Dietary and Lifestyle interventions in Diabetes Management A report by EFAD s ESDN for Diabetes in support of World Diabetes Day

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1 Dietary and Lifestyle interventions in Diabetes Management A report by EFAD s ESDN for Diabetes in support of World Diabetes Day Dr. Aimilia Papakonstantinou, Lead of EFAD s ESDN for Diabetes, Lecturer in Nutrition and Metabolism, Department of Food Science and Human Nutrition, Agricultural University of Athens, Greece Introduction Diabetes is a growing public health issue. In 2015, 415 million adults were living with diabetes and this number is expected to increase to around 642 million or one in ten adults by One in two people with diabetes remain undiagnosed, which makes them particularly susceptible to the complications of the disease. Up to 70% of type 2 diabetes cases can be prevented or delayed by adopting healthier lifestyles, equivalent to up to 160 million cases by 2040 (IDF Diabetes Atlas, 7 th edition, 2015). World Diabetes Day was created in 1991 by the International Diabetes Federation (IDF) and the World Health Organization in response to growing concerns about the escalating health threat posed by diabetes and is celebrated annually on November 14.The theme of World Diabetes Day 2016 is Eyes on Diabetes (WDD, 2016). It is widely recognised by all organisations that an individualised nutrition therapy is recommended for all people with type 1 and type 2 diabetes as aneffective component of the overall treatment plan (Evert et al, 2013). Dietitians role is key in implementing an individualized eating plan and in overall diabetes treatment, as part of the healthcare team. Moreover, patient nutrition education by trained dietitians is crucial to long-term glycemic control and prevention of diabetes complications. The European Specialist Dietetic Network (ESDN) for Diabetes of the European Federation of the Associations of Dietitians (EFAD) supports IDF on World Diabetes Day in raising awareness on the impact of dietary and lifestyle interventions for diabetes prevention and management and brings forward the significant role of dietitians in achieving these goals. Components of lifestyle interventions for diabetes management Dietary and lifestyle interventions play an integral role in both the prevention and management of type 2 diabetes and may reduce the risk of complications, by contributing to better glycemic control. Studies have conclusively shown that reducing hyperglycemia decreasesthe onset and progression of microvascular complications (Inzucchi et al, 2015). An individualized dietary plan, regular physical activity and weight loss, when required, have been recognised as key components of diabetes management (Evert et al, 2013). Recommendations for diabetes prevention and management from both the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) highlight the importance of individualized care to manage the disease, prevent ordelay complications, and improve outcomes

2 (Chamberlain et al, 2016; Inzucchi et al, 2015). Optimal diabetes care addresses behavioral, dietary, lifestyle, and pharmaceutical interventions. Individualized medical nutrition therapy An individualized medical nutrition therapy program, preferably provided by a registered dietitian, is recommended for all people with diabetes as an effective component of the overall treatment. Based on ADA s position, there is not a one-size-fits-all eatingpattern for individuals with diabetes (Evert et al, 2013). Carbohydrates intake Carbohydrate intake has a directeffect on postprandial glucose levels in people with diabetes and is the primarymacronutrient of concern in glycemic management (Franz et al, 2010). While substituting sucrose-containing foods for isocaloric amounts of othercarbohydrates may have similar bloodglucose effects, consumption by people with diabetes should beminimized to avoid displacing nutrientdensefood choices.use of nonnutritive sweeteners has the potential to reduce overall calorieand carbohydrate intake if substituted forcaloric sweeteners without compensationby intake of additional calories from otherfood sources (Evert et al, 2013). Furthermore, EFSA s Panel on Dietetic Products Nutrition and Allergies concluded in 2011, Consumption of foods containing low calorie sweeteners instead of sugar induces a lower blood glucose rise after their consumption compared to sugar-containing foods (EFSA, 2011). Regular physical activity A physical activity planshould include at least 150 minutes of moderateintensityaerobic activity per week, reduced sedentarytime, and resistance training at least twice per week formost adults with diabetes. (Chamberlain et al, 2016). Weight management For people with type 2 diabetes who are overweight or obese, reducing energy intake compared to energy expenditure whilemaintaining a healthful eating pattern is recommended to promote weight loss.modest weight loss may provide clinical benefits (improved glycemia, blood pressure, and/or lipids) in some individuals with diabetes, especially those early in the disease process(evert et al, 2013). Self-monitoring of blood glucose Furthermore, for people with established diabetes, self-monitoring of blood glucose is integral to effective therapy, allowing patients to evaluate theirindividual response and assess whether glycemic targetsare being achieved (The Diabetes Control and Complications Trial Research Group, 1993). References: 1. Chamberlain JJ, et al. Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes Ann Intern Med. 2016; 164: Diabetes UK Nutrition WG. Evidence-based nutrition guidelines for the prevention

