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ADA 2019 Nutrition Therapy Consensus Report: Evaluating Diabetes Nutrition Research and Coming to Consensus:

Part 2

Patti Urbanski, MEd, RD, LD, CDE

Christopher Gardner, PhD

Disclosure to Participants• Notice of Requirements For Successful Completion

– Please refer to learning goals and objectives– Learners must attend the full activity and complete the evaluation in order to claim continuing

education credit/hours

• Conflict of Interest (COI) and Financial Relationship Disclosures:– Christopher Gardner –– Patti Urbanski – Consultant, Abbott Diabetes Care; Spouse – Medtronic Diabetes Stockholder

• Non-Endorsement of Products:– Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products

displayed in conjunction with this educational activity

• Off-Label Use:– Participants will be notified by speakers to any product used for a purpose other than for which it was

approved by the Food and Drug Administration.

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Session Objectives

Attendees will be able to:• Differentiate between the major types of research

studies included in the ADA consensus statement• Describe how to evaluate nutrition research

publications for application in clinical practice• Define a consensus report and explain the process

involved in developing a consensus report

Definition of an ADA Consensus Report

• Comprehensive examination by an expert panel (i.e., consensus panel) of a scientific or medical issue related to diabetes

• A consensus report is not an ADA position and represents expert opinion only

• Required 80% consensus of committee members to include in this report

If I know what the ADA Nutrition Consensus Statement says, why do I need to worry about nutrition research studies?

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How do we know what we know?

Objectives

1. Study Design Framework

2. Study Design (How do we know what we know?)Observational Studies

Less expensive and time-consumingCase-Control

More expensive and time-consumingCohort

Other (Biological Plausibility)Animal studies, cell culture, etc

Intervention StudiesRandomized Controlled Trial (RCT)

Meta-AnalysesSystematic Reviews

Nutrition Data

Health Outcome Data

Country or Population Level Data

IndividualPerson

Level Data

Observational

Cross‐Sectional Prospective

Interventional

Risk Factor Disease Outcome

Primary (prevention) Secondary  (treatment)

FactorsAffectingLevel ofEvidenceContributed

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Nutrition Data

Health Outcome Data

Country or Population Level Data

IndividualPerson

Level Data

Observational

Cross‐Sectional Prospective

Interventional

Risk Factor Disease Outcome

Primary (prevention) Secondary  (treatment)

FactorsAffectingLevel ofEvidenceContributed

Pieces of the Puzzle

Cell & Molecular

Tissues, Organs

Animal

Human Trials

Epidemi‐ology

Nutrients

Foods

Culture

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11

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5

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

Strength of available evidence

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

Strength of available evidence

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Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

Strength of available evidence

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

Strength of available evidence

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

Strength of available evidence

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Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

1 2 3

4 5 6

7 8 9

Added layer of complexity

Observational Studies (Associations)

vs.

Intervention Studies (Cause and Effect)

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

1 2 3

4 5 6

7 8 9

Association

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21

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Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

1 2 3

4 5 6

7 8 9

Cause & Effect

Chronic Disease Risk Factors

vs.

Chronic Disease

Assuming: A powerful drug that lowers HbA1c among adults with prediabetes is shown to be preventive of incident type 2 diabetes

Assuming: A Low-Carb diet lowers HbA1c

Studying Risk Factors vs. Disease Outcomes

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Assuming: A powerful drug that lowers HbA1c among adults with prediabetes is shown to be preventive of incident type 2 diabetes

Assuming: A Low-Carb diet lowers HbA1c

Studying Risk Factors vs. Disease Outcomes

Assuming: A powerful drug that lowers HbA1c among adults with prediabetes is shown to be preventive of incident type 2 diabetes

Assuming: A Low-Carb diet lowers HbA1c

Is it therefore considered proven, indirectly, that going on a low-carb diet will prevent diabetes?

