Diet & Exercise Noelle Cooper

Diabetes Specialist Dietitian

January 2019

Agenda

• New guidance for prevention and management diabetes (2018): remission, low carbohydrate diets for weight loss or type 2 diabetes

• Structured diabetes education: Xpert, Carb Aware & CHOICE

• Carbohydrates: amount and type, e.g. glycaemic Index

• Weight management: food portions, food labels, eating out, mindful eating, volumetrics

• Exercise: guidance, impact on blood glucose control, calories burnt, keeping safe

10 tips for healthy eating with diabetes

www.diabetes.org.uk/10-ways-to-eat-well-with-diabetes

• There is no one-size fits all way of eating

• Why healthier food choices are important

• Focus on specific foods that can complement any diet someone

decides to follow

• For people with Type 1 emphasis on carb counting/awareness

• For people with Type 2 diabetes emphasis on weight loss and

possibility of remission for some

Glycaemic Control: Type 2 Diabetes

What is Recommended:

•Prioritise sustained weight loss of at least 5% in overweight individuals by reducing calorie (energy) intake and increasing energy expenditure

•Aim for a Mediterranean-style diet or equivalent healthy eating pattern

•Offer individualised education to support people to identify and quantify their dietary carbohydrate intake, encourage low glycaemic index (GI) foods and consider reducing the total amount of carbohydrates

•Aim for at least 150 mins per week of moderate to vigorous physical activity, over at least 3 days

Considerations about weight management

A recent meta-analysis concluded that weight loss of ≥5% is necessary to improve glycaemic control significantly:

•7mmol/mol (0.6%) reduction in HbA1c in established Type 2 diabetes

•Up to 13mmol/mol (1.2%) in a newly diagnosed study group

•Longitudinal cohort studies have also indicated that change in BMI is a significant predictor of change in HbA1c, and that people with Type 2 diabetes who lose weight are more likely to achieve HbA1c targets than those with stable weight or weight gain

Franz et al. (2015) J. Acad. Nutr. Diet. 115(9) 1447-63

Considerations about weight management

More intensive weight management can achieve remission of Type 2 diabetes

•11% of people who achieve 8% weight loss

(Gregg et al., JAMA 2012 )

•73% of people with weight loss of greater than 10kg

•86% of those with weight loss >15kg

(Dixon et al., 2008 , Lean et al., 2017 )

While sustained remissions have been reported after bariatric surgery (Buchwald et al., JAMA 2014 ), there remains a major challenge to maintain weight loss after non-surgical interventions.

How is remission achieved?

Bariatric for Type 2 diabetes • 30-60% remission depending on the type of surgery • Median diabetes-free duration is about 8 years • Reports of people going up to 15 years without diabetes

Bariatric Surgery: T2DM is a potentially reversible condition

4.

Type 2 Diabetes Recommendations for Remission

Major weight reductions, e.g. 15% weight loss. 1) Discuss what method is more achievable/sustainable for energy deficit/expenditure (vs specific macronutrient composition) 2) Take action as close to diagnosis as possible 3) Note 10% people with type 2 diabetes are of healthy weight! 4) Other risk factors: where store body fat (visceral fat linked to insulin resistance), genes and family history, some ethnic minority groups, e.g. African, south Asian Still continue HBA1C monitoring and annual diabetes

checks, including retinopathy screening

Cure, Reversal, or Remission? Lifestyle weight management interventions in

Type 2 diabetes

Diabetes UK

• Remission position statement 2017 • Difficulties with what defines remission • ADA’s definition of remission, 2009 Partial remission – HbA1c below 6.5% (48mmol/mol), fasting

glucose between 5.6 and 6.9mmol/l, sustained over at least a year without any diabetes medication

Complete remission – HbA1c below 6% (42mmol/mol) and fasting glucose below 5.6mmol/l, sustained over at least a year without any diabetes medication

Prolonged remission – complete remission of at least 5 years duration

• Diabetes UK is currently working with the ADA and EASD to develop an international consensus to define remission

Is it surgery or the cut in calories?

