Meeting News

Emphasize patient adherence, dietary patterns in recommending diets for patients with diabetes

CHICAGO — While diets that emphasize increasing or decreasing a single nutrient class, such as high-carbohydrate or low-fat diets, are trending in the news, a researcher at the American Heart Association Scientific Sessions said the best diet for patients with diabetes is one that fosters adherence and incorporates the patient’s values and treatment goals.

“I think there’s no clear advantage of a low-carb over high-carb [diet]. Neither one has a monopoly on the evidence,” John L. Sievenpiper, MD, PhD, FRCPC, associate professor in the department of nutritional sciences at the University of Toronto and staff physician in the division of endocrinology and metabolism at St. Michael’s Hospital, said during a presentation. “But that being said, I don’t think low carb is off the table. I think it’s a viable option. It’s just one more dietary pattern tool we put in our toolbox because there are patients where that will fit with their values and preferences and may produce some results.”

Sievenpiper cited two low-carb vs. high-carb diet studies led by Kevin D. Hall, PhD, that tested the predictions of the carbohydrate-insulin model. In the studies, Hall found that the low-carb diet led to a decrease in insulin and an increase in fat oxidation, which was expected. However, “this did not relate to an increase in energy expenditure, which was predicted by the model,” Sievenpiper said.

He also highlighted research led by Christopher D. Gardner, PhD, comprising more than 600 patients that did not find any differences at 1 year between those on “healthy” high- vs. low-carbohydrate diets. Similarly, a meta-analysis of 48 randomized controlled trials with more than 7,000 participants led by Bradley C. Johnston, PhD, showed no significant differences between these diets at 1 year. Sievenpiper also noted that an analysis of randomized trials found no significant differences in HbA1c at 1 year among patients with type 2 diabetes on high- vs. low-carbohydrate diets.

Regarding CVD and mortality, he said an analysis of the PURE trial found an increase in overall mortality and CV mortality with increasing carbohydrate intake. However, he noted many patients were from low- and middle-income countries, which may have impacted the results. In addition, Sievenpiper said other studies have found lower CV mortality with diets rich in legumes and fruit.

Moreover, prospective cohort and high-level evidence studies have consistently shown improved outcomes with diets that focus on carbohydrate quality vs. quantity.

“I’d focus on carb quality rather than quantity. Glycemic index and low GL, food-based approaches such as whole grains, pulses, fruit and fiber, and the patterns that include those like the Mediterranean diet, the DASH diet [and] so on, provide the best evidence for benefit,” Sievenpiper said.

He said clinical practice guidelines are shifting away from a reductionist model to provide choices for patients with diabetes and allow physicians to have discussions with patients about their options.

“[We] are moving away from a one-size-fits all and moving away from this focus on single nutrients toward food and dietary pattern-based approaches,” Sievenpiper said.

“There probably isn’t any one best diet for CVD or diabetes. We have a number of different diets with evidence of advantages and disadvantages, and we have to align that with the values, preferences and treatment goals of our patients,” he added.

Regardless of the diet chosen, he highlighted that adherence is an important determinant of retaining the benefits of any diet.

“Health professionals should advise patients on evidence-based dietary patterns which align best with values, preference and treatment goals of the patients to find the one they can adhere for the long term,” Sievenpiper said. – by Gina Brockenbrough, MA

Reference:

Sievenpiper JL, et al. Abstract 1286. Presented at: American Heart Association Scientific Sessions; Nov. 10-12, 2018; Chicago.

Disclosure: Sievenpiper reports research support from the Almond Board of California, American Peanut Council, California Walnut Commission, Kellogg Canada, Loblaw Companies, Quaker, Unilever, Unico/Primo and WhiteWave Foods; receives honoraria from Abbott, the GI Foundation and Nestle; is a consultant/advisory board member for the European Fruit Juice Association, Tate & Lyle, and Wirtschaftliche Vereinigung Zucker e.V; is director of Toronto 3D Knowledge Synthesis and Clinical Trials Foundation; and is an unpaid science advisor for the Technical Committee on Carbohydrates of the International Life Science Institute North America.

