Better Nutrition, Better Glycemic Control

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1 Better Nutrition, Better Glycemic Control ผศ. พญ. ศ ภวรรณ บ รณพ ร หน วยต อมไร ท อ ภาคว ชาอาย รศาสตร คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม 24 เมษายน 2560

2 Goal of medical nutrition therapy for adults with DM To promote and support healthful eating, emphasizing a variety of nutrient-dense foods in appropriate portion sizes to improve overall health and to achieve and maintain body weight goals attain individualized glycemic, BP, and lipid goals delay or prevent complications of diabetes To address individual nutrition needs based on personal and cultural preferences To maintain pleasure of eating To provide DM patient with practical tools for developing healthful eating patterns American Diabetes Association Standards of Medical Care in Diabetes. Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43

3 Effectiveness of Nutrition Therapy An individualized medical nutrition therapy (MNT) program is recommended for all people with type 1 and type 2 diabetes. For people with T1DM or T2DM on a flexible insulin program, education on CHO counting and, in some cases, fat and protein gram estimation can improve glycemic control. For people whose daily insulin dosing is fixed, a consistent pattern of carb intake can result in improved glycemic control and reduced risk of hypoglycemia. American Diabetes Association Standards of Medical Care in Diabetes. Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43

4 Effectiveness of Nutrition Therapy Emphasizing healthy food choices and portion control may be more helpful for those with T2DM who are not taking insulin, who have limited health literacy or numeracy, and who are elderly and prone to hypoglycemia. Modest weight loss achievable by combination of lifestyle modification and reduction of calorie intake benefits overweight or obese adults with T2DM and also those with prediabetes. American Diabetes Association Standards of Medical Care in Diabetes. Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43

5 Eating patterns & macronutrient distribution Macronutrient distribution should be individualized keeping total calorie and metabolic goals Advise CHO intake from whole grains, vegetables, fruits, legumes and dairy products emphasis on foods higher in fiber and lower in glycemic load, esp those containing sugars. Avoid sugar-sweetened beverages to control weight and reduce risk for CVD and fatty liver and minimize consumption of foods with added sugar that have capacity to displace healthier, more nutrient-dense food choices. American Diabetes Association Standards of Medical Care in Diabetes. Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43

6 Eating patterns & macronutrient distribution A variety of eating patterns are acceptable for T2DM and prediabetes: Mediterranean, DASH and plant-based diets. Ingested protein increases insulin response without increasing plasma glucose. Not use CHO sources high in protein to treat or prevent hypoglycemia An eating plan emphasizing elements of Mediterranean-style diet rich in MUFA may improve glucose metabolism and lower CVD risk and can be effective alternative to a low-fat, high-cho diet. Eating foods containing long-chain ω-3fa (fatty fish, nuts and seeds) is recommended to prevent or treat CVD evidence does not support beneficial role for ω-3 dietary supplements. American Diabetes Association Standards of Medical Care in Diabetes. Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43

7 Nutrition Recommendations for patients with diabetes EASD ADA Canada Thai CHO+MUFA 60-70% Total CHO g 50-60% 50-60% Sucrose 10% 10% 10% 5% Fat < 35% < 30% 30% 30% Sat Fat < 8-10% < 7-10% 10% < 7-10% PUFA < 10% < 10% 10% 10% Protein 10-20% 15-20% 15-20% 12-20% Fiber (g/day) intake intake Salt (g/day) < 6 < 6 < 6 < 6 Total fiber 40 g (soluble 20 g and insoluble 20 g) improve glycemic control in type 2 diabetes

8 Glycemic index (GI) The Glycemic Index (GI) is a scale that ranks carbohydrate-rich foods by how much they raise blood glucose levels compared to a standard food. The standard food is glucose or white bread. ด ชน น าตาล (Glycemic Index) ค อ ค าท บอกให ทราบว า อาหารท ก นเข าไปเปล ยนเป น น าตาลในเล อดและน าตาลใน เล อดส งข นรวดเร วเพ ยงใด The glycemic index (GI) is a number associated with a particular type of food that indicates the food's effect on a person's blood glucose (also called blood sugar) level. A value of 100 represents the standard, an equivalent amount of pure glucose Source:

9 Glycemic index food table

10 Glycemic index food table

11 Glycemic load(gl) calculation GL = GI x P x weight of food 100 P is the proportion of available carbohydrate in the food Low <= 10 Medium= High >= 20 Am J Clin Nutr 2008;87(suppl):237S 43S.

