Take Charge Feel Positive About Nutrition. Marion J. Franz, MS, RD, CDE

Transcription

1 Take Charge Feel Positive About Nutrition Marion J. Franz, MS, RD, CDE

2 Questions What questions do you have? What s important? What s controversial? How important is weight loss? What about physical activity? What works?

3 What questions do you have?

4 Nutrition Therapy and Physical Activity in Diabetes Challenging Essential Important for diabetes management

5 What s important?

6 Serum insulin (mu/l) Normal Insulin Secretion Meal Meal Meal 50 Bolus insulin needs Basal Insulin Needs Hours Kendall DM. N Engl J Med 322:898, 1990

7 Prioritizing Nutrition Recommendations for Type 1 Diabetes (Insulin-Users) Insulin therapy is integrated into your food and physical activity habits Your Eating Plan is based on your appetite, preferred foods, and usual schedule of meals and physical activity Total carbohydrate content of meals (and snacks) is the first priority

8 Insulin by Injection or Pump Bolus or mealtime insulin dose covers need of carbohydrate for insulin (~1/2 of total insulin dose) Basal or background insulin dose covers need for protein and fat for insulin and other insulin needs (~1/2 of total insulin dose)

9 Adjusting Premeal insulin Based on Carbohydrate Amounts Compared high- and low- carbohydrate diets Amount of carbohydrate in the meal did not effect glucose response, if premeal insulin adjusted appropriately Premeal insulin algorithms 1.5 U for 10 g carb at breakfast 1 U for 10 g carb at lunch and dinner Variations in meal glycemic index, fiber, or caloric intake do not influence premeal insulin Rabasa-Lhoret et al. Diabetes Care. 1999;22:667

10 Adjusting Premeal Insulin Adjusting for carbohydrate Small inaccuracies in CHO intake at a meal (10 g) do not increase risk of hypo- or hyperglycemia; not essential to count CHO in grams Give insulin before food Meal routines are important Adjusting for protein Only meals with very large amounts of added protein raised postmeal glucose levels Individual BG response curves vary greatly Smart et al. Diabetic Med 2009;26:279; Smart et al. Diabetic Med 2012; 29:e21; Smart et al. Diabetes Care 2013;36:3897; Garica-Lopez et al. Diab Technol & Ther 2013 ;15:166

11 Insulin-to-Carbohydrate Ratios 1 unit of rapid-acting insulin to match planned CHO intake; taken before meal Adult (normal weight): 1:10 to 1:15 Adult (overweight): 1:7 to 1:10 Adult (obese): 1:5 Correction insulin (insulin sensitivity factor); adding rapid-acting insulin to mealtime dose if BG is above target before a meal (or subtracting if low) Adult (normal weight) 1:40 to 1:50 Adult (overweight) 1:30 to 1:40 Adult (obese) 1:25 American Diabetes Association, Academy of Nutrition and Dietetics. Match Your Insulin to Your Carbs. 2014

12 Protein and Fat Adjustments Usual meals contain moderate amounts of protein and fat; this is covered by usual basal and bolus insulin doses Responses to excessive amounts of protein and fat vary greatly, but may require extra premeal insulin Research at this time does not provide guidelines for insulin adjustment Carmel Smart, John Hunter Children s Hospital, Newcastle, Australia 2015

13 Summary: Insulin Doses Bolus (premeal) insulin covers meal carbohydrate and basal insulin covers protein and fat insulin needs Generally protein and fat intake is fairly consistent and the need to bolus for protein and fat only becomes an issue when excessive amounts are eaten If not self-adjusting insulin, meal times and carbohydrate amounts need to be consistent Franz, In American Diabetes Association Guide to Nutrition Therapy for Diabetes. Second Edition, 2012

14 Type 2 Diabetes: A Progressive Disease BG remains normal until insulin deficiency Glucose (mg/dl) Postprandial glucose Fasting glucose % Relative to Normal 250 Insulin resistance At risk for 50 diabetes b-cell dysfunction Insulin level Years * Post Prandial = 1-2 h ppg Bergenstal RM et al. Management of Type 2 Diabetes in Endocrinology. 4th Edition; Philadelphia, 2001

15 Prioritizing Nutrition Recommendations for Type 2 Diabetes Diet doesn t fail the beta cells of the pancreas fail Nutrition therapy starts by focusing on blood glucose control; results will be known by 6 weeks to 3 months Carbohydrate counting is used to provide flexibility in food choices Small amounts of weight loss are important for prevention of type 2 diabetes and early after diagnosis Physical activity is always important!