CHICAGO — While diets that emphasize increasing or decreasing a single nutrient class, such as high-carbohydrate or low-fat diets, are trending in the news, a researcher at the American Heart Association Scientific Sessions said the best diet for patients with diabetes is one that fosters adherence and incorporates the patient’s values and treatment goals.

“I think there’s no clear advantage of a low-carb over high-carb [diet]. Neither one has a monopoly on the evidence,” John L. Sievenpiper, MD, PhD, FRCPC, associate professor in the department of nutritional sciences at the University of Toronto and staff physician in the division of endocrinology and metabolism at St. Michael’s Hospital, said during a presentation. “But that being said, I don’t think low carb is off the table. I think it’s a viable option. It’s just one more dietary pattern tool we put in our toolbox because there are patients where that will fit with their values and preferences and may produce some results.”

Sievenpiper cited two low-carb vs. high-carb diet studies led by Kevin D. Hall, PhD, that tested the predictions of the carbohydrate-insulin model. In the studies, Hall found that the low-carb diet led to a decrease in insulin and an increase in fat oxidation, which was expected. However, “this did not relate to an increase in energy expenditure, which was predicted by the model,” Sievenpiper said.

He also highlighted research led by Christopher D. Gardner, PhD, comprising more than 600 patients that did not find any differences at 1 year between those on “healthy” high- vs. low-carbohydrate diets. Similarly, a meta-analysis of 48 randomized controlled trials with more than 7,000 participants led by Bradley C. Johnston, PhD, showed no significant differences between these diets at 1 year. Sievenpiper also noted that an analysis of randomized trials found no significant differences in HbA1c at 1 year among patients with type 2 diabetes on high- vs. low-carbohydrate diets.

Regarding CVD and mortality, he said an analysis of the PURE trial found an increase in overall mortality and CV mortality with increasing carbohydrate intake. However, he noted many patients were from low- and middle-income countries, which may have impacted the results. In addition, Sievenpiper said other studies have found lower CV mortality with diets rich in legumes and fruit.

Moreover, prospective cohort and high-level evidence studies have consistently shown improved outcomes with diets that focus on carbohydrate quality vs. quantity.

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“I’d focus on carb quality rather than quantity. Glycemic index and low GL, food-based approaches such as whole grains, pulses, fruit and fiber, and the patterns that include those like the Mediterranean diet, the DASH diet [and] so on, provide the best evidence for benefit,” Sievenpiper said.

He said clinical practice guidelines are shifting away from a reductionist model to provide choices for patients with diabetes and allow physicians to have discussions with patients about their options.

“[We] are moving away from a one-size-fits all and moving away from this focus on single nutrients toward food and dietary pattern-based approaches,” Sievenpiper said.

“There probably isn’t any one best diet for CVD or diabetes. We have a number of different diets with evidence of advantages and disadvantages, and we have to align that with the values, preferences and treatment goals of our patients,” he added.

Regardless of the diet chosen, he highlighted that adherence is an important determinant of retaining the benefits of any diet.

“Health professionals should advise patients on evidence-based dietary patterns which align best with values, preference and treatment goals of the patients to find the one they can adhere for the long term,” Sievenpiper said. – by Gina Brockenbrough, MA

Reference:

Sievenpiper JL, et al. Abstract 1286. Presented at: American Heart Association Scientific Sessions; Nov. 10-12, 2018; Chicago.

Disclosure: Sievenpiper reports research support from the Almond Board of California, American Peanut Council, California Walnut Commission, Kellogg Canada, Loblaw Companies, Quaker, Unilever, Unico/Primo and WhiteWave Foods; receives honoraria from Abbott, the GI Foundation and Nestle; is a consultant/advisory board member for the European Fruit Juice Association, Tate & Lyle, and Wirtschaftliche Vereinigung Zucker e.V; is director of Toronto 3D Knowledge Synthesis and Clinical Trials Foundation; and is an unpaid science advisor for the Technical Committee on Carbohydrates of the International Life Science Institute North America.

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