Studying Risk Factors vs. Disease Outcomes

Assuming: A powerful drug that lowers HbA1c among adults with prediabetes is shown to be preventive of incident type 2 diabetes

Assuming: A Low-Carb diet lowers HbA1c

Is it therefore considered proven, indirectly, that going on a low-carb diet will prevent diabetes?

Is it possible that going on a low-carb diet will actually increase diabetes onset?

Studying Risk Factors vs. Disease Outcomes

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Assuming: A powerful drug that lowers HbA1c among adults with prediabetes is shown to be preventive of incident type 2 diabetes

Assuming: A Low-Carb diet lowers HbA1c

Is it therefore considered proven, indirectly, that going on a low-carb diet will prevent diabetes?

Is it possible that going on a low-carb diet will actually increase diabetes onset?

Studying Risk Factors vs. Disease Outcomes

Assuming: A powerful drug that lowers HbA1c among adults with prediabetes is shown to be preventive of incident type 2 diabetes

Assuming: A Low-Carb diet lowers HbA1c

Is it therefore considered proven, indirectly, that going on a low-carb diet will prevent diabetes?

Is it possible that going on a low-carb diet will actually increase diabetes onset?

Studying Risk Factors vs. Disease Outcomes

Assuming: A powerful drug that lowers HbA1c among adults with prediabetes is shown to be preventive of incident type 2 diabetes

Assuming: A Low-Carb diet lowers HbA1c

Is it therefore considered proven, indirectly, that going on a low-carb diet will prevent diabetes?

Is it possible that going on a low-carb diet will actually increase diabetes onset?

Studying Risk Factors vs. Disease Outcomes

Major limitation of studies with “risk factors” as study outcomes

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Objectives

1. Study Design Framework

2. Study Design (How do we know what we know?)Observational Studies

Less expensive & time-consumingCase-Control

More expensive & time-consumingCohort

Other (Biological Plausibility)Animal studies, cell culture, etc

Intervention StudiesRandomized Controlled Trial (RCT)

Cross‐sectional

Cross‐sectional

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12

0

5

10

15

20

25

30

35

40

≤12 13 - 42 43 - 54 ≥55

Controls (n=966)

Frequency of Tofu Intake (per year)

Tofu and Risk of Breast Cancer in Asian-AmericansChinese-, Japanese- and Filipino-American women

in Los Angeles, San Francisco/Oakland, Oahu

%

Wu et al., Canc Epid BioMark Prev, 1996:5:901-906

0

5

10

15

20

25

30

35

40

≤12 13 - 42 43 - 54 ≥55

Cases (n=597)Controls (n=966)

Frequency of Tofu Intake (per year)

Tofu and Risk of Breast Cancer in Asian-AmericansChinese-, Japanese- and Filipino-American women

in Los Angeles, San Francisco/Oakland, Oahu

%

Wu et al., Canc Epid BioMark Prev, 1996:5:901-906

≤12 13 - 42 43 - 54 ≥55Frequency of Tofu Intake (per year)

Tofu and Risk of Breast Cancer in Asian-AmericansChinese-, Japanese- and Filipino-American women

in Los Angeles, San Francisco/Oakland, Oahu

0

0.2

0.4

0.6

0.8

1.01.2

0.67

0.840.97

Odds Ratio R

eference

Group

Wu et al., Canc Epid BioMark Prev, 1996:5:901-906

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≤12 13 - 42 43 - 54 ≥55Frequency of Tofu Intake (per year)

Wu et al., Canc Epid BioMark Prev, 1996:5:901-906

Tofu and Risk of Breast Cancer in Asian-AmericansChinese-, Japanese- and Filipino-American women

in Los Angeles, San Francisco/Oakland, Oahu

0

0.2

0.4

0.6

0.8

1.01.2

0.67

0.840.97

Odds Ratio

Relative to those consuming tofu <12 times/year, breast cancer rates were 33% lower among those

consuming tofu at least 55 times/year

Reference

Group

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

1 2 3

4 5 6

7 8 9

ObservationOr

Intervention?

