3/21/2011

1

DIABETES PREVENTIONDIABETES PREVENTION::the WEIGHT the WEIGHT is over!is over!the WEIGHT the WEIGHT is over!is over!

What you need to KNOW What you need to KNOW about DIETabout DIET

Catherine M. Champagne, PhD, RDNutritional Epidemiology/Dietary

Assessment & Counseling

3/21/2011

2

Things to considerThings to consider

Success in the Diabetes Prevention Program, the long-term follow-up of those participants, and the Look AHEAD program.AHEAD program.

Dietary strategies for weight control and maintenance: what is proven to work?Diet tips to avoid diabetes or to Diet tips to avoid diabetes or to follow if you are diabetic!

3/21/2011

3

Diabetes Prevention Program Diabetes Prevention Program (DPP) (DPP) Study DesignStudy Design

4000 subjects at 25 centers (~170/site); 3-year enrollment

Subjects followed for 3-6 years Medication groups for double blind, g p ,

placebo controlled study; separate lifestyle group

Adequate design to detect 33% reduction in progression to diabetes (assuming a 7.5% annual progression rate)

3/21/2011

4

Diabetes Prevention Program Diabetes Prevention Program Lifestyle Intervention ArmLifestyle Intervention Arm

An intensive program with the following specific goals:• > 7% loss of body weight and maintenance of weight lossof weight loss

• Dietary fat goal: <25% of energy from fat

• Calorie intake goal: 1200-1800 kcal/day

• > 150 minutes per week of physical activityactivity

3/21/2011

5

DPP Intensive Lifestyle DPP Intensive Lifestyle Intervention MethodsIntervention Methods

• Training in diet, exercise, and behavior modification

• Low-fat, low-calorie diet• 16-session core curriculum (over 24 16 session core curriculum (over 24 weeks)

• Maintenance phase—minimum of monthly contactExercise session at the center • Exercise session at the center 2x/week

3/21/2011

6

Diabetes Prevention ProgramDiabetes Prevention ProgramInterventionsInterventions

Intensive Lifestyle GoalsIntensive Lifestyle Goals

•• Reduction of fat and calorie intakeReduction of fat and calorie intake

Ph i l ti it t l t 150 i t / kPh i l ti it t l t 150 i t / k•• Physical activity at least 150 minutes/week Physical activity at least 150 minutes/week

•• Achieve and maintain at least 7% weight lossAchieve and maintain at least 7% weight loss

MetforminMetformin GoalsGoals•• MetforminMetformin 850 mg twice 850 mg twice dailydaily

3/21/2011

7

Diabetes Prevention Program Diabetes Prevention Program Mean Weight ChangeMean Weight Change

4

-2

0

gh

t C

han

ge

(kg

)

Placebo

Metformin

Lifestyle

-8

-6

-4

Wei

g

0 1 2 3 4

Years from Randomization

The DPP Research Group, NEJM 346:393-403, 2002

3/21/2011

8

Percent developing diabetes

All participants

All participants

DPP: Progression to DiabetesDPP: Progression to Diabetes

30

40Placebo (n=1082)Metformin (n=1073, p<0.001 vs. Plac)Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )

cide

nce

(%)

Risk reductionRisk reduction31% by31% by metforminmetformin

10

20

Cum

ulat

ive

inc 31% by 31% by metforminmetformin

58% by lifestyle58% by lifestyle

0 1 2 3 4

0

Years from randomization

3/21/2011

9

Positive Effects of Weight Positive Effects of Weight Loss on Type 2 DiabetesLoss on Type 2 Diabetes

• Modest weight loss of 5% yields significant results• Modest weight loss of 5% yields significant results

Tuomilehto J, et al. Finnish Diabetes Prevention Study. N Engl J Med. 2001;344:1343.

3/21/2011

10

Macrovascular Microvascular

Potential Lifetime Impact for PrePotential Lifetime Impact for Pre--Diabetes Lifestyle Intervention Diabetes Lifestyle Intervention

Macrovascular MicrovascularStroke

9%

Coronary Heart

Blindness

39%

Life Expectancy:

yDisease

8%

Amputations

End Stage Renal Disease

38%

p yIncrease by

0.5 Years

Aroda VR, Ratner R. JCEM 93(9):3259-65, 2008

p

35%

3/21/2011

11

DPPOS (DPP DPPOS (DPP Outcomes Study)Outcomes Study)

The DPPOS reports: In 10 years, participants in the lifestyle

change group delayed type 2 diabetes by about 4 years compared with placebo, and those in the metforminp ,group delayed it by 2 years.

The benefits of intensive lifestyle change were especially pronounced in the elderly.

People aged 60 and older lowered their People aged 60 and older lowered their rate of developing type 2 diabetes in the next 10 years by about half.

