Vegan Diets for Diabetes - SDAHO
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
9/17/2018
Vegan Diets for Diabetes
Meghan Jardine, MS, MBA, RDN, LD, CDE
Associate Director of Diabetes Nutrition Education
Physicians Committee for Responsible Medicine
Learning Objectives
• Describe the difference in risk factors for and
prevalence of chronic disease in vegetarians
and vegans compared to nonvegetarians.
• Discuss how plant‐based eating patterns
reduce the risk of type 2 diabetes.
• Provide useful dietary information or
resources to a patient with or at risk for
diabetes.
Diabetes is approaching
epidemic proportions
1
9/17/2018
Diabetes Statistics
• 30.3 million have diabetes (9.4%)
• 84.1 million have pre diabetes (11.6%)
• $266 billion cost to US economy
• High intangible cost on society
CDC Diabetes Report Card 2017
US Gallup poll (Nov. 2017)
Number of People with Diabetes
425 Million Worldwide
• 1980: 108 million
• North America 35% ↑
• Europe 16% ↑
• South and Central America 62% ↑
• SE Asia 84% ↑
• Middle East and N. Africa 110% ↑
• Africa 156% ↑
National Diabetes Federation 2017
Vegetarian and
Vegan Diets
2
9/17/2018
Vegetarian Diets
• Vegan diet – 2% of US population
• Vegetarian diet – 5% of US population
• Healthy Vegetarian Diet (2015/2020 USDA DGA)
Vegetarians and Vegans
Lower Risk Factors Reduced Risk of Chronic Disease:
• Body weight • Cardiovascular disease
• Abdominal Obesity • Diabetes
• Blood pressure • Cancer:
• Serum lipids – All
• Markers of inflammation – Colon
• Glucose levels – prostate
• Mortality
Melina V, et al. J Acad Nutr Diet. 2016;116:1970‐1980.
Le TL, Nutrients. 2014;6:2131‐2147.
7th Day Adventists
• Christian denomination
• Encouraged to be healthy
• Encouraged to be vegetarian
• Sets up a natural experiment to evaluate
eating patterns and health outcomes
– Adventist Mortality Study
– Adventist Health Study 1
– Adventist Health Study 2 ‐ >100,000 (ages 30‐112)
3
9/17/2018
Differences between Lacto‐Ovo and
Vegan (AHS‐2)
Lacto‐ovo Vegan
BMI 3 points lower 5 points lower
HTN 55% less 75% less
T2DM 38% to 61% less 47% to 78% less
All‐Cause Mortality 9% lower 14% lower
CVD mortality 23% to 42% 55% lower
• When stratified by ethnicity, RR reduction for diabetes was greater for black
vegetarians
• Reduction in mortality is greater for men than for women
Le et al. Nutrients. 2014;6:2131‐2147.
Adventist Health Study – 2
(N=60,903)
Tonstad, et al. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care. 2009;32:791‐796.
Meat Consumption and Diabetes
• Nurses Health Study I and II
• Health Professionals’ Follow up study
• European Prospective Investigation into
Nutrition and Cancer
• NHANES
Satija A, et al. PLoS Med. 2016:13;e1002039.
Pan A, et al. JAMA. 2013;173:1328‐1335.
van Nielen et al. Diabetes Care 2014;37:1854‐1862.
Sluijs et al. Diabetes Care. 2010;33:43‐48
Wang et al. Int J Obes (lond). June; 33(6):621‐628
4
9/17/2018
Vegetarians have a Higher Diet Quality
(NHANES 1999‐2004)
Higher in: Lower in:
• Fiber • Total fat
• Vitamins A, C, E • Saturated fat
• Calcium • Cholesterol
• Magnesium • Sodium
• Iron • Protein
• Thiamin • Vitamin B12
• Riboflavin • Zinc
• Folate • Niacin
Farmer B, et al. J Am Diet Assoc. 2011;111:819‐827.
Intensive Lifestyle Intervention
(NIH funded)
• 22 week RCT of 99 individuals with T2D:
– Low‐fat vegan group (N=49)
• Consume from “4 food groups”
• Low‐fat, low glycemic index
• No portion control
– Control group (ADA: portion control of CHO, ‐500
kcal/day)
– Both groups received intensive lifestyle therapy.
Barnard, et al. Diabetes Care. 2006;29:1777‐1783.
Results at 22 weeks
Both groups improved:
Vegan Group Control Group
Reduced 43% 26%
Medications
A1C ↓0.96 ↓0.56
A1C – no med ↓1.23 ↓0.38
changes
Body Weight ↓6.5 Kg ↓3.1 Kg
LDL Cholesterol ↓21.2% ↓10.7%
AHEI Score ↑↑ unchanged
Barnard, et al. Diabetes Care. 2006;29:1777‐1783.