• 2011: DUK-funded ‘Counterpoint’ study

• T2DM < 4 years

• 8 week liquid diet + non-starchy veg: 720kcal/d

• Blood glucose normalised in 11/15 participants (73%) with 15kg weight loss

• Reduced fat in liver and pancreas

• ‘Proof of Concept’

Lim et al. Diabetologia 2011; 54: 2506-14

Cluster Randomised (by GP practice)

• T2DM <6 years, not on insulin

• Control: usual diabetes care

• Intervention:

Total Diet Replacement

Transition back to normal foods

Support to keep weight off

Stop all blood glucose lowering medications on day 1

12 Month ITT Analysis

Lean et al, Lancet 2017 DOI:https://doi.org/10.1016/S0140-6736(17)33102-1

Weight losses and likelihood of remission

Lean et al, Lancet 2017 DOI:https://doi.org/10.1016/S0140-6736(17)33102-1

T2DM Remission in Diabetes Guidelines: Diabetes UK (March 2018)

For remission of type 2 diabetes aim for weight loss of approximately 15kg, as soon as possible after diagnosis (if overweight/obese). • This weight loss can be achieved through different means • When remission is achieved, ongoing monitoring and annual reviews, including retinal screening, should continue

EASD/ADA Joint Guidelines (Sept 2018)

”If a patient wishes to aim for remission of type 2 diabetes, particularly within 6 years of diagnosis, evidence-based weight management programmes are often successful. ”The most effective non-surgical strategies…involve food substitution and intensive sustained counselling…”

Davies M et al, Diabetes Care & Diabetologia 2018

Diabetes UK recommends

Ongoing monitoring and annual reviews

Long-term outlook and relapse Not enough data to predict how long remission lasts Not enough data to predict who is likely to relapse and

when Complications Some evidence on CVD risk reduction, no evidence on

actual CVD events Evidence is conflicting for both prevention and

progression retinopathy Little evidence on kidney disease Not much evidence on many other diabetes

complications e.g. amputations

What’s new and what’s not: Weight loss and dietary composition

No one dietary approach can be considered superior based on the current available evidence.

• The ideal proportion of macronutrients to recommend for optimal glycaemic control for T2DM is unclear, but total energy intake, weight loss and overall diet quality are significant factors.

• The role of low carbohydrate diets was acknowledged in the 2011 guidelines. Additional evidence has been included in this update. To date the evidence suggests that although clinical modest but statistically significant improvements can be seen at 3 months, but no differences are seen at 12 months

Snorgaard et al. (2017) BMJ Open Diabetes Res. Care. 5(1) e000354

Dietary strategies for weight loss

• Healthy eating

• Low carbohydrate diets

• Meal replacements

• Mediterranean diets

• Very low energy diets

• Low GI diets

• Commercial groups – Weightwatchers, Slimming World

• Intermittent fasting e.g. 5:2 diet

• Fad diets – cabbage soup, grapefruit diet, egg diet

Low Carbohydrate Diets

• Carbohydrate content of the diet is the prime determinant of glycaemia.

• However, evidence is limited with inconsistent findings, lack of studies of longer term effects, and lack of clarity on what constitutes the definition of low carbohydrate

• A recent 2 year long study with good adherence found similar reductions in weight and HbA1c in both the low carbohydrate and high carbohydrate groups, but a greater reduction in diabetes

medication was seen in the low carbohydrate group

Tay et al. (2017) Diabetes. Obes. Metab.