16 What s controversial? Carbohydrate Carbohydrate Carbohydrate

17 Reported Carbohydrate Intake in Persons with Diabetes Most individuals with db do not eat a low or high CHO diet Usual CHO intake (total kcal) in T1D: 46% (DCCT participants in intensive treatment arm) Usual CHO intake in T2D: 43% in UKPDS (recommended 50-55%); 44% in Look AHEAD Trial Usual CHO intake in youth with T1D or T2D 48% of total kcal NHANES data for adults with diabetes ( ) CHO: 46% of total kcal; total energy intake: ~2,100 kcal/day (no change from 1988) Delahanty et al. Am J Clin Nutr 2009;89:518; Eeley et al. Diabetic Med 1995;13:656; Vitolins et al. J Am Diet Assoc 2009;109;1367; Mayer-Davis et al. J Am Diet Assoc 2006;108:689; Oza-Frank et al. J Am Diet Assoc 2009;109:1173.

18 How Foods Affect Blood Glucose Control Balance between carbohydrate and available insulin determines BG levels after eating Emphasis is on total amount of carbohydrate eaten and not the source or type of the carbohydrate Carbohydrate counting: what foods are carbohydrate; what is a carbohydrate serving; how many carbohydrate servings for meals and snacks? Snacks are not needed unless on regular and NPH insulin

19 Focus on Carbohydrate Useful for all persons with diabetes Emphasizes total amount of carbohydrate not the source Based on 3 food groups: Carbohydrate Protein (Meat and meat substitutes) Fat

20 Carbohydrate Counting Sources of carbohydrate are starches, fruits, milk, and desserts One carbohydrate serving = 15 grams of carbohydrate Most fresh vegetables are free foods

21 Carbohydrate Counting Recommendations Start with 3 to 4 servings per meal for women with type 2 diabetes, 4 to 5 per meal for men with type 2 diabetes; 1 to 2 for a snack Day-to-day consistency is important Test post-meal; goal blood glucose < mg/dl

22 Carbohydrate Monitoring carbohydrate, whether by carbohydrate counting or experiencebased estimation, remains a key strategy in achieving glycemic control For good health, choose carbs from vegetables, fruits, whole grains, legumes, and dairy products rather than carbs that contain added fats, sugars, or sodium Avoid sugar-sweetened beverages

23 Protein and Diabetes Protein you eat does not increase glucose levels but in persons with type 2 diabetes it does increase insulin response Protein is not helpful in treatment of hypoglycemia and does not prevent hypoglycemia Does not need to be added to snacks Just like carbs, there is no ideal amount of protein to eat to improve glucose control or improve heart disease risk factors Evert el al. Diabetes Care 36:3821, 2013; Wheeler et al. Diabetes Care 35:434, 2012; Academy of Nutrition and Dietetics. J Am Diet Assoc 110;1852, 2010

24 Protein and Diabetic Kidney Disease (DKD) In persons with DKD (either micro- or macroalbuminuria), reducing the usual amount of protein eaten is not recommended because it does not improve or change the course of glomerular filtration rate decline Wheeler et al. Diabetes Care 35:434, 2012, Pan et al. Am J Clin Nutr 88:660, 2008, Robertson et al. Cochrane Database Syst Rev 25:645, 2002