3 and management of diabetes. May Available online: amendment-0413.pdf 3. EFSA NDA (EFSA Panel on Dietetic Products Nutrition and Allergies). Scientific opinion on the substantiation of health claims related to intense sweeteners and contribution to the maintenance or achievement of a normal body weight (ID 1136, 1444, 4299), reduction of post-prandial glycaemic responses (ID 4298), maintenance of normal blood glucose concentrations (ID 1221, 4298), and maintenance of tooth mineralisation by decreasing tooth demineralisation (ID 1134, 1167, 1283) pursuant to Article 13(1) of Regulation (EC) No 1924/2006. EFSA 2011 Journal 9: Evert AB, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care, 2013; 36: Franz MJ, Powers MA, Leontos C, et al.the evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc 2010;110: IDF Diabetes Atlas 7th edition, Available online: 7. Inzucchi SE, et al. Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient- Centered Approach Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015; 38: The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993; 329: World Diabetes Day Available online:

4 Review of the evidence in relation tolow calorie sweeteners use by people with diabetes Low calorie sweeteners, otherwise called non-nutritive or intense sweeteners, are added in foods and beverages to replace sugar, and used as tabletop sweeteners, to provide sweet taste with low or no calories. They are hundred times sweeter than sugar and are used in very small amounts to provide the equivalent sweetness without providing calories. Therefore, the use of intense sweeteners such as aspartame, acesulfame-k, cyclamate, saccharin, sucralose and steviol glycosides has been suggested as a mean to reduce sugars and energy intake, and helping in weight and diabetes management. Low calorie sweeteners use and diabetes management Recommendations for diabetes management include monitoring carbohydrate intake. Whether by carbohydrate counting or experiencebasedestimation, remains a key strategy in achieving glycemic control. For good health, carbohydrate intakefrom vegetables, fruits, whole grains,legumes, and dairy products shouldbe advised over intake from othercarbohydrate sources, especiallythose that contain added fats, sugars, or sodium (Evert et al, 2013). Choosing low calorie sweeteners instead of nutritive sweeteners has been suggested as onemethod to assist with moderatingcarbohydrate and sugar intake. Based on conclusions from randomized controlled trials, as described in a recent systematic review (Romo-Romo et al, 2016), low calorie sweeteners do not affect key glycemic indexes, and specifically have not been found to impact blood glucose levels and insulin secretion (Nehring et al, 1985; Mezitis et al, 1996; Grotz et al, 2003; Gregensen et al, 2004; Maki et al, 2008; Fujita et al, 2009; Anton et al, 2010; Ma et al, 2010; Brown et al, 2011; Bryant et al, 2011; Sylvetsky et al 2016). In this context, intense sweetenerscould help people with diabetes control overall carbohydrate intake by substituting for higher energy yielding sweeteners, particularly sugars (Fitch et al, 2012; Russell et al, 2013). Research supports that intense sweeteners do notproduce a glycemic effect; however, foodscontaining low calorie sweeteners may affect glycaemia due to other potential ingredients in the product such as carbohydrates (Franz et al, 2010). People with diabetes should check food labels to review the full ingredients list of all products. Reviewing the scientific evidence in 2011, EFSA s Panel on Dietetic Products Nutrition and Allergies concluded, Consumption of foods containing low calorie sweeteners instead of sugar induces a lower blood glucose rise after their consumption compared to sugar-containing foods (EFSA, 2011).Based on this scientific opinion, the European Commission authorised the above health claim with regard to the beneficial effect of low calorie sweeteners in postprandial glucose (Commission Regulation (EU) No 432/2012). Low calorie sweeteners and energy intake, weight management The balance of scientific evidence indicates that use of low calorie sweeteners in place of sugar, in children and adults, leads to reduced energy intake and

