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Nutrition and Diabetes: Current Controversies

Nutrition and Diabetes: Current Controversies. James L. Rosenzweig, MD Director of Diabetes Services Boston University 12/2/11. Major Diabetes Nutrition Issues. Does it affect blood glucose control? Does it increase or decrease the risk for atherosclerosis?

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Nutrition and Diabetes: Current Controversies

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  1. Endocrine Society 12/2/11

  2. Nutrition and Diabetes: Current Controversies James L. Rosenzweig, MD Director of Diabetes Services Boston University 12/2/11 Endocrine Society 12/2/11

  3. Major Diabetes Nutrition Issues • Does it affect blood glucose control? • Does it increase or decrease the risk for atherosclerosis? • Does it affect weight? Endocrine Society 12/2/11

  4. Diabetes Nutrition Controversies • High Fructose Corn Syrup • Diet Drinks • Caffeine • Omega-3 fats and diabetes • Vitamin D Endocrine Society 12/2/11

  5. High Fructose Corn Syrup;What’s the big deal? Fructose is a monosaccharide It doesn’t raise blood glucose directly, but indirectly from conversion in the liver Fructose is also converted to glycogen (starch) and fats in the liver It is found in fruits, sucrose (table sugar) honey, agave syrup, maple syrup, brown rice syrup, vegetables. Found in HFCS, a commercially prepared sweetener, developed from corn Endocrine Society 12/2/11

  6. High Fructose Corn Syrup;What’s the big deal? • There are two types of HFCS- • HFCS 55 (55% fructose and 42%glucose) • HFCS 42 (42% fructose and 52%glucose) • Used in baked goods, prepared foods, breakfast cereals, frozen desserts, yogurt, sweetened beverages, etc. • The use of HFCS has steadily increased in the past 30 years, while consumption of sucrose has decreased. Endocrine Society 12/2/11

  7. Comparison of Sweetener Compositions Endocrine Society 12/2/11

  8. Possible Areas of Harm with Fructose Link with high consumption to obesity Associated with increase in serum triglycerides, when compared with glucose Women who drank fructose-sweetened beverages had lower levels of leptin and higher levels of ghrelin, two hormones associated with appetite control (controversial, not backed up by other studies.) May be associated with higher levels of uric acid in men—a risk factor for gout, kidney stones, atherosclerosis Endocrine Society 12/2/11

  9. Possible Areas of Harm with Fructose Possible link with hypertension: Data from National Health and Nutrition Examination Study showed association of 74g/day intake with 77% higher risk of substantial blood pressure elevation Recent study at U. of California showed higher levels of lipids, abdominal adipose tissue, and fasting glucose when fructose containing beverages were consumed instead of glucose Studies associate fructose consumption with non-alcoholic fatty liver disease (NAFLD) Endocrine Society 12/2/11

  10. Conflicting Results In a number of large studies of diet and disease risk, fructose not associated with hypertension, and no difference in risk factors when HFCS or sucrose compared with milk, artificially sweetened drinks (Netherlands) No difference between sucrose and HFCS on appetite hormones (U. of RI) Endocrine Society 12/2/11

  11. Take-Home Messages No evidence for increased risk of use of HFCS when compared to table sugar. There is nothing unique about HFCS with respect to risk of obesity and diabetes Fructose itself may have specific metabolic risks when compared with glucose as a sweetener, including worsening lipid profile, increasing obesity risk, hypertension and uric acid, but it is found everywhere, often in “healthy” foods Fructose use has advantages in diabetes with respect to glucose control Endocrine Society 12/2/11

  12. Further Messages • The ADA does not recommend fructose as an added sweetener in diabetes because of its adverse effects on plasma lipids but encourages fruit intake • The ADA, however, recommends that sucrose does not need to be restricted, and can be substituted for other carbohydrates • 20% of adults average more than 120 g/day added sugar (33 tsp/day, 480 calories) Half is fructose • 25% of children average more than 150 g/day added sugar (48 tsp, 600 calories) Half is fructose Endocrine Society 12/2/11

  13. Diet Soft Drinks and Diabetes No Calories Have long been a staple of dietary treatment of patients with diabetes Recent Studies have suggested that they may have other, less beneficial effects. Endocrine Society 12/2/11