12 Nonnutritive sweeteners The use of nonnutritive sweeteners has potential to reduce overall calorie and CHO intake if substituted for caloric sweeteners without compensation by intake of additional calories from other food sources. Nonnutritive sweeteners are generally safe to use within the defined acceptable daily intake levels. American Diabetes Association Standards of Medical Care in Diabetes. Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43

13 Franz MJ. Diabetes Care 2002;25:

14 Micronutrients and herbal supplements No clear evidence that dietary supplementation with vitamins, minerals, herbs, or spices can improve diabetes. There may be safety concerns regarding long-term use of antioxidant supplements such as vitamins E and C and carotene. American Diabetes Association Standards of Medical Care in Diabetes. Lifestyle Management. Diabetes Care 2017; 40 (Suppl. 1): S33-43

15 อาหารทางการแพทย อาหาร ทางการแพทย เป นอาหารท ผล ตข นเพ อใช งาน เฉพาะด าน ให เหมาะสมก บโรคต างๆ โดยท อาหาร ธรรมดาท วไปไม สามารถท าได ค ณสมบ ต ของอาหารทางการแพทย ตามข อก าหนดของ US-FDA ค อ ต องสามารถด ม/ ก นทางปาก หร อให ทางสายยางได ม การระบ การใช งานเฉพาะโรคอย างช ดเจน ต องใช ภายใต การควบค มด แลของท มแพทย

16 Comparison of Standard vs. Diabetes Specific Formulas Standard formulas May lead to elevated blood glucose levels May require initiation or increased dosages of insulin May lead to elevated lipid levels Reduced carbohydrate, modified fat formulas Better blood glucose control Reduced incidence of infections Lower plasma triglyceride levels Higher HDL cholesterol levels Elia et al., Diabetes Care 2005; 28:

17 Meta-Analysis: Glycemic Outcomes Objective: Determine benefits of nutritional support and diabetes-specific formula in patients with DM compared to standard formulas Variable Decrease from Baseline Number of Studies Analyzed PPG 18.5 mg/dl 6 Peak Glucose 28.6 mg/dl 2 AUC Glucose 31%-45% 4 PPG = postprandial glucose level AUC = area under the curve Several studies showed significant reduction in insulin requirements (26% to 71%) Elia et al. Diabetes Care 2005;28:

18 Meta-Analysis: Glycemic Outcomes Elia et al. Diabetes Care 2005;28:

19 Nutrition recommendation and intervention for diabetes Regarding enteral nutritional therapy, diabetes-specific formulas (DSF) appear to be superior to standard formulas in controlling postprandial glucose, A1C and insulin response. Calorie needs kcal/kg/d, protein g/kg/d for most patients When nutritional issues in hospital are complex, a registered dietitian, knowledgeable and skilled in MNT, can serve as an individual inpatient team member. responsible for integrating information about patient s clinical condition, meal planning, and lifestyle habits and for establishing realistic treatment goals after discharge. Diabetes Care 2017;40(Suppl. 1):S120 S127 DOI: /dc17-S017

20 Enteral nutrition in diabetes Macrovascular disease is the major cause of morbidity and mortality in T2DM in particular, and risk of macrovascular complications is relatively unaffected by glycemic control The improved lipid and hemostatic profile achieved with preparations that are high in MUFA is of particular importance in patients on long-term nutritional support Accumulating evidence: high-fat (as MUFA) formulations achieve better overall metabolic control than conventional high-cho preparations. Wright J. Curr Opin Clin Nutr Metab Care 2000;3:5-10.

