Plant-Based Nutrition for Diabetes

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1 Plant-Based Nutrition for Diabetes Meghan Jardine, MS, MBA, RD, LD, CDE Associate Director of Diabetes Nutrition Education Physicians Committee for Responsible Medicine

2 Agenda: Diabetes Mellitus What you need to know Current Guidelines for Diabetes Management New School Diabetes Education Curriculum Review

3 Diabetes Mellitus (DM) in the U.S million people in the U.S. have diabetes. That s 1 our of every 11 people. 1 One out of 4 do not know they have DM 79 ml U.S. adults have pre-diabetes. The prevalence among US adults grew by 45% over the past 20 years. 2 There is an urgent need for planning and delivering primary prevention! 1. Diabetes in the United States: A Snapshot BuskoM, New statistics shed light on worrisome diabetes epidemic. Medscape Medical News, May 15, 2013;

4 Diabetes Cost of Diabetes $245 billion 1 $176 in Direct Medical Costs $79 in Indirect Costs Absenteeism Decreased productivity 1 out of every 5 healthcare dollars Lifetime cost of T2DM $283,000 High intangible cost on society: Reduced quality of life Pain and suffering 50% more likely to have disability 2 Shorter lifespan MD visits 9% Supplies 13% Rx meds 18% Medical Costs Nursing facilities 8% Inpatient 43% 1. American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care 36: , Wong E, et al. Diabetes and the risk of physical disability in adults: a systematic review and meta-analysis. The Lancet Diabetes and Endocrinology. Vol 1, Issue 2, Pages , October 2013.

5 International Diabetes Federation

6 Diabetes, Defined Diabetes is a group of diseases characterized by high blood glucose levels that result from defects in the body's ability to produce and/or use insulin. If not treated appropriately, high blood glucose causes damage to the organs, eyes, nerves, heart and blood vessels.

7 Type 1 Diabetes Genetic trigger is environmental Acute onset Normally occurs in those under 20 years of age Type 2 Diabetes Genetic trigger is lifestyle Slow onset: prediabetes to diabetes takes years; symptoms more subtle Both type 1 and type 2 diabetes cause the same complications and have similar symptoms: extreme thirst, frequent urination, hunger, and weight loss

8 The Pancreas produces insulin

9 Food, Blood Glucose and Insulin Stomach F F F - Food F G - Glucose I - Insulin G G G I I G I G I G I Pancreas Glucose is absorbed into the blood and goes to the cells, Insulin is released

10 Glucose Glucose provides the body with ENERGY! INSULIN

11 Type 1 Diabetes Healthy pancreas makes enough insulin I I I I I Type 1 pancreas makes no insulin

12 Type 2 Diabetes Healthy pancreas makes enough insulin I I I I I I I Type 2 pancreas makes some insulin, but the insulin does not work well I I I

13 Diabetes management is all about balance RAISES BLOOD GLUCOSE Food Stress Illness Certain medications (steroids, diuretics, antipsychotic medications) LOWERS BLOOD GLUCOSE Vigorous activity Certain medications (insulin, some diabetes pills) Goal: Keep fasting blood sugars in the range of mg/dl and A1c below 7.0%, OR as recommended by Health Care Provider.

14 Did You Know? Diabetes is the leading cause of: Blindness Amputations Kidney disease/dialysis Nerve damage Diabetes increases the risk for: Heart attack Stroke Infections Sexual problems Dementia/Alzheimer s Disease

Targets for Blood Glucose Glucose Targets: Preprandial capillary plasma glucose (CPG): 80 130 mg/dl Peak Postprandial CPG < 180 mg/dl Bedtime CPG 100 140

15 Targets for Blood Glucose Glucose Targets: Preprandial capillary plasma glucose (CPG): mg/dl Peak Postprandial CPG < 180 mg/dl Bedtime CPG mg/dl A1C < 7.0% A1C of 7% is equivalent to A mean plasma glucose of 126 mg/dl 1 1. Standards of Medical Care in Diabetes 2015, Diabetes Care. 2015;38:S33-S40

16 A Typical Day in the Life of a Person with Diabetes

18 MNT Medical Nutrition Therapy 2-3 hours Individualized Portion control/carbohydrate counting Goals are to achieve targets for: Blood glucose Blood pressure Lipids Body weight Maintain the pleasure of eating 1 1. Evert AB, Boucher JL, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013;36:

19 DSME Diabetes Self-Management Education (10 hours) AADE7 Healthy Eating Being Active Taking Medications Monitoring BP and glucose Problem Solving Healthy Coping Reducing Risks Despite recommendations only 40% of people with DM receive DSME and 9% receive MNT

20 Medication Use is The Norm Treatment of Diagnosed Diabetes No oral medication or insulin 16% Insulin and oral medication 14% Insulin Only 12% Among U.S. Adults, Oral Medication 58% CDC. National Diabetes Fact Sheet, Source: National Health Interview Survey

