1 / 61

Food as Medicine for Obesity and NIDDM

Food as Medicine for Obesity and NIDDM. Ghana - FIESTA September 14 th -16 th , 2016. SC Ganguli MD FRCPC Gastroenterology Division McMaster University. Global Trends in BMI since 1980 (1980-2008). Men. Women. SCG 2016. Lancet 2011:377:557-67.

dinag
Download Presentation

Food as Medicine for Obesity and NIDDM

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Food as Medicine for Obesity and NIDDM Ghana - FIESTA September 14th-16th, 2016 SC Ganguli MD FRCPC Gastroenterology Division McMaster University

  2. Global Trends in BMI since 1980(1980-2008) Men Women SCG 2016 Lancet 2011:377:557-67

  3. Global Trends in BMI since 1980(Africa 1980 to 2008) Men Women SCG 2016 Lancet 2011:377:557-67

  4. BMI and all-cause mortality(Global, Non-smokers, healthy, after 5 yrs) Hazard Ratio SCG 2016 Body Mass Index Lancet 2016 in press http://dx.doi.org/10.1016/S0140-6736(16)30175-1

  5. Adult Prevalence of Diabetes(Global, 1980-2014) Men Women SCG 2016 Lancet 2016:387:1513-1530

  6. Prevalence of Diabetes in Ghana Prevalence (%) SCG 2016 Lancet 2016:387:1513-30

  7. RCT of lifestyle vs metformin in Prediabetics: DPP Aim Does a lifestyle intervention or treatment with metformin prevent or delay the onset of diabetes ? Design Multicenter RCT, Placebo controlled, double blind. ITT analysis Population (n=3234) meeting all the below criteria: 1) BMI ≥ 24 2) Fasting [Glu] = 5.3 – 6.9 mmol/L 3) 2 hr [Glu] = 7.8 – 11.0 mmol/L after 75g oral glucose load SCG 2016 Knowler WC, NEJM 2002;346:393-403

  8. RCT of lifestyle vs metformin in Prediabetics: DPP Interventions • Standard lifestyle recommendations + Metformin 850 mg BID • Standard lifestyle recommendations + placebo • Intensive lifestyle modification (Goal: achieve/maintain 7% weight reduction) • Moderate physical activity for ≥ 150 minutes per week • Diet: ‘healthy low calorie, low fat diet’ Outcomes – Dx of diabetes (retested at 6 weeks): • Annual oral glucose tolerance test • Semi-annual fasting glucose SCG 2012 Knowler WC, NEJM 2002;346:393-403

  9. DPP: Change in Weight Wt Loss (Kg) 0.1 2.1 5.6 P<0.001 Years Intervention SCG 2016 Knowler WC, NEJM 2002;346:393-403

  10. DPP: Change in Physical Activity SCG 2012 Knowler WC, NEJM 2002;346:393-403

  11. DPP: Incidence of Diabetes NNT (3 yrs) MF = 13.9 Lifestyle = 6.9 SCG 2016 P < 0.001 for each comparison Knowler WC, NEJM 2002;346:393-403

  12. DPP: Glycosylated Hemoglobin SCG 2012 P < 0.001 Knowler WC, NEJM 2002;346:393-403

  13. LTM outcomes (15 yrs): DPPOS In light of the clear evidence of benefit in the lifestyle intervention, all participants were offered the lifestyle intervention in a group format during a 1 year bridge period between DDP and DPPOS. Then maintenance group lifestyle sessions were offered quarterly to all DPPOS participants reinforcing the basic lifestyle content and weight loss and physical activity goals. In addition to maintenance sessions, participants originally assigned to the lifestyle intervention were offered supplementary group programs and an individual lifestyle check-in each twice a year. SCG 2012 DM Nathan Lancet Diabetes Endocrinol 2015:3:866-75

  14. DPPOS & DPP Outcomes at endRate of Developing Diabetes at 15 yrs * * Percent # * * * P < 0.05 vs Placebo # P < 0.05 vs Metformin SCG 2016 DM Nathan Lancet Diabetes Endocrinol 2015:3:866-75

  15. DPPOS & DPP Outcomes at endHbA1c # * Percent * # * * P < 0.05 vs Placebo # P < 0.05 vs Metformin DM Nathan Lancet Diabetes Endocrinol 2015:3:866-75

  16. What to do ? SCG 2012

  17. Incidence Diabetes ITT: (Exercise + diet) vs Standard Rx SCG 2012 ARR = 10.4% NNT = 10 Orozco LJ, Cochrane 2008 Issue 3

  18. Diabetes prevention & types of exercise Aim: Assess influence of aerobic exercise and weight training on risk of NIDDM Design: Prospective cohort study of 32,002 men (Health Professionals followup study) followed from 1990-2008 (508,322 person-yrs): a) Weekly time doing aerobic exercise, weight training b) Assessed at baseline and q 2 yrs for 18 years Analysis: Multivariate adjusted models SCG 2012 A Grontved Arch IM 2012:172(17):1306-12

