Which diet is best for managing Type 2 Diabetes? Dr Rob Andrews Consultant Senior lecturer University of Bristol / Taunton NHS trust

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1 Taunton and Somerset NHS foundation trust NHS Which diet is best for managing Type 2 Diabetes? Dr Rob Andrews Consultant Senior lecturer University of Bristol / Taunton NHS trust

2 If people let government decide what foods they eat and what medicines they take, their bodies will soon be in as sorry a state as are the souls of those who live under tyranny. Thomas Jefferson third President of the United States ( )

3 Consensus statement of the ADA & EASD Therefore, our consensus is that metformin therapy should be initiated concurrently with lifestyle intervention at diagnosis. Medical Management of hyperglycaemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy. Nathan et al Diabetes Care 32 ;

4 Current suggested pathway Step 1 At diagnosis: Metformin + lifestyle Step 2 Well validated Less validated Lifestyle + metformin + basal insulin Lifestyle + metformin + Sulph Lifestyle + metformin + Pio Lifestyle + metformin + GLP-1 agonist Step 3 Lifestyle + metformin + intensive insulin Lifestyle + metformin + Pio + Sulp Lifestyle + metformin +bas insulin

5 Diet in patients with Type 2 Diabetes I think diabetes is affecting my eyesight I have trouble seeing the consequences of poor food choices

6 Dietary recommendations

7 Percentage patients reaching dietary recommendations Recommendation % Total carbohydrate 45-60% 38.1 Protein (no greater than 1g protein / kg body weight) 65.3 Total fat (<=35% total energy intake) 57.9 Saturated and trans fats (together <10% energy) 22.6 Minimum 5 portions fruit and vegetables 34.1 Ate oily fish 42.7 Vitamin D (based on European recommendations of 5ug) 32.5 Based on analysis of food diaries for 329 newly diagnosed patients with T2DM. England & Andrews unpublished

8 Food intake Vitolins et al, J Am Diet Assoc Aug;109(8):

9 Low calorie diets Commercial Diets Bulking Diets Patient led Diets Types of diet Med/Exchange Diets Macronutrient Diets GI diets

10 Low Carbohydrate diet Wt no Follow up 56% Ajala et al Am J Clin Nutri 2013:97:505

11 High protein diets Ajala et al Am J Clin Nutri 2013:97:505

12 Low GI diets Follow data 64% Ajala et al Am J Clin Nutri 2013:97:505

13 Mediterrinean diets Ajala et al Am J Clin Nutri 2013:97:505

14 Low calorie diets Commercial Should work Diets Bulking Research On Diets going Patient led Diets Types of diet Med/Exchange Diets Macronutrient Diets GI diets

15 Low calorie diets Tell me more about the acupuncture diet? Does it really work?

16 Low calorie diet 11 patients Low Calorie diet of 600 cal for 8 weeks Lim et al, diabetologia 2011, 54:2506

17 Low calorie diet Lim et al, diabetologia 2011, 54:2506

18 A larger study - participants Baseline characteristics of participants Males Females All n (%) 17 (18.7) 74 (81.3) 91 (100.0) Age, years (SD) 47.4 (11.4) 45.4 (10.6) 45.7 (10.7) Height, cm (SD) (8.4) (7.0) (8.9) Weight, kg (SD) (31.9) (20.7) (25.2) BMI, kg/m 2 (SD) 49.6 (10.3) 47.6 (6.8) 48.0 (7.6) Lean et al, Br J Gen Pract 2013 Feb:63

19 A larger study - protocol Lean et al, Br J Gen Pract 2013 Feb:63

20 A larger study weight loss Lean et al, Br J Gen Pract 2013 Feb:63

21 Weight loss 12 months A larger study weight loss Patients who continued to weight maintenance Patients who withdrew during food introduction Numbers O to + 10 Kg to O to >10 kg loss 36 9 No data 3 20 Mean loss Lean et al, Br J Gen Pract 2013 Feb:63

22 Summary low calorie diet Seems promising But Very intense High drop out Little data in Diabetes No long term data

23 Patient led diets Of course doughnuts are good for you. They re hole grain!

24 Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial.

25 Aims 1. What are the affects of an Intense diet program early on in T2DM? 2. What are the affects of an Intense diet plus activity program early on in T2DM? 3. Is a diet plus activity program better than a diet alone program?

26 Primary Outcomes Glycaemic control Blood Pressure Glucose control Blood pressure

27 Secondary Outcomes Weight Insulin Resistance Psychological Outcomes Insulin resistance Wellbeing Number tablets

28 Early ACTID Real World Trial Took all-comers Non-prescriptive diet Simple activity intervention

29 Diet Doctor as for usual care Nurse monthly, dietitian 3 monthly Utilised goal orientated motivational interviewing Aimed to get a 5% wt loss 19 visits

30 Diet + activity Doctor and Dietitian visits as for Diet arm Based on motivational interviewing Aim to increase walking by 30 minutes per day on 5 days per week 19 Visits

31 Methods overview visits Randomisation N Care Diet Diet & activity Do N Dt Do N Dt Do N Dt Do= doctor N = nurse Dt = Dietitian Extra 6.5 hrs Extra 6.5 hrs

32 Participants consort diagram Contact (too late, not T2DM) eligible screening (8 DNA, 4 decided not to continue) Consent visit (DNA, weight, too poor control) N Care Diet Diet & Activity Randomisation v moved 1 withdrew 2 moved 1 withdrew 2 moved 4 withdrew 6 month measure 579 (98%) moved 2 withdrew 1 death 1 unable To attend 12 month measure 573 (97%)

33 Early ACTID - Demographics Mean Age (yrs) Male sex 385 (65%) White 567 (96%) Diabetes medication 228 (38%) BP medication 365 (62%) Weight (kg) HbA1c (%) Blood pressure (mmhg) 134/7 + 15/8 Andrews, Lancet Jul 9;378(9786):129-39

34 Minutes of moderate activity Activity across the study Diet + act Usual Diet Months Andrews, Lancet Jul 9;378(9786):129-39

35 Change in weight (kg) Changes in weight across study Usual Diet Diet + act Months Andrews, Lancet Jul 9;378(9786):129-39

36 Change in HbA1c % Diabetes control Usual Diet Diet + act Months 6 months Difference P value D vs D + A D vs U D + A vs U < months Difference P value D vs D +A D vs U D +A vs U <0.0001

37 % change in DM medication Changes in diabetes medication Usual Diet Diet + act Months Andrews, Lancet Jul 9;378(9786):129-39

38 % change in Insulin resistance Change in Insulin resistance Usual Diet Diet + act Months Andrews, Lancet Jul 9;378(9786):129-39

39 Summary Diet + activity Diet and Diet + Activity programmes improve diabetes control, IR and reduce tablet use If Diet is done well it is a good as diet + Activity Diet should be first line

40 Results: changes to nutrients Men (blue) reduced energy by 218±332kcal (p<0.001) Women (pink) reduced energy by 123±270kcal (p<0.001)

41 Changes in mean energy intakes from food groups: men (n=175) England et al 2013 in press

42 Changes in mean energy intakes from food groups: women (n=87) England et al 2013 in press

43 Summary patient led diet Well adhered to The changes made amount to 200 calories Men make different changes to women Small changes can have profound effects

44 Low calorie diets Commercial Diets Bulking Diets Patient led Diets Types of diet Med/Exchange Diets Macronutrient Diets GI diets

45 Which diet is best for diabetes? One that is spare, sensible and taken with exercise; a diet for which pharmacotherapy Is an adjunct, rather than a substitute. A diet that the patient believes in. EAM Gale 2008

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