21 Medication Treatment Options* Metformin Sulfonylureas Thiazolidinediones DPP-4 Inhibitors GLP-1 Receptor Agonists Meglitinides Amylin Mimetics Alpha-glucosidase Inhibitors Bile Acid Sequestrants Dopamine-2 agonists SGLT2 Inhibitor Insulin *May cause low blood sugar

22 Polypharmacy 29.4% of elderly patients prescribed 6 or more concurrent drugs.

24 It is reasonable to reconsider prescribing patterns Six major studies published over the past 13 years showed that intensive therapy increases the risk of heart disease, serious side effects and death. 1 To be approved, diabetes medications must lower blood glucose. The FDA does not require that they prevent complications or extend lives Gandhi GY, Murad MH, Fujiyoshi A, et al. Patient-important outcomes in registered diabetes trials. JAMA 2008; 299:

25 Meta-analysis of 13 RCTs (>34,000 patients) that evaluated intensive glucose lowering: Limited benefits on all-cause and CV mortality. At best, modest benefits for microvascular disease. Decreased albuminuria, a trend toward decreased retinopathy, but little else. Severe hypoglycemia events doubled. Adapted from Ann Bullock, MD, IHS BMJ 2011;343:d4243 doi: /bmj.d4243

26 Low-Blood Glucose/Sugar = Hypoglyemciais linked to: Reduced cognitive function Dementia Cardiovascular disease All cause mortality

27 Hypoglycemia (Low Blood Sugar) Participants need to know how to recognize it and treat it Weakness Rapid heart rate Dizziness Shakiness Nervousness Sweating Cold and clammy Headaches Irritable Treatments: Juice or Hard candies or Regular pop/soda/soft-drink ***Follow with a meal

Hypoglycemia Low Blood Sugar Blood glucose below 70 (or target set with clinician below 80 or even 100 more appropriate, especially for elderly).

28 Hypoglycemia Low Blood Sugar Blood glucose below 70 (or target set with clinician below 80 or even 100 more appropriate, especially for elderly). Encourage follow-up with health care provider to evaluate for need to reduce medication(s). Call healthcare provider if low twice in one week or for a severe low.

29 Obesity and Diabetes Three out of 4 adults with diabetes are overweight Nearly half are obese Studies show that vegetarians and vegans weigh less and have lower rates of diabetes Studies show that as meat consumption increases so does obesity, diabetes, and CVD NutrRev Apr;64(4): Int J Obes(Lond). June; 33(6): ICVN, February 24, Diabetes Care. 2010;33: JAMA Intern Med. 2013;173(14): Nat Med. 2013;19:

30 Adventist Health Study-2 (AHS-2) 1 1. TonstadS, Butler T, Fraser GE, et al. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care May; 32(5):

31 Study Subjects Findings Health Professionals Study ( ) Nurses Health Study ( ) Nurses Health Study II ( ) 26,357 men 112,786 women Increased consumption of red meat by 0.5 servings per day increased incidence of type 2 diabetes by 48% in a four year period. Adventist Health Study 2 ( ) 60,893 men and women Vegan group had a 2.9% incidence of diabetes compared to 7.8% in the non-vegetarian group. The rate of diabetes was significantly less in vegetarians and vegans even after correcting for body weight. European Prospective Investigation into Cancer and Nutrition (EPIC)-NL Study National health and Nutrition Examination Survey (NHANES) merged data: , and ,094 men and women For every 5% calories consumed from animal protein, type 2 diabetes risk increased by 30%. The risk was significant even after correcting for BMI. 8,091 men 8,970 women Meat consumption was associated with: The consumption of 700 more calories per day Positive association with BMI, waist circumference, obesity, and central obesity NHANES III 6,381 men and women over the age of 50 High protein intake group had 5 times the incidence of diabetes mortality across all ages. The risk was only associated with animal protein. There was no risk observed with vegetable protein. Meat Consumption, Diabetes, and Its Complications: A Review of the Literature (up to October 2012) The strongest association for type 2 diabetes was with processed meat. Relative Risk (RR) for: 100 g total meat g Red meat g Poultry g Processed meat 1.32

32 Low-Fat Vegan Diet Intervention 1,2 22-week RCT of a low fat vegan diet in individuals with type 2 diabetes: 99 individuals 49 intervention group Low-fat vegan; 50 in control group Conventional diabetes diet No changes in exercise Objective: whether a low-fat vegan diet improves glycemic control and CV risk factors in individuals with type 2 diabetes Each group received weekly classes for 22 weeks Optional biweekly classes for an addition 52 weeks 1. Barnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. Diabetes Care. 29: , Barnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial. Am J Clin Nutr. 2009;89(suppl):1588S-96S.

