Healthy Food: the only medicine we need to cure type 2 diabetes?

Transcription

1 Healthy Food: the only medicine we need to cure type 2 diabetes? Michael Dedekian, MD, FAAP Pediatric Endocrinology and Diabetes Breanna Lynch MS, RD, CDE Countdown to a Healthy ME AAA 1

2 Countdown to a Healthy ME Philosophy: Patients First and Patient Driven Children with Obesity not Obese Children Motivational Interviewing Focus on health not numerical values Reduce or stabilize BMI, prevent and treat related comorbidities No single strategy works for everyone

3 Part 1: Insulin resistance Outline - Is there a molecular reason we can t figure out which foods are best for human health? Part 2: Review of nutrition guidelines - What do our major professional societies tell us to do? Part 3: Food to cure type 2 diabetes - Is calorie restriction the answer? Part 4: Practical Advice - What do we tell families to do?

4 Part 1: Insulin Resistance Causes of Obesity: A complex storm GENES PARENTING Family History of Obesity, Diabetes, Early CVD, High LDL ENVIRONMENT School, Home, Neighborhood Obesogens BMI Knowledge, Limit Setting, Role Modeling MENTAL HEALTH Poor Self Esteem, Bullying, Depression HORMONES LIFE STYLE Insulin and Leptin Resistance FOOD QUALITY TV, Internet, Texting Low Physical Activity 4

5 Insulin Resistance: a common thread BMI Insulin Resistance PCOS: Metabolic Reproductive Syndrome Type 2 Diabetes Metabolic Syndrome 5

6 Insulin Resistance: What is it? Clinical definition is simpler than a molecular one: High blood sugar Abnormal glucose response to a given level of insulin Acanthosis, PCOS, hypertriglyceridemia 6

7 Insulin Action: what is suppose to happen Insulin VASCULAR SPACE G Insulin Receptor Glut 4 CELL MEMBRANE INTRACELLULAR SPACE 7

8 Insulin Resistance: a lot left to learn about Insulin VASCULAR SPACE G Insulin Receptor IRS-1 IRS-2 RESISTANCE! PI3K FOXO Glut 4 CELL MEMBRANE INTRACELLULAR SPACE Metabolism Cell Growth Organ Survival 8

9 Insulin Signaling Cascade Regulation of: Glucose, glycogen Lipids Proteins Apoptosis Mitochondrial biogenesis Food intake (behavior) Bone Growth Vascular dilation (BP) How does nutrition impact this complicated signaling cascade? With so many variables at play maybe it is not surprising we still debate what type of nutrition is best. 9

10 Prediabetes and type 2 diabetes Prediabetes is not well defined in pediatrics. ADA: A1C >=5.7%, <=6.4% OR WHO: A1C >=6.0% to <=6.4% Adolescents? Diabetes >=6.5%, random or post OGTT BG >= 200 Treatment of diabetes: medication and Food or lifestyle intervention, but what? How? 10

11 Part 2: Nutrition Guidelines 11

12 Treat with insulin if things are really bad. Then: 12

13 Educate at a young age, make institutional change, parental involvement, include nutrition AND physical activity, policy change that limit food availability

14 A.N.D. Position Statement Dietary approaches reviewed Low carb diet Reduced Glycemic Load Non diet approach Modified stoplight diet for children Very Low Calorie Diet Bariatric Surgery

15 A.N.D. Summary Summary: All approaches can be effective short term Long-term and large scale outcomes are unclear. What worked over time? Emphasizing and normalizing healthy foods vs. Structured meal plans 15

16 ADA recommendations 16

17 It is nonsensical that we re expected to prescribe these techniques to our patients while the medical guidelines don t include another better, safer and far cheaper method: a diet low in carbohydrates. 17

18 What happens in the real world? 10-17yo <2yr Type 2, BMI > 85 th 12% met goal of <10% total kcal from sat.fat (vs. 45% girls and 36% boys gen.pop) 11% met fruit goal (> 2 ) (vs.46% girls and 45% boys gen.pop) 5% met vegetable goal (>3) (vs.18% girls and 16% boys gen.pop) 3% met calcium goals (> 1300mg) 33% ate fast food 1x/week 31% ate fast food >2x/week

