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Practical Approach to Popular Diets in Diabetes and Obesity Diabetes Update 2020 Wendy Graham RD CDE
Practical Approach
to Popular Diets
in
Diabetes and
ObesityDiabetes Update 2020
Wendy Graham RD CDE
Objectives
Discuss the pros and cons of various popular diets in the management of people with diabetes and obesity
Popular Diets
MediterraneanIntermittent Fasting
Ketogenic DietLow Carbohydrate
8 hr
Popular Diets
Risks
Hypoglycemia
Hypotension
Dehydration
Protein Malnutrition
Vitamin and Mineral deficiencies
Potential complications
Assess/Advice
Medication adjustment
Blood Glucose monitoring
Monitoring blood pressure
Hydration
Nutrition
Protein
Vitamin & Minerals supplements
Monitoring blood work
Intermittent Fasting
16 : 8 Fasting : Feasting
Time restricted Feeding
5 : 2 Days regular intake: fasting less than 500 calories
Alternate day fasting
8 hr
Intermittent Fasting
• Two fold risk of hypoglycemia on fasting days, despite medication reduction
• Improvement in Weight, A1c and Fasting glucose
• Education, weekly follow-up
12 months, follow-up 24 months
• Similar i weight, i A1c & imedication
• 24 months weight loss was maintained (-3.9 kg)
• A1c increased at FU (0.3%)
• Intermittent(IF) and calorie restriction
equally effective in weight reduction
• IF more effective at retention of lean mass Carter et al. Diabetes Research and Clin Practice 2019:152:11-19.
Corley BT et al. Diabet Med. 2018:35(5):588-94.
Varady KA. Obes Rev 2011:12(7):593-601.
Intermittent Fasting
Hypoglycemia
Hypotension
Dehydration
Protein Malnutrition
Vitamin and Mineral deficiency
8 hr
Risks
Grajower M et al. Nutrients 2019:11: 873-93
Intermittent Fasting
Hypoglycemia
8 hr
Assess/Advice
Medication Class Dose adjustment Comment
Sulfonylureas Omit dose on fast day
**take half dose on fast days
** education required on
hypoglycemiaMeglitinides Omit if no carbohydrate consumed
SGLT2 Inhibitors Omit on day of fast or if concerns of dehydration
Alpha glucosidase inhibitors Omit if no carbohydrate consumed
Basal insulin
(NPH, glargine, basaglar, determir)
-one third of usual dose if blood glucose at
target
-half dose if poorer blood glucose control
still significant hypoglycemia
Basal insulin- long acting No change Monitor and adjust as needed
Prandial insulin Skip dose if not eating carbohydrate reduced by 70 % on fasting days,
still had hypoglycemia
Adapted from Grajower M et al. Nutrients 2019:11: 873-93
Intermittent Fasting
Advise Patient on:
Medication adjustment
Blood Glucose monitoring
Hydration
Nutrition
Protein
Vitamin & Minerals supplements
8 hr
Intermittent Fasting
Pros
No special food preparation
Do not have to be restrictive
every day (5:2)
Cons
Dizziness
Nausea
Insomnia
Syncope
Falls
Headaches
Hunger pangs
Weakness limiting activities
Patient perspective
8 hr
Intermittent Fasting
Summary
Weight reduction similar to other energy restricted diets
Medication reduction may be required to prevent hypoglycemia
No difference in glycemic control
Better reduction in blood pressure and lipids
Better preservation of lean mass
8 hr
People with diabetes…require more careful consideration
at the beginning and during the use of a fasting regimen. Grajower et al
Mediterranean Diet: 9 Components
Olive oil ( 4 Tbsp/ 1/4c per day)
Fresh Vegetables
Fresh Fruit
Nuts
Legumes/Beans
Fish
Whole Grains
Limited Red or Processed Meat
Wine in moderation
2 point improvement in adherence
results in 25% reduction in mortality
Mediterranean Diet: 9 Components
Trichopoulou A, et al N Eng J Med 2003:348:259-2608.
Mediterranean Diet & Weight Reduction
Superior to Low fat diet
Similar weight loss to low carbohydrate and ADA
standard diet
Improves weight and cardiovascular health over
supplementing with specific foods (olive oil, walnuts and
grape juice)
Jaacks et al. 2018 BMC Nutr 4, 26 (2018). https://doi.org/10.1186/s40795-018-0234-y
Mancini et al. 2016. Am J Medicine 129(4):407-15
Mediterranean Diet
Summary
Cardiovascular risk reduction of 30%
Myocardial infarct, stroke and CV death
Weight loss similar to low carbohydrate, superior to low fat diet
Plant based
Sustainable
Extensive research
Estruch R et al. N Eng J Med. 2013:368:1279-90.
Estruch R et al. N Eng J Med. 2018: 378:e34.
Mediterranean Diet
Hypoglycemia
Hypotension
Dehydration
Protein Malnutrition
Vitamin and Mineral deficiencies
Potential complications
RisksAssess/Advice
Medication adjustmentBlood Glucose monitoringMonitoring blood pressureHydrationNutrition
ProteinVitamin & Minerals
supplementsMonitoring blood work
Very Low Carb
20 – 50 grams
70-80 % High Fat
Very Low Carb
<50 grams
40% High Protein
40% Fat
Low Carb
100 grams
Diabetes
>130 grams
45-60 % Carb
Mediterranean
55-60% Carb
30% Fat
NA Diet
50-55% carb
30% Fat
?
Low Carbohydrate
Grams of Carb% Grams of Carb% of total energy vs
Calories 45 % of energy
Grams of Carb
26 % of energy
Grams of Carb
Paul 3000 337 194
Larry 2000 225 130
Carol 1200 135 78
Carbohydrate…..
Source: Dietdoctor.com
Carbohydrate…..
Source: Dietdoctor.com
Low Carbohydrate
ADA / EASD Guidelines 2018
Davie et al. Diabetes Care 2018:41(12) 2669-2701.
“low-carbohydrate diets (<26% of total energy)
produce substantial reductions in HbA1c at 3 months
and 6 months with diminishing effects at 12 and 24
months”
Low CarbohydrateGuidelines
Diabetes UK 2018“The current evidence suggests that low-carb diets can be safe
and effective for people with type 2 diabetes… But there is no
consistent evidence that a low-carb diet is any more effective
than other dietary approaches in the long term, so it should not
be seen as the diet for everyone.” (<130 g)
Diabetes Australia 2018
“Low carbohydrate eating may be an effective way of reducing
glucose levels and achieving weight-loss for people with type 2 diabetes on the short term (6 months)” (<26% /<130 grams)
Low Carbohydrate
Risks
Hypoglycemia
Hypotension
Dehydration
Protein Malnutrition
Vitamin and Mineral deficiencies
Potential complications
Assess/Advice
Medication adjustment
Blood Glucose monitoring
Monitoring blood pressure
Hydration
Nutrition
Protein
Vitamin & Minerals supplements
Monitoring blood work
Low CarbohydratePatient perspective
Difficulty following long term
People think Keto is………
Ketogenic
Ketogenic
<50 grams Carb70 - 90 % Fat20 % Protein
3:1 Fat/ Carb + Protein
2oz salmon1 c grated cauliflower½ portabello mushroom½ c green beans1 c almond milk12 olives2 Tbsp cream cheese3 Tbsp olive oil
7.6 g carb15 g protein63.3 g fat660 calories
Evidence
Weight i similar to controls
Greater iA1c & i medication
Greater reduction in lipids
N= 22, 44 weeksMayers al. Diabetes Obesity Metab 2014:16(1):10.1111/dom.12191et Accessed February 2019
Ketogenic
RCT 2 yr N=61
Similar iWeight iA1c i B/P
Keto superior in i lipids & medication reduction
& glucose stability
Evidence
Ketogenic
Virta Health▪ Individual diet advice▪ Biomarker tracking▪ Access to web based software▪ Social support via online peer
community▪ Weight & A1c reduction over 2 yearsDiabetes reversal 53.5 % @ 2 years( A1c<6.5, can be on metformin)
Hallberg et al 2018; Athinarayanan et al 2019
Evidence
▪ Reduction in A1c
▪ Reduction in triglycerides
▪ Reduction in medication
▪ Improved insulin sensitivity
▪ LDL variable ori
Ketogenic
Contraindications
▪ Cardiomyopathy▪ CHF▪ Chronic Kidney Disease▪ Chronic Metabolic Acidosis▪ Fatty acid oxidation deficit▪ Liver Disease▪ Renal Stones▪ Severe Dyslipidemia▪ Severe Esophageal Reflux▪ Use of SGLT2 medications
Gupta L et al. Ketogenic diet in endocrine disorders:Currrent perspective. J Postgrad Med. 2017 Oct-Dec 63(4):2423-251.
Ketogenic
Contraindications
▪ Pregnancy and Breastfeeding
▪ Type 1 or LADA
▪ Infections
▪ Frail elderly
▪ Eating Disorders
▪ Recent stroke or MI within last 12 months
▪ Alcohol or substance abuse
Caprio M et al. Very-low-calorie ketogenic diet (VLCKD) in the management of metabolic diseases: systematic review and consensus statement from Italian Society of Endocrinology. Journal of Endcrinological Investigattion 2019 May 20. doi: 10.1007/s40618-019-01061-2. Downloaded September 2019.
Ketogenic
Assess/Advice Hypoglycemia
Medications- Westman et al
▪ Stop all oral hypoglycemia agents except metformin
▪ Stop insulin of < 20 units
▪ Insulin over 20 units decreased 30-50%
▪ Anti-hypertensive agents reduced
Westman et al. Expert Review of Endocrinology & Metabolism.2018:13(5):263-272.
Ketogenic
Ketogenic
Nutrient Deficiencies
Supplement:
Vitamin D
Calcium
Thiamine
Vitamin C
Selenium
Folate
?Carnitine
?Fibre
Ketogenic
Risks
Hypoglycemia
Hypotension
Dehydration
Protein Malnutrition
Vitamin and Mineral deficiencies
Potential complications
Assess/Advice
Medication adjustment
Blood Glucose monitoring
Monitoring blood pressure
Hydration
Nutrition
Protein
Vitamin & Minerals supplements
Monitoring blood work
Ketogenic
Summary
▪ Evidence is limited, but evolving
▪ Food Pattern is difficult to maintain
▪ Requires adequate planning and medical
monitoring
▪ Benefit in Highly Motivated patients
▪ improved blood glucose
▪ decreased medication
▪ decreased weight
▪ improved triglycerides, HDL*
Summary Respect your patient’s choices and
Support them in their Diabetes goals, help them do it safely.
Food is to be Eaten and Enjoyed!
Position statement
Low Carbohydrate
Diets