25 Can Individuals Change Macronutrient Intake Long-Term? Researchers comments: Low-carb at 24% at 3-mo; 40% at 12 mo (back to baseline); at 48% at 24-mo ( 8% from baseline) suggests that low-carb diets may be difficult to sustain. Iqbal et al. Prescribed protein of 30% was achieved in only 12 of 207 [6%] of participants in high protein group highlights how difficult it is to achieve and maintain prescribed change individuals trend back to habitual intake over time. Krebs et al. Under real-world conditions, variations in food selection and adherence are likely to attenuate the effect previously demonstrated in controlled feeding studies. Larsen et al. Iqbal et al. Obesity 2010;18:1733; Krebs et al. Diabetetologia 2012;55:905; Larsen et al. Diabetetologia 2011;54:731

26 So what about weight loss?

27 Weight Management: 2016 Modest weight loss is very beneficial for the prevention of chronic diseases including type 2 diabetes and hypertension Plateaus and regain of weight loss are expected; compensatory mechanisms protect against weight loss If treatment is discontinued, weight gain occurs

28 Type 2 Diabetes: A Progressive Disease Lifestyle Lifestyle Interventions Medical Nutrition Therapy Alone or with Medications Medical Nutrition Therapy Medications Insulin Meds

29 The Dilemma of Weight Loss in Diabetes Diet doesn t fail the beta cells of the pancreas fail Insulin resistance Modest amounts of weight loss (and physical activity) can prevent or delay type 2 diabetes Weight loss may improve risk factors Insulin deficiency Focus is on nutrition strategies for normalization of blood glucose levels, lipids and blood pressure Feldstein et al. Diabetes Care 2008;31:1960; Franz. Diabetes Spectrum 2013;26;145

30 What is Known About Weight Management? At ~6 months individuals can lose 5% to 10% of their starting weight Regardless of the intervention, plateaus and regain of weight loss are expected; compensatory mechanisms protect against weight loss If treatment is discontinued, weight gain occurs With support, modest weight loss can be maintained

31 Average Weight Loss Per Subject Completing a Minimum 1-Yr Intervention 60 studies; 18,091 subjects; 13,082 completers (72%) Franz et al. J Am Diet Assoc. 2007;107:1736

32 Why Weight Loss Is Difficult? Genetics - ~50% of variance genetics and 50% environment Weight tightly regulated by neural, hormonal, and metabolic factors Hormonal adaptations ( leptin, peptide YY, cholecystokinin, insulin, and ghrelin, gastric inhibitory polypeptide, pancreatic polypeptide) that encourage weight gain after diet-induced weight loss remain 1-yr after initial weight reduction Weight loss results in adaptive thermogenesis ( resting metabolic rate) maintained up to 1-yr Sumithran et al. N Eng J Med 2011;365:1597; Camps et al. Am J Cl Nutr 2013;97:990 32

33 What Are The Benefits From Modest Weight Loss (~5% of Initial Weight)? Prevention or delay of type 2 diabetes Decreases in systolic and diastolic blood pressure in dose-dependent fashion Decreases in circulating inflammatory markers (Creactive protein and cytokines) Potential improvement in triglyceride levels, total and LDL cholesterol Klein et al. Circulation 110: , 2004

34 Change from Baseline Body Weight (kg) Change in Body Weight and Prevention/Delay of Type 2 Diabetes Placebo Metformin Intensive Lifestyle Base BW (kg) Years after Randomization The Diabetes Prevention Program Research Group. N Eng J Med. 2002;346:393 34

35 Is There an Ideal Diet for Weight Loss? No, let s end the diet macronutrient debate! The key: reducing calories while eating healthfully is recommended to promote weight loss Best approach to achieve modest weight loss: counseling about nutrition therapy, physical activity and behavior change and ongoing support vert AE, et al. Diabetes Care. 2014;36: Pagoto JAMA 310:687, 2013; Evert et al. Diabetes Care 20l3;36:3821

36 Weight Loss Studies in Type 2 Diabetes What are outcomes from WLI resulting in weight losses > or <than 5% at 12 months? What are the outcomes from differing macronutrient percentages in WLI? 11 studies: 8 compared WLI and 3 compared WLI to usual care or control (19 WLI groups) Weight, AlC, lipid, and BP effectiveness Franz et al. Journal of the Academy of Nutrition and Dietetics. 2015;Sept. 36