33 Results at 22 Vegan Group Control Group 22 weeks 22 weeks Weight Loss 5.8 Kg 4.3 Kg A1C (%) No med LDL-C No med 12.5% 2.6% Triglycerides 19% No change AlteredDM Meds 43% 26% Adherence 67% 44%

34 New School Diabetes Education

35 Plant-Based Nutrition (PBN)

36 Plant-Based Nutrition High in: Fiber Vitamins Minerals Anti-oxidants Phytochemicals Low in: Saturated Fat Cholesterol

37 PBN and Microvascular Complications Neuropathy a remarkable study reported alleviation of the sharp, burning pains of peripheral neuropathy in 17 of 21 patient on a low-fat vegan diet along with 30 minute daily walk. 1 PCRM Study demonstrated improvements in clinical and pain measures with a plant-basednutrition intervention. 2 Nephropathy Several Studies have suggested a preservation of renal function when vegetable protein was substituted for animal protein. 3 The Nurse s Health Study demonstrated among women with mild renal insufficiency, animal protein intake predicted further loss of renal function. 4 Animal protein is a risk factor for albuminuria for people with diabetes and HTN. 1. J Nutr Med. 1994;4: Nutrition & Diabetes(2015) 5, e158; doi: /nutd Published online 26 May Diabetes Educ. 1997;23: Ann Intern Med. 2003;138:

38 PBN Highly Effective in Reversing CAD Dean Ornish, MD: The Lifestyle Heart Trial: Demonstrated that intensive life-style changes led to regression of atherosclerotic plaque (measured by angiogram) in one year. Even more regression occurred after 5 years. 1 Preventive Medicine Research Institute: Stress management, smoking cessation, group psycho-social support. Medicare reimburses for Preventive Medicine Research Institute (PMRI) certified sites (includes 72 hours of education for beneficiaries with diagnosed CAD). 1. OrnishD, ScherwitzLW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:

Clinical Practice Guidelines American Diabetes Association 2009-2014 5 A variety of eating patterns have been shown to be effective in

39 Clinical Practice Guidelines American Diabetes Association A variety of eating patterns have been shown to be effective in managing diabetes, including plantbased (vegan or vegetarian). Standards of Medical Care for Type 2 Diabetes. Diabetes Care, :Suppl.1:S29.

40 2009 Position Paper Academy of Nutrition and Dietetics (AND) appropriately planned vegetarian diets, including total vegetarian or vegan diets, are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases.. 1. Craig WJ, MangelsAR; American Dietetic Association. Position of the American Dietetic Association: vegetarian diets. J Am Diet Assoc. 2009;109:

41 Vegetarian Specialty Practice Group with AND

42 Plant-Based Nutrition for Diabetes Community of Interest

43 FOOD FOR LIFE Diabetes Initiative

44 Eight-Week Curriculum Topics 1. How Foods Fight Diabetes 2. The Power of Your Plate 3. Understanding Type 2 Diabetes 4. Designing a Diet for Maximum Weight Control 5. Using the Glycemic Index 6. Keeping a Healthy Heart 7. Diabetes Care from Head to Toe 8. Making It Work for You

45 Principles of a Low-Fat, PBN Eating Pattern Four Food Groups (no portion control): Whole Grains Legumes/Pulses beans, peas, and lentils Vegetables Fruits Include 1 oz. of nuts and seeds Focus on Whole Foods; unprocessed or minimally processed

46 Principles of a Low-Fat, PBN Eating Pattern, continued Limit added vegetables oils and other high fat foods Low Glycemic Index (GI) such as oatmeal, barley, quinoa, sweet potatoes, whole grains, rye or pumpernickel bread, beans, fruits, and vegetables

47 Principles of a Low-Fat, PBN Eating Pattern, continued Avoid all animal products (e.g., meat, chicken, fish, eggs, all dairy) Take a Vitamin B 12 supplement (25-100µg/d) Choose High Fiber Foods: Fiber Intake (g/day) Current Intake of Americans 15 Recommendations PBN Recommendation 40

48 Adopting PBN 3-week trial of 100% PBN eating: Take 2 weeks to plan and try meatless meals and learn a few new recipes Short-term commitment Motivating results

50 What Should Patients Expect? 23 Blood Glucose Changes: Hypoglycemia review prevention, recognition, and treatment Slow decrease in glucose over time Hyperglycemia focus on low GI carbohydrates, utilize carbohydrate counting for the interim Reduction in Blood Pressure Insulin and other medications may need to be adjusted Lower LDL-Cholesterol Reduction in urinary albumin Improvement in neuropathic pain Reduced risk of cardiovascular disease

51 Don t Oversell! Not everyone will be able to reduce or eliminate medications. Some may initially see blood sugars go up (uncommon but can occur). We know the long-term benefits and the impact beyond blood sugar control are significant.

52 Diabetes Web Resources NutritionCME.org Free CE/CME Pcrm.org/Diabetes ThePowerPlate.org Pcrm.org/Nurses NutritionMD.org meal plans

53 Additional Resources You Tube: Neal s Diabetes TEDx talk

54 Thank you! Q & A

Building Our Evidence Base

Building Our Evidence Base Plant-Based Diets Neal D. Barnard, MD, FACC Adjunct Associate Professor of Medicine George Washington University School of Medicine Physicians Committee for Responsible Medicine Washington, DC Building