  14. Current Sweeteners • Saccharin • Aspartame, since 1981 (200x) • Acesulfame K (Sunnet and Sweet One) (180x) • Sucralose (Splenda) 600x • Stevia, a natural product extracted from an herb • Neotame, recently approved (6000-13000x) • Alitame (not yet approved, stable in baking and cooking • Cyclamate (banned in 1969 because of small association with bladder cancer in rats. Available in 55 countries Endocrine Society 12/2/11

  15. Sweetener Controversies FDA acceptable daily intakes are huge (18 cans of diet soda containing aspartame, 32 cans containing acesulfameK, 6 cans of sucralose, 12 packets of saccharin) Blamed for a variety of health concerns—headaches, allergies, digestive problems, neurological disorders, cancer---association largely unproven Up until recently, NO clear association of use with weight loss One large study showed that drinking one or more servings of diet soda was associated with 67% increased risk of developing type 2 diabetes. Endocrine Society 12/2/11

  16. Sweetener Controversies Women’s Health Study showed increased renal kidney function decline with consumption of at least two diet sodas daily Two studies show association of 1 or more servings with 35% increased risk of developing metabolic syndrome (combination of increased risk for CVD and diabetes) High use of aspartame associated with worse glucose control in one study Several sweeteners may work in the brain to stimulate appetite, but may increase production of GI hormones (GLP-1) which can affect satiety. Endocrine Society 12/2/11

  17. Take-Home Messages Artificial sweeteners are extremely helpful in patients with diabetes as aids for glucose control Their use in weight loss, and effects on cardiovascular risk, are more controversial It is not clear whether widespread use in the general population is of benefit or harm, from the perspective of public health The sweeteners should not be “lumped” together. Different agents may have different effects. Endocrine Society 12/2/11

  18. Caffeine Controversies • 17 studies have shown that caffeine can decrease the body’s sensitivity to insulin (increase insulin resistance) in people without diabetes • Two cups of instant coffee can increase the rise in blood glucose after an iv glucose test • Caffeine raised the average blood glucose in patients with diabetes using CGM Endocrine Society 12/2/11 18

  19. Epidemiological Studies • A large study of 17,111 men and women without diabetes indicated that those who drank 7 or more cups of coffee per day were half as likely to develop type 2 DM • The study was adjusted for confounding variables, like weight, physical activity, alcohol, smoking • A meta-analysis of 18 studies involving 450,000 people found that each daily cup of coffee is associated with a 7% lower risk of diabetes • Is it something other than caffeine that is beneficial? Endocrine Society 12/2/11 19

  20. Omega 3 Fats and Diabetes Omega -3 PUFA is found principally in fish, flax seed oils, and walnuts Known to have anti-inflammatory and anti-coagulant properties Early studies appeared to show Omega-3 increased insulin resistance, potentially worsening blood glucose control A more recent large meta-analysis shows no effect on insulin sensitivity Recent studies show major benefits on cardiovascular risk prevention in diabetes Recent presentation at Renal Meetings showed marked prolongation of graft patency with Omega-3 treatment Endocrine Society 12/2/11 20

  21. Vitamin D and Diabetes 25% of American population is vitamin D deficient Vitamin D deficiency is associated with an increased risk of type 1 diabetes In one study with patients with LADA (latent autoimmune diabetes of adults) vitamin D in combination with insulin protected the beta cells (which make insulin) from further damage Vitamin D reduces insulin resistance in a number of studies, and treatment reduces markers of insulin resistance There is an increased association of vitamin D deficiency with type 2 diabetes Endocrine Society 12/2/11 21

  22. Vitamin D and Diabetes There is an increased association of diabetes and osteoporosis A study of vitamin D with yogurt improved markers of vascular disease in patients with type 2 diabetes Major study, VITAL, will evaluate effects of Omega 3 fats and vitamin D on prevention of CVD and cancer, as well as diabetes There is no question that vitamin D deficiency is especially harmful in both type 1 and type 2 diabetes: The question is, are the appropriate levels of vitamin D the same for patients with diabetes and other individuals, and is the necessary replacement dose different? Endocrine Society 12/2/11 22

  23. Special Thanks to: Karen Chalmers, RD, CDE Diabetes Education Program Manager Boston University School of Medicine

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