21 Parenteral nutrition in diabetes Those patients who require parenteral nutrition should be treated using regimens similar to those used in nondiabetic patients, along with sufficient insulin (given by separate infusion) to maintain near-normal glycemia. The role of novel substrates in diabetes remains to be established. Wright J. Curr Opin Clin Nutr Metab Care 2000;3:5-10.

22 Inpatient Glycemic Control Consensus Statement American Diabetes Association (ADA) & American Academy of Clinical Endocrinologists (AACE): Critically ill patients: mg/dl on insulin therapy Non-critically ill patients: Premeal glucose: < 140 mg/dl Random glucose: < 180 mg/dl ALSO: (i) Can have lower targets in selected patients but keep 110 mg/dl (ii) Emphasize insulin therapy using. tested algorithms with infrequent hypoglycemia (iii) Frequent glucose monitoring AACE/ADA Consensus statement. Endocrine Practice. 2009;15:1-17

23 ONCE PRO-the new DM formula ONCE PRO % Caloric distribution 20 : 40 : 40 (P:F:CHO ) Glycemic Index Whey protein isolate Protein Soy protein isolate Maltodextrin Isomaltulose (GI = 32) Carbohydrate Maltitol (GI = 35) Fibersol (GI < 5) FOS (GI ~ 1) Canola oil HOSO oil Fat Ricebran oil Fish oil Protein Carbohydrate Fat Main Ingredients (% approximate w/w) Whey protein isolate 10.37% Soy protein isolate 10.37% Maltodextrin Isomaltulose Maltitol Fibersol FOS Canola oil HOSO oil Ricebran oil Fish oil 23.76% 9.22% 9.22% 4.61% 2.30% 9.22% 4.61% 4.15% 0.92%

24 Summary ONCE PRO benefit % Caloric distribution P:F:CHO Protein Ingredients 20 : 40 : 40 Low carbohydrate Whey protein isolate Benefit Control blood glucose and muscle building Soy protein isolate Cholesterol controlling Carbohydrate Fat Maltodextrin Isomaltulose Maltitol Fibersol FOS Canola oil High oleic safflower oil Ricebran oil Fish oil Slow release blood glucose Control calories, Low GI Blood glucose and cholesterol controlling High MUFA better glycemic control Decrease LDL Increase HDL Decrease triglyceride Triglyceride controlling

25 ONCE PRO: Product comparison ONCE PRO Glucerna tipple care Nutren Balance Category Medical food Medical food Medical food %Cal dis. 20:40:40 20:43:37 15:45:40 Protein Isolated Soy Protein Isolated Soy Protein Whey Isolated whey Protein Casein Casein Milk Carbohydrate Maltodextrin Maltodextrin Tapioca flour Isomaltulose Fructose Potato starch Maltitol Maltitol maltodextrin Sucromalt Fat Canola oil Soybean oil Canola oil High oleic safflower oil High oleic sun flower oil sun flower oil Rice bran oil Soy oil Soy lecithin Fish oil Fiber FOS FOS Gum arabic Fibersol-2 Fibersol-2 Soy fiber

26 Soy protein and cholesterol lowering: Possible mechanism cholesterol absorption Isoflavone or saponin content fecal cholesterol excretion Low lysine/arginine ratio Soy protein hydrolysate direct inhibit solubilization of micellar cholesterol

27 Effects of soy protein on serum lipids Percent change in plasma lipids and lipoproteins during soy consumption compared with control diets * -12.9* * Total Cholesterol LDL-C HDL-C Triglycerides * = statistically significant, p<0.05 Anderson JW. N Engl J Med 1995

28 Whey protein Provides high level of branched and essential chain amino acids and rich in minerals and vitamins. Easily and quickly digested. Excellent protein for individuals of all ages for healthy diet and to improve and maintain their health. Helps to control blood glucose levels and provides additional beneficial for weight management Whey proteins promote: Muscle strength/ muscle synthesis Improved immune system Performance / endurance/ more favorable body composition Recovery Shankar JR. International Journal of Advanced Biotechnology and Research 2013;4:15-19

