EFFECTS OF MEAL PATTERNS ON INDICES OF GLYCEMIC CONTROL

Transcription

1 EFFECTS OF MEAL PATTERNS ON INDICES OF GLYCEMIC CONTROL Aimilia Papakonstantinou, PhD Dietitian Lecturer in Nutrition and Metabolism Department of Food Science and Human Nutrition Agricultural University of Athens

2 SMALLER, FREQUENT MEALS CONSUMED AT REGULAR TIMES Pro Con Almost All Associations of Dietitians Reduce hunger and thereby decrease consumption during main meals (?) Improve postprandial glucose, insulin and blood lipids and decrease insulin resistance (?) Increase thermic effect of food (?) Increase possibility of weight gain due to increased lipogenesis or fat deposition after meals or simply because one eats more kcal (?) Frequent meals increase postprandial glucose and insulin and increase insulin resistance (?) Where does the science stand?

3 OUTLINE Definition of a meal Importance of macronutrient composition Importance of carbohydrate distribution Importance of meal timing Meal frequency and indices of glycemic control Proposed mechanisms for meal frequency Conclusions

4 Meal consumption of a food or snack (solid or liquid) that contains energy, which lasts at least 1 minute and abstains from the next consumption of food for at least 1 hour. Bhutani, S. and K.A. Varady, Nutr Rev, Rogers, P.J. and J.E. Blundell, Neurosci Biobehav Rev, Farshchi, H.R., M.A. Taylor, and I.A. Macdonald, Am J Clin Nutr, 2005.

5 Plasma glucose and insulin concentrations in healthy and people with type 2 diabetes after meal consumption Type 2 Arterial plasma glucose (mm) Meal Control Time (min) Arterial plasma insulin (mu/l) Control Type 2 Dimitriadis G. et al, Eur J Clin Invest 34: , Meal Time (min)

6 OUTLINE Definition of a meal Importance of macronutrient composition Importance of carbohydrate distribution Importance of meal timing Meal frequency and indices of glycemic control Proposed mechanisms for meal frequency Conclusions

7 HISTORIC RETROSPECT OF MACRONUTRIENTS IN THE DIETS PROPOSED TO DIABETES Year Before 1921 Carbohydrates (%EI) Protein (%EI) Very low calorie and very restrictive diet < * * (CHO + MUFA++) *+ Fat (%EI) *Based on dietary evaluation and medical therapy, which differ from patient to patient + < 10% from saturated fat ++ CHO: carbohydrates, MUFA: monounsaturated fatty acids

8 CURRENT RECOMMENDATIONS Nutrient ADA ( ), Diabetes UK 2011 ADA (2008) EASD (2004) CDA (2008) Protein Individualized 15-20% EI 10-20% EI 15-20% EI Fat Individualized Individualized < 35% EI 30% EI Saturated fat < 7% EI < 7% EI < 10% EI (SFA + Trans) < 8% EI LDL Trans fat Minimum Minimum Minimum Cholesterol < 200 mg < 200 mg < 300 mg < 200 mg ΜUFA Individualized Individualized 60-70% CHO+ MUFA % PUFA Individualized Ω3: fish 2 portions/week Individualized Ω3: fish 2 portions/week 10% EI fish 2-3 portions/week < 10% EI (fish and plant oils) Carbohydrates Individualized Individualized 45-60% EI 45-60% EI Glycemic index GI & GL moderate extra benefit GI & GL moderate extra benefit Emphasis to low GI foods Fiber 14 g/1000 kcal 14 g/1000 kcal 40 g/day (20 g/1000 kcal) ½ from soluble fiber More frequent preference for low GI foods g/day

9 OPTIMAL MACRONUTRIENT COMPOSITION There is no optimal %energy from CHO, protein, and fat for people with diabetes [Level of Evidence B] Macronutrient distribution should be based on individualized assessment of current eating practices, preferences, and metabolic goals [Level of Evidence Ε] A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preference (i.e. tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating patterns over another (Level of Evidence E) American Diabetes Association. Diabetes Care 2014; 37:S29-33 Diabetes UK. Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabet. Med. 2011;28:

10 OUTLINE Definition of a meal Importance of macronutrient composition Importance of carbohydrate distribution Importance of meal timing of food Meal frequency and indices of glycemic control Proposed mechanisms for meal frequency Conclusions