  19. Weight Training, Exercise & Risk NIDDM(Adjusted for each other) Relative Risk SCG 2016 Time per week (minutes) A Grontved Arch IM 2012:172(17):1306-12

  20. Glycemic Index Different carbohydrate foods have different effects on blood glucose and can be ranked by the overall effect on blood glucose levels using the glycemic index. By resulting in a slower supply of glucose to the bloodstream, low GI foods may result in improved glycemic control. Glycemic load represents the overall glycemic effect of the diet and is calculated by multiplying the GI by the grams of carbohydrates. SCG 2012 Thomas D, Cochrane Library 2009 Issue 1

  21. HbA1c: Low GI/Glycemic Load diets for Diabetes Wks 12 24 52 6 4 4 NIDDM adult IDDM adult IDDM kids NIDDM adult NIDDM female NIDDM male SCG 2012 Thomas D, Cochrane Library 2009 Issue 1

  22. Efficacy of Oral Agents & Low GI Diet HbA1c Change SCG 2016 Thomas D, Cochrane Library 2009 Issue 1 AJ Krentz Drugs 2005;65(3):385-411

  23. Is that all ? SCG 2012 3

  24. Red Meat Consumption & NIDDM Prospectively followed 37,083 men (Health Professionals follow-up study, 1986-2008) & 79,570 women (Nurses Health Study I 1976-) plus 87,504 (NHS-II, 1989-) who were free of CV disease and cancer at baseline. Diet assessed by validated questionnaire & updated every 4 years. Excluded baseline IDDM & NIDDM, CVD, cancer Aims 1) Assess effect of meat consumption on NIDDM in large cohorts 2) Updated meta-analysis 3) Estimate effect of substituting low fat dairy, nuts, whole grains for red meat on NIDDM risk Used data from present study to update previous meta-analyses Multivariate adjustments for major lifestyle & dietary risk factors. SCG 2016 A Pan Am J Clin Nutr 2011;94:1088-96

  25. Red Meat Consumption & NIDDM Multivariate analysis to adjust for: • Intakes of : total energy (in quintiles) • Age, BMI • Race (white, nonwhite) • Smoking status (never, past, current [3 ranges]) • EtOH intake (0 plus 3 levels) • Physical activity (5 levels) • Family Hx: DM • Baseline history of Htn, hypercholestrolemia • Women: postmenopausal status, menopausal hormone & OCP use SCG 2012 A Pan Archives IM 2012 epub

  26. Red Meat & NIDDM: Results Incident cases of NIDDM: - 2438 during max 20 y followup in HPFS = 1.9% - 8253 during max 28 y followup in NHS-I = 2.0% - 3068 during max 16 y followup in NHS-II = 1.1% Overall 13,759 cases out of 803,001 = 1.7% Definitions of a meat portion: Unprocessed red meat = 85g = 3 oz Hot dog = 45 g Bacon = 28g (2 slices) Other processed red meat = 45 g SCG 2012 A Pan Am J Clin Nutr 2011;94:1088-96

  27. Total Red Meat & NIDDMAdjusted for: BMI, Age, Calorie intake Physical activity, smoking, EtOH, race Increase in Hazard Ratio (%) Portions per day SCG 2012 A Pan Am J Clin Nutr 2011;94:1088-96

  28. Red Meat Consumption & NIDDMEffect of a 1 serving per day increase Increase in Hazard Ratio (%) SCG 2012 A Pan Am J Clin Nutr 2011;94:1088-96

  29. NIDDM: Replacing Red MeatResult of replacing 1 serving/day with other food groups SCG 2012 A Pan Am J Clin Nutr 2011;94:1088-96

  30. Meta-analysis: Unprocessed Red MeatHR for 100gunprocessed meat & NIDDM SCG 2012 A Pan Am J Clin Nutr 2011;94:1088-96

  31. Meta-analysis: Processed Red MeatHR for 50 gprocessed meat & NIDDM SCG 2012 A Pan Am J Clin Nutr 2011;94:1088-96

  32. Red Meat Consumption & NIDDM • 100 g/day unprocessed red meat increase is associated with a 19% increased risk of NIDDM (consistent with other studies) • 50 g/day of processed red meat is associated with a 51% increased risk of NIDDM • Possible mechanisms: 1) Heme iron 2) Increase in BMI 3) Processed meats – Na, nitrosamines • Strengths of study: large sample size, good follow-up, repeated assessments of diet & lifestyle variables. • Drawbacks: 1) Population mainly of European ancestry (generalizability) 2) Association not same as causation (observational study) SCG 2012 A Pan Am J Clin Nutr 2011;94:1088-96

  33. Red Meat Consumption & OutcomesEffect of a 1 serving per day increase Increase in Hazard Ratio (%) SCG 2012 CVD = cardiovascular disease A Pan Archives IM 2012 172(7):555-63