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

Association

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Case‐Control StudyMajor limitation(s):

• Many alternate hypotheses• Can’t tell if dietary habit preceded, or followed the

onset of disease (temporal relationship unclear)(i.e., finding out about your disease may have caused you to changeyour diet, or may bias your memory of your diet [RECALL BIAS])

Major advantage(s):• Relatively quick and inexpensive• Particularly appropriate for RARE diseases!

(e.g., study of folic acid & birth defects)

Case‐Control StudyMajor limitation(s):

• Many alternate hypotheses• Can’t tell if dietary habit preceded, or followed the

onset of disease (temporal relationship unclear)(i.e., finding out about your disease may have caused you to changeyour diet, or may bias your memory of your diet [RECALL BIAS])

Major advantage(s):• Relatively quick and inexpensive• Particularly appropriate for RARE diseases!

(e.g., study of folic acid & birth defects)

Prospective /Longitudinal

Note: The majority of newspaper headlines linking

diet to health come from cohort studies

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Healthy Unhealthy

Nurses Health Study

(n=69,949)

Nurses Health Study

2(n=90,239)

Health Professionals

Study(n=40,539)

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

1 2 3

4 5 6

7 8 9

ObservationOr

Intervention?

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Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

Association

Cohort StudyMajor limitation(s):

Many alternate hypotheses can explainthe same observation

Expensive, and long durations

Major advantage(s):Establishes prospective nature of

relationship (e.g., temporal sequence) between diet and health

Examines achievable range of diet variability(e.g., comparing lowest to highest intake)

Cohort StudyMajor limitation(s):

Many alternate hypotheses can explainthe same observation

Expensive, and long durations

Major advantage(s):Establishes prospective nature of

relationship (e.g., temporal sequence) between diet and health

Examines achievable range of diet variability(e.g., comparing lowest to highest intake)

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Plausibility/Mechanism1. Observational (convenience)

Case reports

2. Observational (more intensive) plus diet data collected from individuals

Case-Control studies - humansCohort studies – humans

3. Biological PlausibilityAnimal and cell studies

Mechanism

Biological plausibility

Mechanism

Biological plausibility

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Animal/Cell StudiesMajor limitation(s):

Extrapolating to human health

Major advantage(s):Establishes biological plausibility(i.e., mechanisms)

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Oral Glucose Tolerance Test

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The Gold Standard1. Observational (convenience)

Ecological studiesCase reports

2. Observational (more intensive) plus diet data collected from individuals

Case-Control studies - humansCohort studies – humans

3. Biological PlausibilityAnimal and cell studies

4. Clinical Trials

The “Gold Standard” of “Evidence‐Based” Science

Clinical Trials

Cohort Studies

Case-control Studies

Ecological Studies

Molecular & cell biology

Animal models

The “Gold Standard” of “Evidence‐Based” Science

Clinical Trials

Molecular & cell biology

Animal models

= Observational

Cohort Studies

Case-control Studies

Ecological Studies

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The GOLD standard of science:The double‐blind,Placebo‐controlled,Randomized,Clinical trial

If we feed “X” vs. a Placebo to a group of “ABC’s” at a dose of “D”for a duration of “T” there will be more/less of “IT”.

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~160,000 screened~4,000 randomized

~40:1

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Hazard ratio for diabetes, 0.88 (95% CI, 0.75-1.04) P=0.12

4,000 IU/d

Gold Standard to establish cause and effect

Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic Disease

1 2 3

4 5 6

7 8 9

ObservationOr

Intervention?

