poorer blood glucose control

still significant hypoglycemia

Basal insulin- long acting No change Monitor and adjust as needed

Prandial insulin Skip dose if not eating carbohydrate reduced by 70 % on fasting days,

still had hypoglycemia

Adapted from Grajower M et al. Nutrients 2019:11: 873-93

Intermittent Fasting

Advise Patient on:

Medication adjustment

Blood Glucose monitoring

Hydration

Nutrition

Protein

Vitamin & Minerals supplements

8 hr

Intermittent Fasting

Pros

No special food preparation

Do not have to be restrictive

every day (5:2)

Cons

Dizziness

Nausea

Insomnia

Syncope

Falls

Headaches

Hunger pangs

Weakness limiting activities

Patient perspective

8 hr

Intermittent Fasting

Summary

Weight reduction similar to other energy restricted diets

Medication reduction may be required to prevent hypoglycemia

No difference in glycemic control

Better reduction in blood pressure and lipids

Better preservation of lean mass

8 hr

People with diabetes…require more careful consideration

at the beginning and during the use of a fasting regimen. Grajower et al

Mediterranean Diet: 9 Components

Olive oil ( 4 Tbsp/ 1/4c per day)

Fresh Vegetables

Fresh Fruit

Nuts

Legumes/Beans

Fish

Whole Grains

Limited Red or Processed Meat

Wine in moderation

2 point improvement in adherence

results in 25% reduction in mortality

Mediterranean Diet: 9 Components

Trichopoulou A, et al N Eng J Med 2003:348:259-2608.

Mediterranean Diet & Weight Reduction

Superior to Low fat diet

Similar weight loss to low carbohydrate and ADA

standard diet

Improves weight and cardiovascular health over

supplementing with specific foods (olive oil, walnuts and

grape juice)

Jaacks et al. 2018 BMC Nutr 4, 26 (2018). https://doi.org/10.1186/s40795-018-0234-y

Mancini et al. 2016. Am J Medicine 129(4):407-15

Mediterranean Diet

Summary

Cardiovascular risk reduction of 30%

Myocardial infarct, stroke and CV death

Weight loss similar to low carbohydrate, superior to low fat diet

Plant based

Sustainable

Extensive research

Estruch R et al. N Eng J Med. 2013:368:1279-90.

Estruch R et al. N Eng J Med. 2018: 378:e34.

Mediterranean Diet

Hypoglycemia

Hypotension

Dehydration

Protein Malnutrition

Vitamin and Mineral deficiencies

Potential complications

RisksAssess/Advice

Medication adjustmentBlood Glucose monitoringMonitoring blood pressureHydrationNutrition

ProteinVitamin & Minerals

supplementsMonitoring blood work

Very Low Carb

20 – 50 grams

70-80 % High Fat

Very Low Carb

<50 grams

40% High Protein

40% Fat

Low Carb

100 grams

Diabetes

>130 grams

45-60 % Carb

Mediterranean

55-60% Carb

30% Fat

NA Diet

50-55% carb

30% Fat

?

Low Carbohydrate

Grams of Carb% Grams of Carb% of total energy vs

Calories 45 % of energy

Grams of Carb

26 % of energy

Grams of Carb

Paul 3000 337 194

Larry 2000 225 130

Carol 1200 135 78

Carbohydrate…..

Source: Dietdoctor.com

Carbohydrate…..

Source: Dietdoctor.com

Low Carbohydrate

ADA / EASD Guidelines 2018

Davie et al. Diabetes Care 2018:41(12) 2669-2701.

“low-carbohydrate diets (<26% of total energy)

produce substantial reductions in HbA1c at 3 months

and 6 months with diminishing effects at 12 and 24

months”

Low CarbohydrateGuidelines

Diabetes UK 2018“The current evidence suggests that low-carb diets can be safe

and effective for people with type 2 diabetes… But there is no

consistent evidence that a low-carb diet is any more effective

than other dietary approaches in the long term, so it should not

be seen as the diet for everyone.” (<130 g)

Diabetes Australia 2018

“Low carbohydrate eating may be an effective way of reducing

glucose levels and achieving weight-loss for people with type 2 diabetes on the short term (6 months)” (<26% /<130 grams)