29 Whey protein Composition (%) of whey protein forms Component Whey Powder Whey Concentrate Whey Isolate Protein Lactose Milk Fat Jay R. Hoffman and Michael J. Falvo, PROTEIN WHICH IS BEST, Journal of Sports Science and Medicine, 2004

30 Effect of whey on BG and insulin responses to composite breakfast and lunch meals in T2DM 14 DM type II patients High GI breakfast (white bread) High GI Lunch (mashed potatoes, meatballs) Blood sample time 0 and at 10, 20, 30, 40, 60, 120, 180, and 240 min after breakfast night Breakfast Blood Blood Lunch sample sample 10, 20, 30, 40, 60, 120, and 180 min after lunch. Ander H Frid et alam J Clin Nutr 2005;82:69 75.

31 Effect of whey on blood glucose and insulin responses to composite breakfast and lunch meals in type 2 diabetic subjects Ander H Frid et al. Am J Clin Nutr 2005;82:69 75.

32 High MUFA diets lower both plasma cholesterol and triacylglycerol concentrations 22 healthy subjects AAD 7days Step II 7days OO 7days PO 7days PPB 7days Kris-Etherton et al. Am J Clin Nutr 1999;70:

33 High MUFA diets lower both plasma cholesterol and triacylglycerol concentrations 1 Least-squares mean ± SE. Within a row, values with different superscript letters are significantly different, P < Different from AAD, P = n = 20; subjects whose values were < 0.05 g/l for all diet treatments were dropped from the analysis. Conclusion: A high MUFA, cholesterol-lowering diet may be preferable to a low-fat diet because of more favorable effects on the CVD risk profile. Kris-Etherton et al. Am J Clin Nutr 1999;70:

34 Effect of fish oil on plasma triglyceride level Dose dependent Robinson JG_Am J Cardiol2006

35 Benefits of soluble fiber: FOS & Fibersol Helps manage constipation and diarrhea Supports healthy intestinal microflora Inhibits growth of C. difficile Reduces gastrointestinal transit time Increases intestinal acidity and fecal weight 3 1 Favorably modulates lipid profile Breaks down to form short chain fatty acids (SCFAs) SCFAs serve as metabolic fuels for support of gut immune cells 2 Nutrition Fact Sheet: Dietary Fiber, Nutrition, Feinberg School of Medicine. Accessed 1/15/2008, last updated 7/28/2007. Dietary fiber: An essential part of a healthy diet - MayoClinic.com. Accessed 2/13/2008, last updated 11/30/2007.

36 The study of glycemic index of ONCE PRO Performed at the Research Center of Phramongkutklao Hospital. Inclusion criteria: healthy and 18 years of age with BMI kg/m2 and had no family history of DM. Exclusion criteria: chronic diseases such as DM, hypertension, CVD, liver disease, renal disease, GI related to absorption process, and metabolic diseases. OGTT 50g of Glucose 10 healthy person 50g of Carb ONCE PRO (100.92g) 400 ml in 5 min Blood sample time 0, 30, 60, 90 and 120 min Boonyavarakul A. J Med Assoc Thai 2013; 96:911-6.

37 Study of GI of ONCE PRO ONCE PRO Taking ONCE PRO Boonyavarakul A. J Med Assoc Thai 2013;96;911-6.

38 Study of GI of ONCE PRO ONCE PRO New DM formula The GI obtained from 10 healthy subjects was used as the GI rating for ONCE PRO. Consequently, ONCE PRO could be classified as the low-gl nutrition. Data from the DECODE study showed that an increase of 18 mg/dl in postprandial blood glucose resulted in 7% increase in total mortality over 5-l0 year period. Boonyavarakul A. J Med Assoc Thai 2013;96;911-6.

39 Glycemic load(gl) of ONCE PRO GL = GI x P x weight of food 100 ONCE PRO 1 แก ว (6 ช อนตวง) ม คาร โบไอเดรต กร ม ฉะน น GL= (27.29/100) X = 6.6 Low <= 10 Medium= High >= 20 Am J Clin Nutr 2008;87(suppl):237S 43S.