5 body weight, based onconclusions of systematic reviews and meta-analysis (de la Hunty et al, 2006; Miller and Perez, 2014; Rogers et al, 2016). Randomized controlled trials have shown that using low calorie sweetened foods and drinks as part of a weight management programme may facilitate weight loss (Raben et al, 2002; Tate et al, 2012; Piernas et al, 2013; Peters et al, 2014; Sorensen et al, 2014; Peters et al, 2016). Some observational studies have reported that regular use of intense sweeteners may lead to obesity, diabetes and the metabolicsyndrome,although the data were not alwaysconsistent. Importantly, the evidence level of observational studies cannot establish causality. The reasons for the different results between observational trials and RCTs are not entirelyclear although many could argue that simple reverse causality andresidual confounding in the observational studies provides the explanation (Peters and Beck, 2016). This means that people who are gaining weight may initiate low calorie sweeteners use for weight control and, similarly, people faced with the onset of type 2 diabetes may do the same, not only in an effort to manage their body weight, but also to avoid consumption of addedsugars.a recent analysesfound that the intent to lose or maintain body weight over a 12- monthperiod was associated with higher low calorie sweeteners use, independent of bodyweight (Drewnowski and Rehm, 2016). Medical associations such as American Heart Association, American Diabetes Association (Gardner et al., 2012), and the Academy of Nutrition and Dietetics (Fitch et al, 2012) suggest that substituting lowcalorie sweeteners for added sugars in beverages and other foods has the potential to help people reach and maintain a healthy body weight and help people with diabetes with glucose control. Conclusion In conclusion, evidence overall suggests that intense sweeteners can be useful when used to replace sugar, especially in beverages, to reduce energy intake and facilitate in weight loss and maintenance, when used as part of a weight management program without compensationby intake of additional calories from otherfood sources (Raben and Richelsen, 2012; Bellisle, 2015; Rogers et al, 2016). For people with diabetes, the use of low calorie sweeteners does not affect glycemic control and seems to have a beneficial effect in postprandial glucose levels, when used in place of sugar (EFSA, 2011; Gardner et al, 2012; Romo-Romo et al, 2016). More randomized controlled trials are still needed to explore the role of the long-term use of products with intense sweeteners in overall diabetes management and to determine if their consumption could help in long-term glucose control. References: 1. Anton SD, Martin CK, Han H, Coulon S, Cefalu WT, Geiselman P et al. Effects of stevia, aspartame, and sucrose on food intake, satiety, and postprandial glucose and insulin levels. Appetite 2010; 55: Bellisle F, Drewnowski A. Intense sweeteners, energy intake and the control of body weight. Eur J ClinNutr 2007; 61: Brown AW et al. Short-term consumption of sucralose, a nonnutritive sweetener, is similar to water with regard to select markers of hunger signaling and short-term