5
9/17/2018
Mechanisms:
Why does this work?
Potential Mechanisms
Plant‐Based Diet Meat‐Based Diet
Diet Quality Fiber Saturated Fats
Antioxidants and Heme‐iron
Phytochemicals and trans fats
Protein
Low‐GI
Polyphenols
AGE
Anti‐inflammatory
Nitrates/Nitrites Dysbiosis
Vitamins/Minerals Chiuve SE, et al J Nutr. 2012;142:1009‐1018.
Insulin Resistance Wolfram T. Endocr Pract., 2011:17:132‐142.
Kim y. Nutrients. 2016;8:17.
Radulian G. Nutr J. 2009;8:5.
Beta‐cell Dysfunction Estadella D. Mediators Inflamm. 2013;
doi.org/10.1155/2013/137579.
Wolk. J Intern Med. 2017;281:106‐122.
Serrano SE. Environ Health. 2014;13:43.
Fatty Acids and Insulin Resistance
Obesity ↓Insulin signaling
↓mitochondrial
High Fat Feeding FOX
↑gluconeogenesis
↑inflamma on
↑ plasma
FFA
↑release of
adipokines
Insulin Resistance Type 2 diabetes, CAD,
CVD, PAD, NAFLD
Boden G. Curr Diab Rep. 2006;6:177‐181
Boden G. Curr Opin Endocrinol Diabetes Obes. 2011;18:139‐143.
6
9/17/2018
Inside the Cell
Glucose Insulin
●
●
●
●
●
●●
●
Intramyocellular lipid
PBD Improves Beta Cell Function
• 16 week dietary intervention
• N=75, overweight adults randomized to:
– Low‐fat vegan diet
– No dietary changes
• Intervention results:
– ↑ in post meal s mulated insulin secre on
occurred in the LFV group (p < 0.001)
– ↓ in insulin resistance (HOMA‐IR) (p < 0.001)
Kahleova H. et al. Nutrients. 2018;10:189
79/17/2018
Why do plant‐based diets
cause weight loss (without
portion control)?
Fiber is Filling
Fiber tells the brain you’re full.
Carbohydrate has 4 kcal/gram
Fat has 9 kcal/gram
119 calories
89/17/2018
The After‐Meal Calorie Burn
Barnard ND, Scialli AR, Turner-McGrievy G, Lanou AJ, Glass J. The effects of a
low-fat, plant-based dietary intervention on body weight, metabolism, and insulin
sensitivity. Am J Med 2005;118:991-997.
The After‐Meal Calorie Burn
Barnard ND, Scialli AR, Turner-McGrievy G, Lanou AJ, Glass J. The effects of a
low-fat, plant-based dietary intervention on body weight, metabolism, and insulin
sensitivity. Am J Med 2005;118:991-997.
Changes in Microbiota
Non‐digestible
Short Chain
polysaccharides
Fatty Acids:
Fermented by
gut bacteria
• Butyrate
• Propionate
• Acetate
99/17/2018
Short Chain Fatty Acids (SCFA)
Enhance nutrient absorption
Improve Gut Barrier Function ↑Satiety
↓ Food intake
↑ FOX
↓Endotoxin
↓Inflammation
Cani PD, et al. Current Pharmaceutical Design. 2009;15:1546-1558
↑Release of gut Allin KH, et al. Eur J Endocrinol. 2015;172:R167-R177
peptides Tilg H, et al. Gut. 2014;63:1513-1521.
Conlon et al. Nutrients. 2015;7:17-44
↑Glycemic control
Diabetes Remission Occurs
with Calorie Restriction.
Reversal of Diabetes
• Metabolic surgery
• Very Low calorie Diets
– The Counterpoint Study – 640 – 700 kcal /d (50%
remission)
– Primary care‐led weight managegment for remission
of type 2 diabetes (DiRECT) – 825‐853 kcal/d (46%
remission)
– Insulin sensitivity occurs within days
– Beta cell function improves within weeks
Taylor, R. Diabet Medi. 2012;30:267‐275
Lean ME, et al. Lancet 2017doi.org/10.1016/s0140‐6736(17)33102‐1
109/17/2018
High CHO, High Fiber No Weight Loss
• N=20 men with T2DM on insulin
• Metabolic ward
– Control diet 7 days
– Intervention: 70% carbohydrate, > 60 grams fiber,
< 20 grams fat, 16 days
• Designed to maintain body weight
Anderson JW. Am J Clin Nutr. 1979;32:2312‐2321
Results
• No changes in body weight
• 9 out of 20 patients discontinued insulin.
• Insulin reduced: from 26 + 3 units/day to 11 +
3 units per day.
• Fasting and 3‐hour post prandial glucose
levels decreased significantly
• Cholesterol was reduced: 206 + 10 mg/dL to
147 + 5
What About Just a Small
Amount of Animal products?
119/17/2018
The Tzu Chi Health Study
• 4,384 Taiwanese Buddhist volunteers
– 1,484 vegetarians
– 2,900 non‐vegetarians
Vegetarians Non‐Vegetarians
Consumed more soy, Traditional Asian diet
vegetables, whole grains Women: fish or meat 1X/wk.
Men: fish or meat every few
days
Chiu TH. PLOS One. 2014;9:e88547.
Tzu Chi Diabetes Results
OR for Diabetes for
Vegetarians
Premenopausal Women 0.26
(N=866)
Menopausal Women 0.25
(N=1382)
Men (N=1253) 0.49
Vegan (n=69) 0 cases of DM
Chiu, et al. PlosOne 2014;9:e88547
129/17/2018
Nutrition Adequacy
Position of AND
• “...appropriately planned vegetarian, including
vegan, diets are healthful, nutritionally
adequate, and may provide health benefits in
the prevention and treatment of certain
diseases.”
Melina V, et al. J Acad Nutr Diet. 2016;116:1970‐1980
Key Nutrients
• Protein:
– Beans, lentils, peas, tofu, tempeh, seitan, grains, and green vegetables
• Vitamin B12:
– Fortified non‐dairy milks, cereals, meat analogs, supplementation is recommended
• Iron:
– Green leafy vegetables and legumes, tempeh, pumpkin seeds, almonds, dried figs, molasses
– Incidence of iron deficiency is similar for vegetarians and non‐vegetarians.
• Omega 3 Fatty Acids:
– EPA and DHA can be synthesized from alpha‐linolenic acid (consume less corn, sunflower and
safflower oils).
– Ground flaxseeds, walnuts, cauliflower, soybeans, tofu, dark green leafy vegetables, microalgae
supplements
• Iodine:
– Sea vegetables, iodized salt, multivitamin.
Melina V, et al. J Acad Nutr Diet. 2016;116:1970‐1980
139/17/2018
AND B12 Recommendations
• Fortified foods contain B-12
• Vegans should get regular reliable source:
– 500 to 1,000 μg several times per week
– Based on 1% (passive) absorption
Melina V, et al. J Acad Nutr Diet. 2016;116:1970‐1980
Vitamin B‐12
• B‐12 Deficiency:
– Elevated homocysteine: CVD risk
– Macrocytic anemia: fatigue
– Nerve damage: tingling in fingers and toes
– Poor cognition, digestion, FTT
– Stroke, dementia, and poor bone health
• Metformin is associated with vitamin B‐12
deficiency: periodic testing is recommended.
Melina V, et al. J Acad Nutr Diet. 2016;116:1970‐1980
Diabetes Care 2018;41:S1‐159.
Key Nutrients of Concern (continued.)
• Calcium (1 c. milk has 96 mg absorbable Ca+); So do
these foods:
– ½ cup Chinese cabbage
– 1 cup Bok choy
– 1 ½ cups kale
– 5.5 oz. calcium‐set tofu
– 2 cups white beans
• Vitamin D:
– Sunlight exposure
– Fortified plant milk
– Mushrooms exposed to UV light
Presentation by Reed Mangels at 6th International Congress in Vegetarian
Nutrition Feb 26, 2013 “Bone Nutrients for Vegetarians”,
J Am Diet Assoc. 2009;109:1266‐1282
149/17/2018
Calcium in Foods
Food Serving Amount (mg)
Dried figs 10 figs 269
Total cereal, General Mills ¾ cup 250
Ca+ fortified orange juice 8 ounces 250
Collards, frozen, boiled ½ cup 179
Tofu, raw, firm ½ cup 130
Vegetarian baked beans 1 cup 128
Great northern beans, boiled 1 cup 120
Kale, boiled 1 cup 90
Navel orange 1 medium 52
Raisins, golden, seedless 2/3 cup 53
Broccoli, boiled 1 cup 72
Brussels sprouts, boiled 1 cup 46
Kale, boiled 1 cup 90 Pennington JAT. Bowes & Church’s
Food Values of Portions Commonly
Chick peas, canned 1 cup 77
Used. Lippincott, New York, 1998.
Kidney beans, canned 1 cup 69
Plant‐based Eating Pattern
for Diabetes
Principles of a Plant‐Based Eating Pattern
• Four Food Groups (no portion control):
• Whole Grains (5 or more)
• Legumes – beans, peas, and lentils (2 or more)
• Vegetables ‐ (4 or more)
• Fruits – (3 or more)
• Include 1 oz. of nuts and seeds
Diabetes Spectrum. 2012;25:39‐44.
159/17/2018
Principles of a Low‐Fat, PPN Eating Pattern,
continued
• Limit added vegetables oils and other high
fat foods.
• Low Glycemic Index (GI) such as oatmeal,
barley, quinoa, sweet potatoes, whole
grains, rye or pumpernickel bread, beans,
fruits, and vegetables.
Diabetes Spectrum. 2012;25:39‐44.
Principles of a Low‐Fat, PPN Eating Pattern,
continued
• Avoid all animal products (e.g., meat,
chicken, fish, eggs, all dairy)
• Take a Vitamin B12 supplement
• Choose High Fiber Foods
Fiber Intake (g/day)
Current Intake of Americans 15
Recommendations 25‐38
PBN Recommendation 40
Diabetes Spectrum. 2012;25:39‐44.
Macronutrient Mix
Barnard et al. Diabetes Care. 2006;29:1777‐1783.
Evert AB, et al. Diabetes Care. 2013;36:38213842.
De Souza RJ, et al. Am J Clin Nutr. 2008;88:1‐11.
169/17/2018
Low‐Carbohydrate/High Fat Diets
• Short term studies show significant ↑ in post
prandial glucose (OGTT) compared to a low fat
diet (69%).
• Prospec ve studies show ↑ in CVD and all‐
cause mortality.
• Fat displaces high‐fiber foods, ↓ quality.
• Increases pro‐inflammatory species in gut
Numao S, et al. Eur J Clin Nutr. 2012;66:926‐931.
Lagiou P. et al. BMJ. 2012;344:e4026.
Noto H, et al. PLoS One. 2013;8:e55030
Aren’t Carbohydrates Bad
for Diabetes?
Historical Eating Patterns
Rice and
Legumes in America, Rye in Asia
Europe, and Asia
Barley, Oats, Wheat in
Middle and Far East
Corn and Sweet
Potatoes in North,
Central, and South Millet and
America Sorghum in
Africa
179/17/2018
Okinawa Longevity Diet
Case Studies
Marc Ramirez
189/17/2018
Pre Plant‐Based Diet
Diagnosed with Type 2 DM
in 2002
Medications (2011)
Lantus, Simvastatin,
Lisinopril, Metformin, and
Januvia
9/9/2011 12/29/2011
Total Cholesterol (mg/dL) 164 104 PBD 12/3/11
Triglycerides (mg/dL) 192 111 Changes after
HDL‐C (mg/dL) 39 38 26 days
LDL‐C (mg/dL) 87 44
A1C (%) 10.5 8.1
2011 to 2018
Has lost 50 lbs
A1C=5.5%
He is currently
on no
medications
Application to Practice
199/17/2018
Clinical Practice Guidelines
American Diabetes Association
2009‐2018
“The Mediterranean,
Dietary Approaches to
Stop Hypertension (DASH),
and plant‐based diets are
all examples of healthful
eating patterns that have
shown positive results in
research….”
Standards of Medical Care for Type
2 Diabetes‐2015. Diabetes Care,
2018. 41:S1‐159.
209/17/2018
Barnard Medical Center
• Focuses on prevention and nutrition.
• Use nutrition to treat/reverse diabetes, heart disease, high
blood pressure, and other chronic diseases.
• MNT and DSMES
• Weekly nutrition classes
Adopting a Plant Based Diet
• 3‐week trial of 100% PBN eating:
– Take 2 weeks to plan and try meatless meals
and learn a few new recipes
– Short‐term commitment
– Motivating results
219/17/2018
Foods to Try
Breakfast
Lunch
Dinner
Snack
Foods to Try
Breakfast
• Oatmeal, strawberries, ½ oz. walnuts, soymilk
• Tofu scramble with onions, garlic, and peppers, and
roasted potatoes
Lunch
• Black bean chili, green salad, apple
• No-tuna on a pita with veggies, grapes
• Veggies pizza, hold the cheese
Dinner
• Pasta with marinara, add veggies or lentils, salad
• Stir fry with tofu and veggies, brown rice
Snack:
• Hummus with carrots, fruit,
What Should Patients Expect?
• Blood Glucose Changes:
– Hypoglycemia – review prevention, recognition,
and treatment
– Slow decrease in glucose over time
– Hyperglycemia – focus on low GI carbohydrates,
utilize carbohydrate counting for the interim
• Reduction in Blood Pressure
• Insulin and other medications may need
to be adjusted
229/17/2018
Why Do People Like It?
• No artificial calorie limits.
• No portion sizes.
• No carbohydrate‐counting – except in T1D
• Major health benefits
• May be able to reduce or get off meds (but
not everyone does)
• Improves insulin sensitivity
PCRM.ORG
Thank you
Q&A
Mjardine@pcrm.org
23You can also read