  34. Adventist Study 1960-1981Meat & Diabetes (Logistic regression) SCG 2014 DA Snowdon Am J Public Health 1985:75:507-12

  35. Comparison of Diets SCG 2012

  36. Nutrient Profiles of Vegetarian & Non-vegetarian Dietary Patterns Aim: To compare nutrient intakes between dietary patterns characterized by consumption or exclusion of meat and dairy products Cross-sectional study of 71,751 subjects (mean age 59 yrs) from the Adventist Health Study 2. Data collected between 2002 and 2007 204 item validated semi-quantitative food frequency questionnaire Dietary patterns: non-vegetarian, semi-vegetarian, pesco vegetarian, lacto-ovo vegetarian, strict vegetarian. SCG 2013 J Acad Nutrition & Dietetics 2013:113:1610-1619

  37. Dietary Patterns Non-vegetarian: (meat + fish) > 1/week with red meat/poultry at least once/month Semi-vegetarian: (meat + fish) one or more times per month but less than 1/week Pesco-vegtarians: fish >= 1/month, but red meat/poultry < 1/month (OK – dairy/egg) Lacto-ovo: (meat + poultry + fish) < 1/mo, OK eggs/dairy Strict: less than 1/mo of: meat (red/poultry), fish, eggs, milk, dairy SCG 2016 J Acad Nutrition & Dietetics 2013:113:1610-1619

  38. Dietary mean protein intakes. USDA SCG 2013 J Acad Nutrition & Dietetics 2013:113:1610-1619

  39. Total Calorie Intake[Mean, 5th and 95th %ile] Calories (g/day) SCG 2013 J Acad Nutrition & Dietetics 2013:113:1610-1619

  40. Body Mass Index BMI SCG 2013 P < 0.001 J Acad Nutrition & Dietetics 2013:113:1610-1619

  41. RCT Primary Prevention of Diabetes with a Mediterranean Diet Population: (n=418) Individuals 55-80 yrs (M 55-80, F 60-80) without CV disease at baseline and 3 of: (smoking, Htn, inc LDL, low HDL, overweight/obese, FH premature CAD). Intervention (1:1:1): • Advice to reduce dietary fat • Mediterranean diet + extra-virgin olive oil • Mediterranean diet + nuts Outcomes: Primary: New onset NIDDM as per ADA criteria (confirmed) Occurred in 54 participants (12.9%). SCG 2016 J Salas-Salvado. Diabetes Care 2011:34:14-19

  42. RCT Mediterranean Diet to Prevent Diabetes Rates Diabetes Control = 17.9% Med + oil = 10.1% Med + nuts = 11.0% NNT = 13 SCG 2016 J Salas-Salvado. Diabetes Care 2011:34:14-19

  43. What about individuals who already have diabetes ? SCG 2012

  44. RCT Vegan vs ADA diet in NIDDM Population (n=99) NIDDM, using hypoglycemic medications at least 6 mos. - had to have HBA1c between 6.5% and 10.5% - if on insulin had to be using it < 5 yrs Intervention (22 weeks then to 74 weeks) Vegan: 10% of energy from fat. Encouraged to favor low GI foods. No restrictions on portion size, energy or CHO intake. B12 pill given. ADA diet: Individualised based on body weight, lipid concentrations. If BMI > 25 also prescribed energy intake deficit of 500-1000 cal/day All participants asked NOT to alter their exercise habits during the intervention period Both groups started with 1 h with dietician then weekly 1 hr meetings for nutrition/cooking instruction. Did unannounced 24 hr diet recalls at weeks 4, 8, 13, 20 SCG 2016 Barnard ND Diabetes Care 2006:29:1777-83 Barnard ND Am J Clin Nutrition 2009:89 sup: 1588S-96S

  45. RCT Vegan vs Std Diabetic Diet in NIDDM SCG 2012 P = 0.03 Am J Clin Nutrition 2009:89sup:1588S-1596S

  46. RCT Vegan vs ADA diet in NIDDMChange in HBA1c (74 wks) P = 0.03 HBA1C Reduction (%) SCG 2016 Barnard ND Am J Clin Nutrition 2009:89 sup: 1588S=96S

  47. RCT Vegan vs ADA diet in NIDDMChange in weight & BMI (74 wks) Change (KG, BMI) SCG 2016 Barnard ND Am J Clin Nutrition 2009:89 sup: 1588S=96S

  48. RCT Vegan vs ADA diet in NIDDMChange in Lipids (74 wks) P = 0.03 P = 0.01 Lipid Reduction (mg/dL) SCG 2016 Barnard ND Am J Clin Nutrition 2009:89 sup: 1588S=96S

  49. RCT Vegan vs ADA diet in NIDDM Conclusions • Both a low fat vegan and the ADA 2003 diet resulted in long term weight reduction • When controlling for medication changes the vegan diet was more effective for control of glycemia and plasma lipid concentrations. SCG 2014 Barnard ND Diabetes Care 2006:29:1777-83 Barnard ND Am J Clin Nutrition 2009:89 sup: 1588S=96S

  50. Meta: Vegetarian Diets & Diabetes Control P = 0.001 P for heterogeneity = 0.389 Overall mean drop in HbA1c of 0.39% SCG 2016 Y Yokoyama. Cardiovasc Diagn Ther 2014:4(5):373-382

More Related