6 glucose homeostasis in women. Nutr Res 2011; 31(12): Bryant CE, Wasse LK, Astbury N, Nandra G, McLaughlin JT. Non-nutritive sweeteners: no class effect on the glycaemic or appetite responses to ingested glucose. European journal of clinical nutrition. 2014; 68(5): Commission Regulation (EU) No 432/2012 of 16 May 2012 establishing a list of permitted health claims made on foods, other than those referring to the reduction of disease risk and to children s development and health. 6. de la Hunty A, Gibson S, Ashwell M. A review of the effectiveness of aspartame in helping with weight control. Nutr Bull 2006; 31: Drewnowski A., Rehm C., The use of low-calorie sweeteners is associated with selfreported prior intent to lose weight in a representative sample of US adults Nutrition & Diabetes (2016) 6, e202; doi: /nutd EFSA NDA (EFSA Panel on Dietetic Products Nutrition and Allergies). Scientific opinion on the substantiation of health claims related to intense sweeteners and contribution to the maintenance or achievement of a normal body weight (ID 1136, 1444, 4299), reduction of post-prandial glycaemic responses (ID 4298), maintenance of normal blood glucose concentrations (ID 1221, 4298), and maintenance of tooth mineralisation by decreasing tooth demineralisation (ID 1134, 1167, 1283) pursuant to Article 13(1) of Regulation (EC) No 1924/2006. EFSA 2011 Journal 9: Evert AB, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care, 2013; 36: Fitch C, Keim KS. Academy of Nutrition and Dietetics. Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. J AcadNutr Diet 2012; 112: Franz MJ, Powers MA, Leontos C, et al.the evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc 2010;110: Fujita Y et al. Incretin release from gut is acutely enhanced by sugar but not by sweeteners in vivo. Am J PhysiolEndocrinolMetab, 2009; 296(3): E Gardner C, Wylie-Rosett J, Gidding SS, Steffen LM, Johnson RK, Reader D, Lichtenstein AH. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2012; 126: Gregersen S, Jeppesen PB, Holst JJ, Hermansen K. Antihyperglycemic effects of stevioside in type 2 diabetic subjects. Metabolism: clinical and experimental. 2004; 53(1): Grotz VL, Henry RR, McGill JB, Prince MJ, Shamoon H, Trout JR and Pi Sunyer FX. Lack of effect of sucralose on glucose homeostasis in subjects with type 2 diabetes. Journal of the American Dietetic Association, 2003; 103: Ma J, Chang J, Checklin HL, Young RL, Jones KL, Horowitz M, et al. Effect of the artificial sweetener, sucralose, on small intestinal glucose absorption in healthy human subjects. The British journal of nutrition. 2010; 104(6): Maki KC, Curry LL, Reeves MS, Toth PD, McKenney JM, Farmer MV, et al. Chronic consumption of rebaudioside A, a steviol glycoside, in men and women with type 2 diabetes mellitus. Food and chemical toxicology: an international journal published for the British Industrial Biological Research Association. 2008; 46 Suppl 7: S Mezitis NH, Maggio CA, Koch P, Quddoos A, Allison DB, Pi-Sunyer FX. Glycemic effect of a single high oral dose of the novel sweetener sucralose in patients with diabetes. Diabetes care. 1996; 19(9): Miller P, Perez V. Low-calorie sweeteners and body weight and composition: a metaanalysis of randomized controlled trials and prospective cohorts (391.1). FASEB J 2014; 28: Nehrling JK, Kobe P, McLane MP, Olson RE, Kamath S, Horwitz DL. Aspartame use by persons with diabetes. Diabetes care. 1985; 8(5): Peters JC, Wyatt HR, Foster GD, Pan Z, Wojtanowski AC, Vander Veur SS et al. The effects of water and non-nutritive sweetened beverages on weight loss during a 12- week weight loss treatment program. Obesity 2014; 22: Peters JC, Beck J, Cardel M, et al. The effects of water and non-nutritive sweetened beverages on weight loss and weight maintenance: A randomized clinical trial. Obesity (Silver Spring) 2016; 24(2):

7 23. Peters JC, and Beck J. Low calorie sweeteners use and energy balance. PhysiolBehav. 2016;164(Pt B): Piernas C, Tate DF, Wang X, Popkin BM. Does diet-beverage intake affect dietary consumption patterns? Results from the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J ClinNutr 2013; 97: Raben A, Vasilaras TH, Mu ller AC, Astrup A. Sucrose compared with artificial sweeteners: different effects on ad libitum food intake and body weight after 10 wk of supplementation in overweight subjects. Am J ClinNutr 2002; 76: Raben A, Richelsen B. Artificial sweeteners: a place in the field of functional foods? Focus on obesity and related metabolic disorders. CurrOpinClinNutrMetab Care 2012; 15: Rogers PJ, Hogenkamp PS, de Graaf K, et al. Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies. Int J Obes 2016; 40(3): Romo-Romo A, Aguilar-Salinas CA, Brito-Cordova GX, et al. Effects of the nonnutritive sweeteners on glucose metabolism and appetite regulating hormones: Systematic review of observational prospective studies and clinical trials. Plos One 2016; 11(8): e Russell W, et al. Impact of Diet Composition on Blood Glucose Regulation. Critical Reviews infood Science and Nutrition, 2013; 56:4: Sorensen LB, Vasilaras TH, Astrup A, Raben A. Sucrose compared with artificial sweeteners: a clinical intervention study of effects on energy intake, appetite, and energy expenditureafter 10 wk of supplementation in overweight subjects. Am J ClinNutr 2014;100: Sylvetsky AC, Brown RJ, Blau JE, Walter M, Rother KI. Hormonal responses to nonnutritive sweeteners in water and diet soda. NutrMetab (Lond) 2016: Tate DF, Turner-McGrievy G, Lyons E, Stevens J, Erickson K, Polzien K et al. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J ClinNutr 2012; 95: