Evidence Behind Dietary Intervention in Diabetes in 2020 John L Sievenpiper, MD, PhD, FRCPC 1,2,3,4,5 1 Diabetes Canada Clinician Scientist 2 Associate Professor, Department of Nutritional Sciences, University of Toronto 3 Staff Physican, Division of Endocrinology & Metabolism, St. Michael’s Hospital 4 Scientist, Li Ka Shing Knowledge Institute, St. Michael’s Hospital 5 Lifestyle Medicine Lead, MD Program, University of Toronto Diabetes Update 2020 Toronto, Canada May 1, 2020
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Evidence Behind Dietary Intervention in Diabetes in 2020
John L Sievenpiper, MD, PhD, FRCPC1,2,3,4,5
1Diabetes Canada Clinician Scientist2Associate Professor, Department of Nutritional Sciences, University of Toronto3Staff Physican, Division of Endocrinology & Metabolism, St. Michael’s Hospital
4Scientist, Li Ka Shing Knowledge Institute, St. Michael’s Hospital 5Lifestyle Medicine Lead, MD Program, University of Toronto
Diabetes Update 2020
Toronto, Canada
May 1, 2020
Learning Objective
Following this session, participants will be able to:
Review current and evolving nutritional approaches for the prevention and management of diabetes
Does diet matter?
Poor diet is greatest contributor to total and cardiovascular disease and death worldwide:
Global burden of disease attributable to 79 risk factors inGlobal Burden of Disease Study 2015 and 2017
James Lind FRSE FRCPE (4 October 1716 – 13 July 1794), a Scottish Physician in the Royal Navy, conducted the first ever clinical trial in 1747 showing that oranges and lemons cured scurvy
http://www.jameslindlibrary.org/lind-j-1753/
Failure of the “nutrient-based” model
in chronic disease
“Overall mortality was 8 percent higher among participants who received beta carotene than among those not given beta carotene (95 percent confidence interval, 1 to 16, P=0.02)”
The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. 1994; 330:1030-1035
Beta carotene increases total mortality: ATBC trial, N=29,133 male smokers (age:50-69y), 876 cases, FU=5-8y
The Jenkins et al. JACC 2018;71:2570–84
Antioxidants fail to achieve anticipated decrease in CV events and increase total mortality:
SRMA, 21 RCTS, N=105,780, 8,472 deaths
Emergenceof the “Dietary pattern-based”
model
Importance of vales, preferences, and treatment goals
“Values and preferences. Adherence is one of the most important determinants for attaining the benefits of any diet. High food costs (e.g. fresh fruits and vegetables), allergies (e.g. peanut and tree nut allergies), intolerances (e.g. lactose intolerance), and gastrointestinal (GI) side effects (e.g. flatulence and bloating from fibre) may present as important barriers to adherence. Other barriers may include culinary (e.g. ability and time to prepare foods), cultural (e.g. culturally specific foods), and ecological/environmental (e.g. sustainability of diets) considerations. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long term.”
Anderson JT et al. Can J Cardiol. 2016 Jul 25. pii: S0828-282X(16)30732-2.Sievenpiper et al. Can J Diabetes. 2018;42 (Suppl 1):S64-S79.
“A Mediterranean diet primarily refers to a plant-based diet first described in the 1960s (136). General features include highconsumption of fruits, vegetables, legumes, nuts, seeds, cereals and whole grains; moderate-to-high consumption of olive oil (as the principal source of fat); low-to-moderateconsumption of dairy products, fish and poultry; low consumption of red meat; and low-to-moderate consumption of wine, mainly during meals (136,137).”
Sievenpiper et al. Can J Diabetes. 2018;42 (Suppl 1):S64-S79.
Mediterranean diet supplemented with tree nuts (30g/day) reduces major cardiovascular events:
PREDIMED trial, N=7,447 (288 events), FU=4.8y
Estruch et al. N Engl J Med 2018;378:e34
Mediterranean diet supplemented with tree nuts (30g/day) reduces incident diabetes:
PREDIMED (Reus) trial, N=418, 54 cases, FU=4y
Salas-Salvado et al. Diabetes Care 2011;34:14–19Salas-Salvado et al. Diabetes Care 2018 Oct; 41(10): 2259-2260
a, EVOO: RR=0.47 (0.23-0.97)b, Nuts: RR=0.47 (0.23-0.98)
Diabetes Canada:
2018 Clinical Practice Guidelines for Nutrition Therapy
Sievenpiper et al. Can J Diabetes. 2018;42 (Suppl 1):S64-S79.
Diabetes Canada:
2018 Clinical Practice Guidelines for Nutrition Therapy
Sievenpiper et al. Can J Diabetes. 2018;42 (Suppl 1):S64-S79.
Chiavaroli et al. Prog Cardiovasc Dis 2018;61:43-55
“The combination of a Portfolio dietary pattern and NCEP Step II diet significantly lowered the primary outcome LDL-C by 17% (21% in efficacy and 12% in effectiveness trials)… suggesting that the benefit of the intended combination… would result in LDL-C reductions of ~27% (32% in efficacy and 15% in effectiveness trials) in clinical practice.”
Portfolio dietary pattern is associated with decreased incidence and mortality of CVD outcomes:
Women’s Health Initiative (WHI), n= 107,387, mean FU=14.9y
Glenn AJ et al., submitted
OUTCOME # CASES Q1HR [95% CIs]
Q2HR [95% CIs]
Q3HR [95% CIs]
Q4HR [95% CIs]
Total CVD 11,370 1.0 (Ref) 0.98 [0.93-1.03]
0.92 [0.87-0.97]
0.89 [0.84-0.95]
CHD 5, 739 1.0 (Ref) 0.92 [0.86-0.99]
0.86 [0.79-0.93]
0.87 [0.79-0.95]
Stroke 4, 451 1.0 (Ref) 1.03 [0.94-1.13]
0.99 [0.89-1.09]
0.97 [0.87-1.08]
Heart Failure 1, 946 1.0 (Ref) 1.06 [0.87-1.28]
0.85 [0.74-0.98]
0.83[0.70-0.98]
Andrea Glenn, MSc, RD
Simin Liu,MD, ScD
How do you prescribe diet?
Case
Case of a 74-year old man with mixed dyslipidemia & MetS
ID: 74 year old, male, Caucasian
RFR: Hyplidipidemia w/ inability to meet targets
PMH: OW, HTN, Colon CA (remission), hypothyroidism
CV risk factors: Visceral obesity Ex-15 pack year smoker HTNNo DM (pre-DM)No FHx of premature CVD
Diet & Lifestyle: High red meatHigh refined starch, low fibreLow fruit & veg
O/E: No stigmataBMI 29.8, WC >102cmBP 154/91 mmHgOtherwise unremarkable
Labs: Nov 2014 (“off”) Jan 2015 (“on”) Total-C 8.81 → 5.45TGs 2.56 → 2.29HDL-C 1.40 → 1.23 LDL-C 6.25 → 3.18 Non-HDL-C 7.41 → 4.22Apo B 1.79
HbA1c: 6.1%
Normal thyroid, liver, renal tests
FRS: >30%
A/P: Mixed dyslipidemiaMetS 4/5 (WC, TG, BP, Pre-DM)Lipids not at target of ≤2mmol/L or ≥50% ↓ LDL-COn max dual therapy - ? approachHTN – started ramipril 10mg1
Importance of vales, preferences, and treatment goals
“Values and preferences. Adherence is one of the most important determinants for attaining the benefits of any diet. High food costs (e.g. fresh fruits and vegetables), allergies (e.g. peanut and tree nut allergies), intolerances (e.g. lactose intolerance), and gastrointestinal (GI) side effects (e.g. flatulence and bloating from fibre) may present as important barriers to adherence. Other barriers may include culinary (e.g. ability and time to prepare foods), cultural (e.g. culturally specific foods), and ecological/environmental (e.g. sustainability of diets) considerations. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long term.”
Anderson JT et al. Can J Cardiol. 2016 Jul 25. pii: S0828-282X(16)30732-2.Sievenpiper et al. Can J Diabetes. 2018;42 (Suppl 1):S64-S79.
What is the Portfolio Diet? A dietary portfolio of cholesterol-lowering foods
45g/dayPeanuts, tree nuts
45g/daySoy products, pulses
20g/dayOats, barley, psyllium, pulses, eggplant, okra, temperate climate fruit
Weight loss (baseline, 96.3kg): 7.2kg or 8% (lowest) to 4.1kg or 4.3% (present)
* -48%** -44% *** -45%
additional lowering beyond dual max therapy
Off Rx On Rx “Rx + Portfolio”
Conclusions
Conclusions
1. Dietary guidelines have moved away from “nutrient-based recommendations” (“low fat”, “low carb”, “high protein”) to more “food- and dietary pattern-based recommendations”.
2. Comprehensive dietary patterns that combine the advantages of different foods (e.g. Med diet, DASH diet, Portfolio Diet,) result in clinically meaningful improvements in cardiometabolic risk factors and associated reductions in cardiovascular disease comparable to those seen with medications.
3. Physicians (with the assistance of a registered dietitian where possible) have an important opportunity to make an impact prescribing diet and exercise to their patients.
Practice Applications1. Use food and dietary pattern-based strategies such as
Mediterranean, Portfolio, Low glycemic index, Vegetarian, or DASHdietary patterns to modify cardiometabolic risk factors and reduce disease risk as 1st-line therapy in your patients
2. To achieve the greatest benefit in those already treated with medications, consider food and dietary pattern-based strategies as add-on therapy.
3. Help your patient (with the assistance of a registered dietitian) to choose the dietary pattern that best aligns with their values, preferences and treatment goals to ensure the greatest adherence over the long term
Acknowledgements
Acknowledgements
Current lab membersDr. Sonia Blanco Mejia, MD, MSC (Research Associate)Ms. Maxine Seider, RD, MSc (Research Coordinator)Dr. Tauseef Khan, MBBS, PhD (PDF)Dr. Laura Chiavaroli, PhD (PDF)Ms. Stephanie Nishi, MSc, RD (PhD student)Mr. Rodney Au Yeung, MSc (PhD student)Ms. Andrea Glenn, MSc, RD (PhD student)Ms. Nema McGlynn, HBASc, RD (MSc student)Ms. Sabrina Ayoub-Charette, HBSc (MSc student)Ms. Annette Cheung, HBASc, RD (MSc student)Ms. Qi “Annie” Liu (HBSc project student)Ms. Danielle Lee (HBSc project student)Ms. Amna Ahmed (HBSc project student)
Former lab membersMs. Catherine Braustein, MScMr. Jarvis Nooranha, MScMs. Effie Viguiliouk, MScMs. Vivian Choo, MSc (MD student)Mr. Viranda Jayalath, MAN (MD student)Dr. Vanesa Ha, PhD, (MD student)Ms. Christine Tsilas, HBSc, (RD intern)Ms. Shana Kim, MSc (PhD student)Dr. Adrian Cozma, MD (Resident)Dr. Shari Li, MD (Resident)Dr. Arash Mirrahimi, MD, MSc (Resident)Dr. David Wang, MD (Resident)Mr. Simon Chiu, HBScMs. Reem Tawfik, HBScMs. Sara Rehman, HBScDr. Matt E Yu, HBSc, DDS
CollaboratorsDr. David JA Jenkins, MD, PhD, DScDr. Cyril Kendall, PhDDr. Lawrence A Leiter, MD, FRCPCDr. Thomas MS Wolever MD, PhDDr. Elena Comelli, PhDDr. Richard Bazinet, PhDDr. Anthony Hanley, PhDDr. Ahmed El-Sohemy, PhD
CollaboratorDr. Vasanti Malik, PhD
CollaboratorDr. Jordi Salas-Salvado, MD, PhD
CollaboratorsDr. Russell J de Souza, RD, ScDDr. Joseph Beyene, PhD