37 Weight losses at 1-yr: Systematic Review cont. <5%: 17 interventions: -1.9 to 4.8 kg >5%: 2, Mediterranean-style -6.2 kg; ILI -8.4 kg Weight loss <5%: NS benefits on A1C, lipids, or blood pressure at 1-yr Weight loss >5% MED-style in newly diagnosed adults and ILI in the Look AHEAD trial: significant benefits on A1C, lipids, and BP Both included regular physical activity and frequent contacts with health professionals

38 Average Weight Loss/Maintenance in Persons with Type 2 Diabetes (11 studies; 6,710 participants) Kg mo 12 mo 18 mo 2 yr 3 yr 4 yr Usual Care/Control (3) n=2,709 Meal Replacements (2) n=102 Individualized Food Plan (2) n=109 Group Behavioral Wt Mgmt (2) n=217 High-CHO (3) n=310 Low-CHO (2) n=85 Low-Fat (3) n=188 High MUFA (1) n=43 High-Protein (2) n=260 Franz MJ. JAND 2015 MED (1) n=108; 6 mo data not available ILI (1) n=2,570; 6 mo data not available

39 Type of Diet 5 studies (10 study arms) compared macronutrients (all reported similar weight changes, less than 9 lbs) High MUFA vs high CHO Low CHO vs low fat (2) High protein vs high CHO (2) No differences in A1C, lipids, and BP Brehm et al. Db Care. 2009;32:215; Davis et al. Db Care 2009;32:1147; Larsen et al. Diabetologia 2011l54:731; Krebs et al. Diabetologia 2012;55:905; Guldbrand et al. Diabetologia. 55:2118, 2012

40 Why doesn t weight loss always lead to improved glycemia? Usual weight loss therapies do not lead to adequate weight loss OR Persons are primarily insulin deficient need medications to be combined with nutrition therapy OR Energy restriction leads to improved glycemia, not weight loss per se

41 Focus on Blood Glucose Control Not Weight Loss Improving blood glucose control is a higher priority than weight loss Watch portion sizes Eat healthfully Participate in regular physical activities Lifestyle changes and medication usually need to be combined With insulin deficiency, insulin is needed

42 What about physical activity?

43 Being Fit Reduces the Hazards of Obesity Lee et al. Am J Clin Nutr 69:373, ,389 men followed for 8 years Physical fitness, regardless of BMI, decreases risk of mortality from all chronic diseases 3 RR of All-Cause Mortality and Heart Disease Fit Unfit Lean Normal Obese

44 Exercise Guidelines For fitness and reduced risk of chronic health conditions: 30 min/day of moderate physical activity (i.e., walking 3 to 4 miles/hr) For prevention of weight gain: 60 min/day (increases energy expenditure by ~150 to 200 kcal) To avoid regain of weight loss: 60 to 90 min/day For children for healthy weight gain during growth: 60 min/day Vigorous physical activity provides greater benefits 2015 Report of the Dietary Guidelines Advisory Committee

45 What works?

46 Strategies for Changing Behavior Self-monitoring (recording behaviors) - always rated by participants as most helpful Realistic goals small changes make a difference Stimulus control restructure your environment, eliminating eating cues Contingency management - rewards by self or professionals, rated as least important Stress management - #1 predictor of relapse

47 Strategies for Maintenance of Behavior Change Exercise (physical activity) - major predictor of maintenance Social support - family, peer support, self-help or work-site groups Relapse prevention Stress management Social situations Continuing support

48 In An Ideal World All people with type 2 diabetes: Lose 5% to 10% of baseline weight Eat a nutrient dense eating pattern in appropriate portion sizes Participate in 150 min/wk of regular physical activity All people with type 1 diabetes: Count carbohydrates Adjust insulin based on insulin-to-cho ratios Use insulin correction factors

49 In the Real World You must decide what behavior changes you are willing and able to make A variety of nutrition therapy and physical activity interventions can be implemented But nutrition therapy for diabetes is effective!

50 The way to live a long life is to contract a chronic disease and take care of it. Sir William Osler, 1919