Doi: 10.1111/dom.13164

Low Carbohydrate Diets for Weight Loss

Popular strategy for weight loss and for the prevention and treatment of type 2 diabetes

Mean weight losses of 6.1kg are reported with low carbohydrate diets

Currently, there is no agreement about the definition of ‘low carbohydrate’, although a recommendation has been made that any diet providing <130g (<26% CHO) carbohydrate/day should be regarded as low carbohydrate, and diets providing <50g (<10% CHO) carbohydrate/day and which induce ketosis should be termed very low carbohydrate ketogenic diets (VLCKD).

Based on 2000 kcal diet

Low Carbohydrate Diets for Weight Loss

There is little evidence of superiority over other dietary interventions, with meta-analyses reporting contradictory results re: weight loss success.

Weaker evidence for CVD risk, compared to other strategies, but may reduce risk by lowering triglycerides and increasing HDL.

BUT they may also increase risk by raising both LDL and total cholesterol.

Weight loss reduces risk of CVD, irrespective of dietary intervention.

Low Carbohydrate Diets for Type 2 Diabetes

Intervention studies show that low carb diets: -reduce body weight by mean 4.8kg -decrease HbA1C by 0.5% (6 mmol/mol) -have little or no effect on CVD risk factors with a trend showing 2-3 mmol/l decrease in triglycerides Low carb diets are associated with weight loss,

improvements in glycaemic control and reductions in CVD risk in people with type 2 diabetes.

However, most studies fail to show superiority of low carb diets over other dietary strategies.

It is likely that a variety of dietary strategies are equally effective for people with type 2 diabetes.

Adverse Effects of Low Carbohydrate Diets

Low carb diets can be high in saturated fat Low carb diets are high in protein and have adverse

effects on renal function Ketosis induces acidosis which promotes urinary

calcium loss, leading to low bone mineral density and increased risk of osteoporosis

Restricting carbohydrate leads to sub-optimal intake of dietary fibre and some micronutrients

Risk of hypoglycaemia or in rare cases, ketoacidosis, for those on glucose lowering drugs, e.g. insulin

The British Dietetic Association (BDA) believes

1. Low-carbohydrate diets can be effective in managing weight, improving glycaemic control and cardiovascular risk in people with Type 2 diabetes in the short term (Diabetes UK 2018). This is probably due to the accompanying reduction in energy (calorie) intake and subsequent weight loss (Diabetes UK 2018).

2. More research is needed to find out how much carbohydrate needs to be restricted in order to lower glucose concentrations and control diabetes in people with type 2 diabetes in the short and long term (i.e. >12 months)

3. When considering a low carbohydrate diet as an option, people with diabetes who are on certain drugs including insulin should be made aware of possible side effects such as the risk of hypoglycaemia or in rare cases ketoacidosis; it is important that individuals on such treatments should be supported by doctors and dietitians to manage such risks which may involve adjusting medication.

The BDA believes

4. People with type 2 diabetes who choose to follow a low carbohydrate diet should be supported by a dietitian to ensure that their diet is nutritionally adequate, enjoyable and fits in with lifestyle and cultural preferences.

5. When people restrict their intake of carbohydrate they either replace some or all of the calories lost by eating more protein foods or more fat and fatty foods (including saturated fats as well as healthier unsaturated fats). However, more research is needed to find out what effects these versions of the low carbohydrate diet have on blood fats and therefore on the risk of developing cardiovascular disease in people with type 2 diabetes.

6. Weight loss is still the cornerstone of management of type 2 diabetes. There is insufficient evidence to indicate that low carbohydrate diets are a superior or better approach than other strategies for weight loss and subsequent weight maintenance in the long term.

Nutrition for Cardiovascular Disease Prevention

Recommendations:

Dietary patterns, specifically the Mediterranean and DASH-style diets, are recommended to reduce CVD risk factors and CVD events in people with diabetes. Key features of these diets include:

• Decrease salt intake (<6g/day)

• Eat 2 portions of oily fish each week

• Eat more wholegrains, fruit and vegetables, fish, nuts and legumes (pulses)

• Eat less red and processed meat, refined carbohydrates and sugar sweetened beverages

• Replace saturated fats (SFA) with unsaturated fats, and limit intakes of trans fatty acids (TFA)

• Limit alcohol intake to <14 units a week

Nutrition for Cardiovascular Disease Prevention

Recommendations additional points:

• Aim for modest weight loss of at least 5% in overweight individuals

• Aim for at least 150 mins per week of moderate to vigorous

physical activity, over at least 3 days.