19 Part 3: Can Diet Alone Cure Diabetes? 19

20 A Very Low Calorie Diet 8 weeks of Optifast three times a day plus up to 240 g of nonstarchy vegetables per day kcal/day 1 week wean off of shakes to an isocaloric diet. Participants stopped all diabetes medications prior to starting the study. 20

21 OPTIFAST 800 Shakes Ready to Drink Chill and enjoy! Available in three flavors - French Vanilla, Chocolate, and Strawberry - OPTIFAST 800 Ready to Drink formula is a full meal replacement product. Nutritional Information Calories 160 Protein (g) 14 Carbohydrate (g) 20 Fat (g) 3 Sodium (mg) 220 Potassium (mg) 470 Fiber (g) 0 Vitamins & Minerals 10-30% of RDI Lactose (g) <1 624 calories of Optifast = 78 g carbohydrate = 55 g protein = 12 g fat 21

22 Diabetes resolved in 40% overall, 60% of those with short duration diabetes 22

23 Additional Observations Liver and insulin fat content: normalized in responders and non-responders with weight loss and remained constant. Laboratory measures of insulin resistance normalized in responders and non-responders with weight loss. In the UK historical population data demonstrates 1 in 3 cases of new onset type 2 diabetes were in adults with BMI <25 kg/m2 23

24 Dietary Fat Fructose Triglyceride Adipose Tissue Threshold Metabolic Syndrome Why is the threshold different in different people? Patients with normal BMI get T2DM (5-60%) Patients with very high BMI don t always get T2DM (30%) 24

25 Clinical Science Apr 01, 2015, 128(7) Personal Metabolic Threshold High BMI High BMI T2DM Lean with T2DM OBESE BMI Obese with T2DM Metabolic Threshold Low BMI Low BMI 25

26 Can we extend this simple model to communicate with families? Personal Metabolic Threshold Higher Food Intake Higher Food Intake OBESITY Child with Obesity Normal Weight Sibling Metabolic Threshold Lower Food Intake Lower Food Intake 26

27 Where does this leave us? Optifast for all? Limited data on caloric restriction in children and adolescents. Impractical for children and adolescents. Why did it work? Calories? Carbs? Other factors (eg. Microbiome?) But diabetes went away... And adolescents by definition have short duration disease 27

28 Part 4: Practical Nutrition Guidelines for Anyone with Type 2 Limited carbohydrates, spread throughout the day Always pair with a healthy protein/fat Restrict liquids with calories Meal/snack pattern- don t skip/don t graze

29 Special considerations in Children with Type 2 Diabetes Many outside influences Peers Drive thru/gas stations/fast food/concession stand School/Work place- How accurate are the carb counts at school? Are they available? Free/discounted food at the work place Family Dynamics Who buys the food? Where do they shop? What cooking skills do they have? Do the adults eat balanced meals? The skinny sibling problem

30 Nutrition Resources

31 Nutrition Resources

32 Nutrition Resources

33 Daily Meal Plan Breakfast (45-60g CHO) 2 premade egg muffins with 2% cheese and veg (0g) 1 whole wheat english muffin (30g) Banana (30g) Snack (15-30g) Trail mix (30g) Lunch (45-60g) School wrap (35g) with grilled chicken/lettuce/mustard G2 (15g) ½ c cottage cheese and cucumbers from salad bar (<10g) Snack (15-30g) Peanut butter and jelly Smoothie (ice/1c frozen raspberries(15)/1t pb(4)/unsweetened vanilla almond milk) Dinner (45-60g) Pulled pork open faced sandwich (30g) Roasted veggies (15g) 1cup milk (12g)

34 Is food the only medicine we need to cure type 2 diabetes? Maybe in a perfect world for young patients. How do we tackle all the barriers to using food alone? Behavior change, MI is slow, is it too slow for some of our sickest patients? What we say: reduce all carbs to grams per meal, the closer to 30 the better. Limited snacks of 15 grams of carbs or less. 34

35 Michael Dedekian MD Breanna Lynch RD CDE Thank You! AAA 35