11 MOST FAVORABLE POSTPRANDIAL GLUCOSE PROFILE IS ACHIEVED BY CONSUMING MAJORITY OF CARBOHYDRATES AT LUNCH AND NOT BY EQUAL DISTRIBUTION DURING THE DAY Crossover RCT with 23 people with type 2 diabetes Continuous blood glucose monitoring Four 3-d interventions with identical foods provided diet composition: %carbohydrate:protein:fat 40:34:26 Differing in carbohydrate content at each meal Even distribution (70 g CHO) Breakfast (125 g CHO) Lunch (125 g CHO) Dinner (125 g CHO) Pearce KL et al. Am J ClinNutr. 2008;87:638-44

12 Glucose concentration during the night CHO load at breakfast CHO load at lunch CHO distributed evenly during the day CHO load at dinner Pearce KL et al. Am J ClinNutr. 2008;87:638-44

13 Parallel RCT with 59 overweight/obese adults with type 2 diabetes 2 isocaloric breakfast 3 months Big Breakfast (BB) rich in fat & protein, 33% Total EI Small Breakfast rich in CHO, 12.5% Total EI Results: Similar BW BB: HbA1c, Fas ng Glu, SBP, hunger Fasting Glucose (mg/dl) BB SB Obesity. 2014;22:E46-E54

14 BREAKFAST RICH IN CHO IS DETRIMENTAL TO PEOPLE WITH IMPAIRED GLUCOSE REGULATION Compared diff proportions of CHO in breakfast on postprandial glucose fluctuations in impaired glucose regulation (IGR, n=55) and normal glucose regulation (NGT, n=78) Low-CHO (LC) (<45%), medium-cho (MC) (45 65%), & high-cho (HC) (>65%) Continuous glucose monitoring Results: Postprandial glucose fluctuations of glucose with CHO in both groups In the IGR subjects, a HC meal should be avoided and a LC meal should be recommended Kang X et al. Diabetes Technology & Therapeutics. 2013;15:

15 OUTLINE Definition of a meal Importance of macronutrient composition Importance of carbohydrate distribution Importance of meal timing Meal frequency and indices of glycemic control Proposed mechanisms for meal frequency Conclusions

16 TIMING OF FOOD AFFECTS METABOLISM Oike H et al. Curr Nutr Rep 2014;3:

17 Changes in meal timing influence obesity and success of weight loss therapy Unusual feeding time can induce a disruption of the circadian system Digestive enzymes express in a circadian manner and are synchronized by food Feeding is the source of energy for adipose tissue. The time of feeding is decisive Clock genes are important in meal timing by changes in circadian control of hunger

18 EATING IN BETWEEN LUNCH AND DINNER MAY BE ADVANTAGEOUS TO WEIGHT CONTROL ISSUES WHEN CONSUMING FOOD AT A NON- HUNGRY STATE? McCrory MA & Cambell WW. J Nutr. 2011;141:144-7

19 OUTLINE Definition of a meal Importance of macronutrient composition Importance of carbohydrate distribution Importance of timing of food Meal frequency and indices of glycemic control Proposed mechanisms for meal frequency Conclusions

20 Meal frequency in relation to overweight, hypercholesterolemia and glucose tolerance in 379 men, y J Nutr. 2011;141:148S-153S

21 SKIPPING BREAKFAST AND CONSUMING FEWER THAN 3 MEALS PER DAY INCREASES RISK FOR TYPE 2 DIABETES IN MEN Assessed eating patterns in cohort of 29,206 US men in the Health Professionals Follow-Up Study free of DM2, cardiovascular disease, and cancer followed for 16 y Results 1944 T2D cases during follow-up Breakfast skipping increased risk for DM2 by 21% Compared with men who ate 3 times/d, men who ate 1 2 times/d had a 25% higher risk for DM2 Additional snacks beyond 3 main meals (B,L,D) were associated with increased DM2 risk, but these associations were attenuated after adjustment for BMI. Mekary RA et al. Am J Clin Nutr 2012;95:

22 NOT CONSUMING BREAKFAST ON A DAILY BASIS INCREASES RISK OF DIABETES IN WOMEN - NO ASSOCIATION BETWEEN MEAL FREQUENCY AND DIABETES RISK IN WOMEN Assessed eating pattern in a cohort of 46,289 US women in the Nurses Health Study free of DM2, cardiovascular disease, or cancer followed for 6 y Results 1560 DM2 cases during follow-up Women who consumed breakfast irregularly (0 6 times/wk) were at 20% higher risk of DM2 vs daily consumption after BMI adjustment Meal frequency did not affect risk for DM2 Mekary RA et al. Am J Clin Nutr 2013;98:

23 MEAL FREQUENCY AND INDICES OF GLYCEMIC CONTROL IN PEOPLE WITH DIABETES FROM RANDOMIZED CONTROLLED CLINICAL TRIALS Ref Jenkins, 1992 Bertelsen Arnold, 1997 Salehi, 2014 Kahleova 2014 Papakons tantinou (unpub) Subjects/d uration 11 2 d: 9.5h obser/tion 12 2 d: 8hr obser/tion 13 8 weeks 66 3 months 54 6 months 29 (DM2), 19 IGT 6 months Methods Measurements Results Crossover RCT Isocaloric diet 1 st phase (1 day): 1 st group: 3 meals + 1 snack, 2 nd group: 13 snacks 2 nd phase (1 day): the opposite Crossover, 2 isocaloric diets with 6 vs 2 meals IVGTT at the end Crossover, isocaloric meals 3 vs 9 for 4 weeks each Parallel, energy deficit diet, isocaloric meals 6 meals vs 5 meals OGTT Crossover, Pts on medication, energy deficit diet, isocaloric meals 6 vs 2 (Breakfast and Lunch) for 12 weeks each. OGTT, Insulin clamp, pedometers Crossover, Pts not on medication, weight maintenance diet, isocaloric meals 6 vs 3 for 12 weeks each, OGTT Glucose, insulin, C-peptide, 24-h urinary C-peptide, TG, FFA Glucose, insulin, FFA Glucose, insulin, blood lipids Glucose, insulin, HBA1c, malondialdehyde, blood lipids BW, HbA1c, Glucose, insulin, C-peptide, glucagon, ind calorimetry, calc whole body sensitivity, BP, lipids HbA1c, Glucose, Insulin, lipids, hepatic enzymes, subjective appetite Jenkins DJ et al. Am J Clin Nutr. 1992;55: ; Bertelsen J et al. Diabetes Care. 1993;16:4-7 Arnold L et al. Diabetes Care. 1997;20: ; Salehi M et al. Iran J Med Sci. 2014;39: Kahleova H et al. Diabetologia. 2014;57: ; Papakonstantinou et al. (Unpublished data) 13 snacks: Glu, Ins, C- peptide, TG vs 4 meals No difference in NEFA 2 meals induced 84% amplitude of glucose excursions and insulin vs 6 meals Both FFA NS for all variables 6 meals: BW & HbA1c vs 3 meals NS Glu & insulin (fasting and postprandial), lipids, MDA 2 meals: BW, Fasting glucose, C-peptide, glucagon vs 6 meals NS Fasting insulin, HbA1c, insulin sensitivity, lipids NS in all variables

24 6 MEAL PATTERN MORE BENEFICIAL FOR POSTPRANDIAL INSULIN SENSITIVITY VS 3 MEAL PATTERN IN WOMEN WITH PCOS Papakonstantinou et al. (Unpublished data)

25 THE EFFECT OF MEAL FREQUENCY ON ADIPOSITY IS UNCLEAR CONTRADICTORY RESULTS FROM EPIDEMIOLOGICAL & CLINICAL TRIALS J Nutr. 2011;141:148S-153S