40 Effect of ONCE PRO as a Meal Replacement on Glycemic Control in Type 2 Diabetes Patients: A Randomized Controlled Trial Apussanee Boonyavarakul, Rattana Leelawattana, Chatlert Pongchaiyakul, Supawan Buranapin, Pariya Phanachet and Pornpoj Pramayothin

41 Investigators Assoc.Prof. Apussanee Boonyavarakul,MD (Principal Investigator) Phramongkutklao Hospital Prof. Chatlert Pongchaiyakul, MD. Srinakagind Hospital Assoc. Prof. Rattana Leelawattana, MD. Songnagarind Hospital Assist. Prof. Supawan Buranapin, MD Maharaj Nakorn Chingmai Hospital Pariya Phanachet, MD. Ramathibodhi hospital Pornpoj Pramyothin, MD. Siriraj Hospital

42 Objective of clinical study Primary Objective To evaluate the outcomes of ONCE PRO as a meal replacement on HbA1C in type 2 diabetes patients. Secondary Objective To evaluate the outcomes of ONCE PRO as a meal replacement on fasting plasma glucose, 2-hour postprandial plasma glucose, lipid profile, BW, BMI and waist-circumference in poorly controlled type 2 diabetes patients.

43 Material and method 152 DM PATIENTS WERE SCREENED 119 DM PATIENTS WERE ELIGIBLE DIET CONTROL GROUP (N=59) MEAL REPLACEMENT GROUP (N=60) 3 months DIETARY COUNSELLING DIETARY COUNSELLING MEAL REPLACEMENT WITH ONCE PRO (30% OF TOTAL ENERGY) HbA1C fasting plasma glucose 2-hour postprandial plasma glucose body weight, body mass index waist-circumference lipid profile The nutrition goal was to provide kcal/kg/day based on ideal body weight (IBW) and physical activity with caloric distribution of protein: fat: carbohydrate at 20: 30: 50

44 Clinical Study Outcome Within ONCE PRO group Variables n ONCE PRO (Mean difference) SD p-value HbA 1C Glucose (mg/dl) Total cholesterol (mg/dl) Triglyceride (mg/dl) LDL (mg/dl) HDL (mg/dl) Body weight (kg) Body Mass Index Waist-circumference (cm)

45 Clinical Study Outcome Diet control group Variables n Normal diet (Mean difference) SD p-value HbA 1C Glucose (mg/dl) Total cholesterol (mg/dl) Triglyceride (mg/dl) LDL (mg/dl) HDL (mg/dl) Body weight (kg) Body Mass Index Waist-circumference (cm)

46 Clinical Study Outcome Compare between group (day 90) Variables n ONCE PRO (Mean) SD n Diet control (Mean) SD p- value HbA 1C Glucose (mg/dl) Total cholesterol (mg/dl) Triglyceride (mg/dl) LDL-C (mg/dl) HDL-C (mg/dl) Body weight (kg) Body Mass Index Waist-circumference (cm)

47 Clinical Study Outcome Compare between gr. (diff of post-pre) Variables n ONCE PRO (Mean) SD n Normal diet (Mean) SD p-value Glucose (mg/dl) Total cholesterol (mg/dl) Triglyceride (mg/dl) LDL (mg/dl) HDL (mg/dl) Body weight (kg) Body Mass Index Waistcircumference (cm)

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49 Conclusion อาหารท เหมาะสมส าหร บผ ป วยเบาหวานควร เป นอาหารท ม ใยอาหารส ง แต ม glycemic load ต า หล กเล ยงน าตาลเป นส วนประกอบ ในคนท ก นอาหารปกต ได ไม เพ ยงพอ อาจเสร ม ด วยอาหารทางการแพทย ส ตรเบาหวานท ม ด ชน น าตาลต า ม MUFA, soy and whey protein เป นส วนประกอบ เพราะนอกจากช วยควบค ม น าตาลหล งอาหารแล ว ย งช วยลด LDL-C และ เพ ม HDL-C ได อ กด วย

50 Thank you for your attention