Low Carbohydrate

Risks

Hypoglycemia

Hypotension

Dehydration

Protein Malnutrition

Vitamin and Mineral deficiencies

Potential complications

Assess/Advice

Medication adjustment

Blood Glucose monitoring

Monitoring blood pressure

Hydration

Nutrition

Protein

Vitamin & Minerals supplements

Monitoring blood work

Low CarbohydratePatient perspective

Difficulty following long term

People think Keto is………

Ketogenic

Ketogenic

<50 grams Carb70 - 90 % Fat20 % Protein

3:1 Fat/ Carb + Protein

2oz salmon1 c grated cauliflower½ portabello mushroom½ c green beans1 c almond milk12 olives2 Tbsp cream cheese3 Tbsp olive oil

7.6 g carb15 g protein63.3 g fat660 calories

Evidence

Weight i similar to controls

Greater iA1c & i medication

Greater reduction in lipids

N= 22, 44 weeksMayers al. Diabetes Obesity Metab 2014:16(1):10.1111/dom.12191et Accessed February 2019

Ketogenic

RCT 2 yr N=61

Similar iWeight iA1c i B/P

Keto superior in i lipids & medication reduction

& glucose stability

Evidence

Ketogenic

Virta Health▪ Individual diet advice▪ Biomarker tracking▪ Access to web based software▪ Social support via online peer

community▪ Weight & A1c reduction over 2 yearsDiabetes reversal 53.5 % @ 2 years( A1c<6.5, can be on metformin)

Hallberg et al 2018; Athinarayanan et al 2019

Evidence

▪ Reduction in A1c

▪ Reduction in triglycerides

▪ Reduction in medication

▪ Improved insulin sensitivity

▪ LDL variable ori

Ketogenic

Contraindications

▪ Cardiomyopathy▪ CHF▪ Chronic Kidney Disease▪ Chronic Metabolic Acidosis▪ Fatty acid oxidation deficit▪ Liver Disease▪ Renal Stones▪ Severe Dyslipidemia▪ Severe Esophageal Reflux▪ Use of SGLT2 medications

Gupta L et al. Ketogenic diet in endocrine disorders:Currrent perspective. J Postgrad Med. 2017 Oct-Dec 63(4):2423-251.

Ketogenic

Contraindications

▪ Pregnancy and Breastfeeding

▪ Type 1 or LADA

▪ Infections

▪ Frail elderly

▪ Eating Disorders

▪ Recent stroke or MI within last 12 months

▪ Alcohol or substance abuse

Caprio M et al. Very-low-calorie ketogenic diet (VLCKD) in the management of metabolic diseases: systematic review and consensus statement from Italian Society of Endocrinology. Journal of Endcrinological Investigattion 2019 May 20. doi: 10.1007/s40618-019-01061-2. Downloaded September 2019.

Ketogenic

Assess/Advice Hypoglycemia

Medications- Westman et al

▪ Stop all oral hypoglycemia agents except metformin

▪ Stop insulin of < 20 units

▪ Insulin over 20 units decreased 30-50%

▪ Anti-hypertensive agents reduced

Westman et al. Expert Review of Endocrinology & Metabolism.2018:13(5):263-272.

Ketogenic

Ketogenic

Nutrient Deficiencies

Supplement:

Vitamin D

Calcium

Thiamine

Vitamin C

Selenium

Folate

?Carnitine

?Fibre

Ketogenic

Risks

Hypoglycemia

Hypotension

Dehydration

Protein Malnutrition

Vitamin and Mineral deficiencies

Potential complications

Assess/Advice

Medication adjustment

Blood Glucose monitoring

Monitoring blood pressure

Hydration

Nutrition

Protein

Vitamin & Minerals supplements

Monitoring blood work

Ketogenic

Summary

▪ Evidence is limited, but evolving

▪ Food Pattern is difficult to maintain

▪ Requires adequate planning and medical

monitoring

▪ Benefit in Highly Motivated patients

▪ improved blood glucose

▪ decreased medication

▪ decreased weight

▪ improved triglycerides, HDL*

Summary Respect your patient’s choices and

Support them in their Diabetes goals, help them do it safely.

Food is to be Eaten and Enjoyed!

Position statement

Low Carbohydrate

Diets

Thank you

Wendy.dietitian795@gmail.com