26 Ref Subjects Duration Finkelstein et al. (1971) Jenkins et al. (1989), (1995) Arnold et al. (1993) Farshchi et al. (2004), (2005) 8, BMI: y 7, BMI>30 ~ 40 y 9, 10, BMI=23,1 32 y 9, BMI= 23, y 10, BMI= 37, y Non snackers: 50, 43 Poston et al. (2005) Snackers: 50, 44 BMI >30, y Carlson et al. (2007) Berteus F et al. (2008) Leidy et al. (2011) Heden et al. (2013) Munsters et al. (2012) 5, 10, BMI= 23, y 36, 104, BMI= y 13, BMI= 31,3 51 ± 4 ετών ~2 mos Number of meals 3 meals (+1 bedtime snack) vs 6 meals Weight loss Glu Results Ins Yes NS No data 2 wks 3 meals vs 17 meals No NS in 17 meals ~2 mos 3 meals vs 9 meals No NS NS ~1,5 mo 6 meals vs irregular meals (3 to 9) No NS NS 6 mos 3 meals vs 6 meals Yes (NS) (NS) 6 mos 1 meals vs 3 meals No In 3 meals 1 yr 3 meals vs 6 meals Yes (NS) (NS) 4 11 hr 3 meals vs 6 meals Diff protein compositn No In 6 meals in 6 meals 8, BMI > hr 3 meals vs 6 meals No No data 12, BMI = 21,6 23 ± 1,2 y 2 36 hr 3 meals vs 14 meals No AUC in 3 meals iauc in 3 meals Finkelstein B and Fryer BA. Am J Clin Nutr. 1971;24:465-8; Jenkins DJ et al. N Engl J Med. 1989;321:929-34; Jenkins DJ et al. Metabolism. 1995;44:549-55; Arnold LM et al. Am J Clin Nutr. 1993;57:446-51; Farshchi HR et al. Am J Clin Nutr. 2005;81:16-24; Farshchi HR et al. Int J Obes. 2004;28:653-60; Poston WS et al. Int J Obes. 2005;29: ; Carlson O et al. Metabolism. 2007;56: ; Berteus Forslund H et al. Eur J Clin Nutr. 2008;62: ; Leidy HJ et al. Obesity. 19:818-24; Heden TD et al. Obesity. 2013;21:123-9; Munsters MJ et al. PLoS One. 2012;7:e38632 NS

27 Ref Subjects Duration Kanaley et al. (2014) Zargaran et al. (2014) 10, 3 BMI: y 90 BMI>28 ~ 37 y 3 X 12hr 3 mos Number of meals 3 meals (every 4h, 15% pro, 65% CHO) vs 6 meals (every 2h, 15% pro, 65% CHO) vs 6 meals PRO (every 2h, 45% pro, 35% CHO) 6 meals vs 3 meals + 2 snacks Weight loss Wt stable Glu In 6 meals PRO vs 3 meals or 6 meals Results Ins AUC in 3 meals Yes No data No data Kanaley JA et al. Br J Nutr. 2014; Sep 18:1-10; Zargaran ZH et al. Int Cardiovasc Res J. 2014;8:52-56;

28 OUTLINE Definition of a meal Importance of macronutrient composition Importance of carbohydrate distribution Importance of timing of food Meal frequency and indices of glycemic control Proposed mechanisms for meal frequency Conclusions

29 PROS FOR FREQUENT MEALS IN DIABETES Macronutrient distribution into smaller frequent meals is beneficial: Better appetite control Weight loss and weight maintenance Suppression of FFAs from adipose tissue better glucose clearance and glucose disposition in tissues Decreased insulin secretion Smaller gastric distention Reduced rhythm of transport of nutrients to the intestine, requiring less insulin for euglycemia and glycemic control Meal frequency does not influence rates of lipogenesis Speechly DP et al. Appetite 1999;33: Speechly DP et al. Int J Obes & Relat Metabol Disord 1999;23: Kirk TR et al. Proceedings Nutr Soc 2000;59: Louis-Sylvestre J et al. Forum of nutrition 2003;56:126-8 Drummond S et al. Eur J Clin nutr 1996;50: Jenkins DJ. Br J Nutr 1997;77:S71-81 Jones PJH et al. Metabolism 1995;44: Kulovitz MG et al. Nutrition. 2014;30:

30 CONS FOR FREQUENT MEALS IN DIABETES Macronutrient distribution into 1 or 2 larger meals is beneficial: Eating more often than 3 times a day Weight gain Increases food stimuli and difficulty controlling energy balance Lower fat deposition with less frequent meals due to increased thermogenic response Howarth NC et al. Int J Obes 2005;31: Duval K et al. Am J Clin Nutr 2008;88: Fernemark H et al. PLoS One 2013;8:e79324 Tai MM et al. Am J Clin Nutr 1991;54:783-7

31 CONCLUSION There is no consensus on the definition of a meal There is no consensus for the number of meals that may or may not be beneficial to people at risk or with diagnosed diabetes Individualization of nutrition plan and patterns, based on personal preferences, lifestyle, habits, cultural and religious differences IS KEY strategy It may be that consistency in the timing of consumption and number of meals consumed is important for metabolism and glucose regulation More well-designed clinical studies with adequate sample are needed

32 Thank you for your attention! AGRICULTURAL UNIVERSITY OF ATHENS