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Nutrients

Foods

Culture

AcuteOnsetDisease

Chronic Disease

Risk FactorsChronic DiseaseCause & Effect

Typical “Scientific” approach to diet complexity

1 food item

Sum total of consumable foods (diets)

Health related factors

1 nutrient or phyto-chemical

Diseases

1 risk factor1 disease

Reductionist / Isolationist approach

Example: Low Carb Diet and HbA1c

HbA1c and Diabetes

Overall health is goal, but there could be benefits for one outcome and increased risk for another

IsoflavonesEstrogen-like molecules in soy

Lipids

CVD Breast Cancer

Menopausal symptoms

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Clinical Nutrition Trials:Advantages

• Cause and effect established

• Human relevance clear(conducted with humans)

• End points clinically relevant

Clinical Nutrition Trials:Limitations (Issues)

• Generalizability (often limited, due to……)

• Population (often specific)

• Dose (usually just one at a time)

• Duration (often relatively short)

• Effect attributable to what was eaten or what was replaced?

• Risk factor benefits may not lead to improved health outcomes

• Usually focuses on one health outcome, not overall health

• Result reproducible?

One specific answer to one specific question

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2017 Feb 23;5(1):e000354

2017 Feb 23;5(1):e000354

2017 Feb 23;5(1):e000354

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2017 Feb 23;5(1):e000354

Nutrition Data

Health Outcome Data

Country or Population Level Data

IndividualPerson

Level Data

Observational

Cross‐Sectional Prospective

Interventional

Risk Factor Disease Outcome

Primary (prevention) Secondary  (treatment)

FactorsAffectingLevel ofEvidenceContributed

Nutrition Data

Health Outcome Data

Country or Population Level Data

IndividualPerson

Level Data

Observational

Cross‐Sectional Prospective

Interventional

Risk Factor Disease Outcome

Primary (prevention) Secondary  (treatment)

FactorsAffectingLevel ofEvidenceContributed

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Pieces of the Puzzle

Cell & Molecular

Tissues, Organs

Animal

Human Trials

Epidemi‐ology

Inclusion criteria for ADA consensus report

• Subjects 18 years of age or older

• Outpatient/ambulatory care, community, metabolic/clinical research unit settings

• Non-hospitalized, no acute illness

• Diabetes or prediabetes diagnosis!

• Sample size of 10 subjects per study group

• 50% retention rate

Inclusion criteria for ADA consensus report, continued

• English language

• Study design preferences– RCT or clinical controlled studies

– Single-arm clinical study

– Prospective observational study

– Cross-sectional observational study

– Case-control studies

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Process of coming to consensus on controversial topics

• Monthly telephone conference calls and email discussions led by committee co-chairs, February 2018 through January 2019

• Evidence presented and discussed

• Bullet-point statements suggested and discussed

• 80% consensus needed to include major statements in paper

Committee member search and selection process

• National call for expert committee applications

• Diversity sought in professional interest and cultural background

• Each topic team included both researchers and MNT clinicians

The challenge of clinical nutrition research trials

• Sample size

• Funding challenges

• Study length

• Adherence and retention confusion

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Nutrition

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNSMORBIDITY /MORTALITY

Heart DiseaseStrokeCancer

DiabetesOsteoporosis

Nutrition HealthOutcomes

?

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSNutrition

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89

90

31

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

Nutrition

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

MORBIDITY /MORTALITY

Heart DiseaseStrokeCancerDiabetes

Osteoporosis

Nutrition HealthOutcomes

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

MORBIDITY /MORTALITY

Heart DiseaseStrokeCancer

DiabetesOsteoporosis

DyslipidemiaDysglycemia

HyperinsulinemiaHypertensionInflammation

ObesityBone densityAnd more….

PHYSIOLOGY /METABOLISM

Nutrition HealthOutcomes

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92

93

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MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

MORBIDITY /MORTALITY

Heart DiseaseStrokeCancer

DiabetesOsteoporosis

DyslipidemiaDysglycemia

HyperinsulinemiaHypertensionInflammation

ObesityBone densityAnd more….

PHYSIOLOGY /METABOLISM

DyslipidemiaLDL‐cholesterolHDL‐cholesterolTriglycerides

DysglycemiaFasting glucose

HbA1cOGTT

HypoglycemiaHyperinsulinemiaFasting insulin

HOMA‐IRInsulin ResistanceMatsuda IndexHypertensionSystolic BPDiastolic BPHeart rate

Ejection fractionInflammation

CRPIL‐6

TNF‐alphaCytokines

And More…..Obesity

Central adiposityVisceral fat

Waist/Hip ratioAnd more….MicrobiomeFirmicutes

BacteroidetesDiversitySCFA

Bone densityAnd more….

MARKERS/RISK FACTORSNutrition Health

Outcomes

VITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

DyslipidemiaLDL‐cholesterolHDL‐cholesterolTriglycerides

DysglycemiaFasting glucose

HbA1cOGTT

HypoglycemiaHyperinsulinemiaFasting insulin

HOMA‐IRInsulin ResistanceMatsuda IndexHypertensionSystolic BPDiastolic BPHeart rate

Ejection fractionInflammation

CRPIL‐6

TNF‐alphaCytokines

And More…..Obesity

Central adiposityVisceral fat

Waist/Hip ratioAnd more….MicrobiomeFirmicutes

BacteroidetesDiversitySCFA

Bone densityAnd more….

MARKERS/RISK FACTORSNutrition Health

Outcomes

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

Dyslipidemia

DysglycemiaHyperinsulinemia

HypertensionInflammation

ObesityBone densityAnd more….

PHYSIOLOGY /METABOLISM

DyslipidemiaLDL‐cholesterolHDL‐cholesterolTriglycerides

DysglycemiaFasting glucose

HbA1cOGTT

HypoglycemiaHyperinsulinemiaFasting insulin

HOMA‐IRInsulin ResistanceMatsuda IndexHypertensionSystolic BPDiastolic BPHeart rate

Ejection fractionInflammation

CRPIL‐6

TNF‐alphaCytokines

And More…..Obesity

Central adiposityVisceral fat

Waist/Hip ratioAnd more….MicrobiomeFirmicutes

BacteroidetesDiversitySCFA

Bone densityAnd more….

MARKERS/RISK FACTORSNutrition Health

Outcomes

94

95

96

33

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

MORBIDITY /MORTALITY

Heart DiseaseStrokeCancer

DiabetesOsteoporosis

DyslipidemiaDysglycemia

HyperinsulinemiaHypertensionInflammation

ObesityBone densityAnd more….

PHYSIOLOGY /METABOLISM

DyslipidemiaLDL‐cholesterolHDL‐cholesterolTriglycerides

DysglycemiaFasting glucose

HbA1cOGTT

HypoglycemiaHyperinsulinemiaFasting insulin

HOMA‐IRInsulin ResistanceMatsuda IndexHypertensionSystolic BPDiastolic BPHeart rate

Ejection fractionInflammation

CRPIL‐6

TNF‐alphaCytokines

And More…..Obesity

Central adiposityVisceral fat

Waist/Hip ratioAnd more….MicrobiomeFirmicutes

BacteroidetesDiversitySCFA

Bone densityAnd more….

MARKERS/RISK FACTORSNutrition Health

Outcomes

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

MORBIDITY /MORTALITY

Heart DiseaseStrokeCancer

DiabetesOsteoporosis

DyslipidemiaDysglycemia

HyperinsulinemiaHypertensionInflammation

ObesityBone densityAnd more….

PHYSIOLOGY /METABOLISM

DyslipidemiaLDL‐cholesterolHDL‐cholesterolTriglycerides

DysglycemiaFasting glucose

HbA1cOGTT

HypoglycemiaHyperinsulinemiaFasting insulin

HOMA‐IRInsulin ResistanceMatsuda IndexHypertensionSystolic BPDiastolic BPHeart rate

Ejection fractionInflammation

CRPIL‐6

TNF‐alphaCytokines

And More…..Obesity

Central adiposityVisceral fat

Waist/Hip ratioAnd more….MicrobiomeFirmicutes

BacteroidetesDiversitySCFA

Bone densityAnd more….

MARKERS/RISK FACTORS

DOSE – SOURCE ‐ DURATION

Nutrition HealthOutcomes

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

MORBIDITY /MORTALITY

Heart DiseaseStrokeCancer

DiabetesOsteoporosis

DyslipidemiaDysglycemia

HyperinsulinemiaHypertensionInflammation

ObesityBone densityAnd more….

PHYSIOLOGY /METABOLISM

DyslipidemiaLDL‐cholesterolHDL‐cholesterolTriglycerides

DysglycemiaFasting glucose

HbA1cOGTT

HypoglycemiaHyperinsulinemiaFasting insulin

HOMA‐IRInsulin ResistanceMatsuda IndexHypertensionSystolic BPDiastolic BPHeart rate

Ejection fractionInflammation

CRPIL‐6

TNF‐alphaCytokines

And More…..Obesity

Central adiposityVisceral fat

Waist/Hip ratioAnd more….MicrobiomeFirmicutes

BacteroidetesDiversitySCFA

Bone densityAnd more….

MARKERS/RISK FACTORS

DOSE – SOURCE ‐ DURATION

POPULATIONAge

GenderRace/Ethnicity

Health/Disease Status

Nutrition HealthOutcomes

97

98

99

34

MediterraneanVegetarianVeganPaleo

Low‐CarbKetogenic

Middle EasternLatin American

JapaneseChinese

ScandinavianAnd more…..

DIET PATTERNS

VEGETABLESBroccoliPeppersTomatoes

Kale

BEANS/PEASGarbanzoLentilsKidneySoy

GRAINSOatsWheatBarley

Amaranth

FRUITSMango

RaspberriesBananaAppleOrangeDAIRYMilkYogurt

Ice Cream

MEAT/FISHBeefPork

ChickenSalmonEGGS

ALCOHOLWineBeerLiquor

COFFEEFAST FOODFrench friesMilkshakes

CandyAND MORE….

FOODSVITAMINSA – Retinol/alB1 – ThiaminB2 – RiboflavinB3 – Niacin

B6 ‐ PyridoxalB9 – Folate

B12 – CobalaminVit CVit DVit EVit K

MINERALSCalciumPotassiumMagnesiumSodiumIronIodineZinc

FATPalmitic acidStearic acidOleic acid

Linoleic acidLinolenic acid

EPADHA

And more….

PROTEINTryptophanLeucineLysine

And 17 more….CARBOHYDRATE

GlucoseFructoseGalactosePectin

CelluloseAnd more fibers…

HERBS/SPICESTurmericGingerGarlic

And more…..

PHYTOCHEMICALSBeta‐CaroteneResveratrolGenistein

AnthocyaninsIsothiocyanates

Indole-3 carbinolSulforphaneFlavonoids

AND MORE….

MOLECULES

MORBIDITY /MORTALITY

Heart DiseaseStrokeCancer

DiabetesOsteoporosis

DyslipidemiaDysglycemia

HyperinsulinemiaHypertensionInflammation

ObesityBone densityAnd more….

PHYSIOLOGY /METABOLISM

DyslipidemiaLDL‐cholesterolHDL‐cholesterolTriglycerides

DysglycemiaFasting glucose

HbA1cOGTT

HypoglycemiaHyperinsulinemiaFasting insulin

HOMA‐IRInsulin ResistanceMatsuda IndexHypertensionSystolic BPDiastolic BPHeart rate

Ejection fractionInflammation

CRPIL‐6

TNF‐alphaCytokines

And More…..Obesity

Central adiposityVisceral fat

Waist/Hip ratioAnd more….MicrobiomeFirmicutes

BacteroidetesDiversitySCFA

Bone densityAnd more….

MARKERS/RISK FACTORS

DOSE – SOURCE ‐ DURATION

POPULATIONAge

GenderRace/Ethnicity

Health/Disease Status

Nutrition HealthOutcomes

100

101