3/21/2011

12

Look AHEAD (Look AHEAD (AAction for ction for HeaHealth in lth in DDiabetes) Trialiabetes) Trial

Multicenter trial of 5,145 individuals with type 2 diabetes• Intensive lifestyle intervention (ILI) caloric

restriction, minimum weight loss goal of 7%, & physical activity goal 175 min/wk versus& physical activity goal 175 min/wk versusdiabetes support & education (DSE) sessions• Wt loss: 8.6% (ILI) vs 0.7% (DSE)• Mean fitness ↑: 20.9% (ILI) vs 5.8% (DSE) • HbA1c ↓: 7.3 to 6.6% (ILI) vs 7.3 to 7.2% (DSE)• BP, TG, HDL all improved significantly in ILI vs

DSE

The Look AHEAD Research Group. Diabetes Care 2007;30:1374

3/21/2011

13

Dietary Strategies inDietary Strategies inLook AHEADLook AHEADDi t b d t ADA Diet was based on current ADA recommendations for <30% of calories from fat & <10% from sat fat

Calorie and fat targets given to each participant• For those weighing 250 lbs or less: 1200-1500 kcals• For those weighing 250 lbs or less: 1200-1500 kcals

• For those weighing over 250 lbs: 1500-1800 kcals

Self monitoring of foods eaten, portions, calories, and fat grams

Meal replacements: 2/day recommended, and Meal replacements: 2/day recommended, and 1/day encouraged after the first 4 months

3/21/2011

14

Dietary Strategies inDietary Strategies inLook AHEADLook AHEAD

Healthy, balanced meals, plenty of fruits and vegetables and healthy cooking techniques encouraged

Structured meal plans also given to help i h hi l i lwith reaching calorie goals

Discussed eating out and making good choices

Calorie density covered in second 6 o th ( ol et i )months (volumetrics)

3/21/2011

15

Successful weight loss strategies:Successful weight loss strategies:

Strategy total dietary calories

Target portion sizes Slow down

eating f i d f d total fat intake fried foods

fats, both in cooking and at table

3/21/2011

16

Most difficult issues in keeping a Most difficult issues in keeping a healthy weighthealthy weight

Maintenance of weight loss

Continued use of self-monitoring of dietary intake

Weighing oneself regularly

Continuing behaviors that enabled initial success (examples: motivation, time management etc )time management, etc.)

3/21/2011

17

Food Food Behaviors of Successful LongBehaviors of Successful Long--term term Weight Weight Management: Management: National National Weight Weight Control Registry DataControl Registry Data

Self-monitoring:• Diet: record food intake daily, limit certain foods or food quantity

• Weight: check body weight >1 x/wk Low-calorie low-fat diet: Low-calorie, low-fat diet:

• Total energy intake: 1300-1400 kcal/d• Energy intake from fat: 20%-25%

Eat breakfast daily Regular physical activity: 2500-3000

k l/ k ( lk 4 il /d)kcal/wk (eg, walk 4 miles/d)

Klem et al. Am J Clin Nutr 1997;66:239. McGuire et al.Int J Obes Relat Metab Disord 1998;22:572.

3/21/2011

18

Making Healthy Food Choices to Making Healthy Food Choices to Prevent Diabetes (healthy for DM)Prevent Diabetes (healthy for DM)

Watch those CALORIES! Eating too much of even healthy foods can result in weight gain. Watch your portion sizes. Keep your eyes on the

i i b l h b iNutrition Facts Label when buying and choosing your foods.

Eat lots of vegetables and fruits. Focus on color variety to maximize health benefits health benefits.

3/21/2011

19

Making Healthy Food Choices to Making Healthy Food Choices to Prevent Diabetes (healthy for DM)Prevent Diabetes (healthy for DM)

Have non-starchy vegetables such as spinach, carrots, broccoli or green beans with meals. Health benefits are highest with raw or steamed

bl d ’ kvegetables, so don’t overcook vegetables.

Choose whole grain foods over refined grains. Transition gradually to brown rice or whole wheat pastarice or whole wheat pasta.

3/21/2011

20

Making Healthy Food Choices to Making Healthy Food Choices to Prevent Diabetes (healthy for DM)Prevent Diabetes (healthy for DM)

Include dried beans (like kidney or pinto beans) in your meals. Red beans and brown rice can become a tradition. tradition.

Include fish 2-3 times a week. Make your meat choices lean, such as

sirloin or pork loin. Remove the skin from chicken and turkey from chicken and turkey.

3/21/2011

21

Making Healthy Food Choices to Making Healthy Food Choices to Prevent Diabetes (healthy for DM)Prevent Diabetes (healthy for DM)

Consume non-fat dairy: skim milk, non-fat yogurt and non-fat cheese. If you don’t like these choices, then like these choices, then choose the low-fat dairy versions.

Avoid sweetened drinks, opting for water and calorie-opting for water and caloriefree "diet" drinks instead.

3/21/2011

22

Making Healthy Food Choices to Making Healthy Food Choices to Prevent Diabetes (healthy for DM)Prevent Diabetes (healthy for DM)

Choose liquid oils instead of solid fats that can be high in saturated and trans fats, both for cooking and at the table. Remember that fats are high in e e be t at ats a e gcalories. If you're trying to lose weight, watch your portion sizes of added fats. The Nutrition Facts Label is a great help here.

Cut back on high calorie snack gfoods and desserts.

3/21/2011

23

WeightWeightManagement

HealthManagement=

••And, yes, you can have that favorite food you like.And, yes, you can have that favorite food you like.

••You just can’t have it every day and you can’t have a lot You just can’t have it every day and you can’t have a lot j y y yj y y yof it. of it.

••Work it into your diet plan and… write it down!!!!Work it into your diet plan and… write it down!!!!

3/21/2011

24