• Products containing 2-3g of plant stanols and sterols per day can be recommended (note caveat)

Fat – a major issue?

• The exact proportion of energy that should be derived from total fat intake does not appear to be critical

• In people with diabetes, studies recommending up to 40% of energy from fat (mostly unsaturated fat) have resulted in beneficial effects on lipid profiles, blood pressure and weight similar to approaches using less than 30% of energy from fat.

Esposito et al. (2015) BMJ Open, 5(8) e008222

Look AHEAD (2010) Arch. Intern. Med. 170(17) 1566-75

• These findings suggest that any effects of fat on CVD risk factors are likely to be derived from the type of fat rather than the amount per se.

Dietary Patterns and Cardiovascular Disease Risk

Mediterranean Diet

•Lower total and CVD mortality in general population and people with diabetes

•PREDIMED RCT (n = 3614) confirmed beneficial effects of a Mediterranean diet supplemented with either extra virgin olive oil

or with mixed nuts

•In T2DM, meta-analyses of RCTs of Mediterranean diets have reported greater reductions in HbA1c, total cholesterol and

triglycerides, and an increase in HDL cholesterol compared to control diets such as low fat diets and low carbohydrate diets

Esposito et al. (2015) BMJ Open, 5(8) e008222

Estruch et al. (2013) NEJM 368. 1279-90

Martinez-Gonzalez et al. (2015) Progress Cardiovascular Dis. 58.

50-60

Dietary Patterns and Cardiovascular Disease Risk

Other dietary patterns

•Both low fat and low carbohydrate diets have also shown positive results in reducing CVD risk factors in people with Type 2 diabetes

Van Wyk et al. (2016) Diabet Med. 33(2) 148-57

Rees et al. (2013) Cochrane 2013(3) CD002128

• Low fat diet failed to show significant reductions in actual CVD events and CVD mortality in people with Type 2 diabetes when compared with usual care

Look AHEAD (2013) NEJM 369(2) 145-54

•To date there are no RCTs reporting the long term effects of low carbohydrate diets on CVD endpoints in people with diabetes.

Content of Food

• Blood glucose levels are affected by the type of food eaten.

• Key to controlling blood glucose levels is to understand how and why different foods affect it. Dietary changes can help to keep blood glucose levels within the target range.

• Food consists of 3 main nutrients which are broken down to form their basic units.

Carbohydrates Sugars

Protein Amino acids

Fats Fatty acids & Glycerol

Carbohydrates

• All carbohydrate

eaten and drank

are broken down

into sugars.

• Carbohydrates

can be classified

into two main

groups.

– Starch

– Sugar

Principle of the Glycaemic Index

• The type and amount of carbohydrate consumed makes a difference to blood glucose levels.

• Some carbohydrate foods breakdown more quickly than others.

• Quick = High Glycaemic Index

• Slow = Low Glycaemic Index

• Type of starch, fibre content,

cooking process, high

fat/protein content, acidic

foods affect the glycaemic

index of food.

Food Challenge

Food Low

Glycaemic

Medium

Glycaemic

High

Glycaemic

Apple

Banana

Watermelon

Mash Potato

New potatoes

Sweet potato

Cornflakes

Shredded Wheat

Muesli

Soya & linseed bread

White bread

Food Low

Glycaemic

Medium

Glycaemic

High

Glycaemic

Ryvita

Chappati

Baked beans

Lentils

Pasta

Basmati rice

Milk

Ice cream

Jelly beans

Dark chocolate