Evidence Behind Dietary Intervention in Diabetes in 2020. Dr. John Sievenpiper_Archive.pdfEvidence Behind Dietary Intervention in . Diabetes in 2020. ... Review current and evolving

Evidence Behind Dietary Intervention in Diabetes in 2020

John L Sievenpiper, MD, PhD, FRCPC1,2,3,4,5

1Diabetes Canada Clinician Scientist2Associate Professor, Department of Nutritional Sciences, University of Toronto3Staff Physican, Division of Endocrinology & Metabolism, St. Michael’s Hospital

4Scientist, Li Ka Shing Knowledge Institute, St. Michael’s Hospital 5Lifestyle Medicine Lead, MD Program, University of Toronto

Diabetes Update 2020

Toronto, Canada

May 1, 2020

Learning Objective

Following this session, participants will be able to:

Review current and evolving nutritional approaches for the prevention and management of diabetes

Does diet matter?

Poor diet is greatest contributor to total and cardiovascular disease and death worldwide:

Global burden of disease attributable to 79 risk factors inGlobal Burden of Disease Study 2015 and 2017

GBD 2015 Risk Factors Collaborators. Lancet 2016; 388: 1659–724GBD 2017 Diet Collaborators. Lancet 2019 Apr 3. pii: S0140-6736(19)30041-8 [Epub ahead of print]

0 2.5 5.0 7.5 10 12.5 15 17.5DALYs (%)

Deaths DALYs

91% CV deaths95% CV DALYs

Clinical Practice Guidelines (CPGs)

Nutrition is the cornerstone of therapy: CPGs for Diabetes, Dyslipidemia, Hypertension

“Lifestyle interventions remain the cornerstone of chronic

disease prevention, including CVD”

Sievenpiper et al. Can J Diabetes. 2018;42 (Suppl 1):S64-S79.

Anderson JT et al. Can J Cardiol. 2016;pii:S0828-282X(16)30732-2.

Nerenberg et al. Canadian Journal of Cardiology 2018;34:506e525.

[pending 2020]

Paradigm shift

Paradigm shift:“Nutrient-based” to “food- and dietary pattern-based”

recommendations

Sievenpiper, Dworatzek. Can J Diabetes 2013;37:S1-S7

Sievenpiper et al. Can J Diabetes 2018;42:s64-s79

Dworatzek et al. Can J Diabetes 2013;37:S45eS55

Anderson et al. Can J Cardiol 2016;32:1263e1282

[pending]

Successof the “nutrient-based” model

in diseases of deficiency

Early success of the reductionist model: Scurvy and Vitamin C Deficiency

http://exhibits.hsl.virginia.edu/treasures/james-lind-1716-1794/https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101651412-img

James Lind FRSE FRCPE (4 October 1716 – 13 July 1794), a Scottish Physician in the Royal Navy, conducted the first ever clinical trial in 1747 showing that oranges and lemons cured scurvy

http://www.jameslindlibrary.org/lind-j-1753/

Failure of the “nutrient-based” model

in chronic disease

“Overall mortality was 8 percent higher among participants who received beta carotene than among those not given beta carotene (95 percent confidence interval, 1 to 16, P=0.02)”

The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. 1994; 330:1030-1035

Beta carotene increases total mortality: ATBC trial, N=29,133 male smokers (age:50-69y), 876 cases, FU=5-8y

The Jenkins et al. JACC 2018;71:2570–84

Antioxidants fail to achieve anticipated decrease in CV events and increase total mortality:

SRMA, 21 RCTS, N=105,780, 8,472 deaths

Emergenceof the “Dietary pattern-based”

model

Importance of vales, preferences, and treatment goals

“Values and preferences. Adherence is one of the most important determinants for attaining the benefits of any diet. High food costs (e.g. fresh fruits and vegetables), allergies (e.g. peanut and tree nut allergies), intolerances (e.g. lactose intolerance), and gastrointestinal (GI) side effects (e.g. flatulence and bloating from fibre) may present as important barriers to adherence. Other barriers may include culinary (e.g. ability and time to prepare foods), cultural (e.g. culturally specific foods), and ecological/environmental (e.g. sustainability of diets) considerations. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long term.”

Anderson JT et al. Can J Cardiol. 2016 Jul 25. pii: S0828-282X(16)30732-2.Sievenpiper et al. Can J Diabetes. 2018;42 (Suppl 1):S64-S79.

What is the evidence?

Hierarchy of evidence in evidence based medicine

Systematic Reviews &

meta-analyses

RCTs

NRCTs

Cohorts studies

Case-control studies

Cross-sectional studies

Case series/time series

Expert opinion

Decreasing bias

Systematic Reviews &

meta-analyses

DOWNgrades1. ROB2. Inconsistency3. Imprecision4. Indirectness5. Publication bias

UPgrades1. Large magnitude

of association2. Dose-response3. Attenuation by

confounding

HighModerateLowVery low

Diabetes Canada:

2018 Clinical Practice Guidelines for Nutrition Therapy


Diabetes Canada:



Diabetes Canada:



Low glycemic index (low-GI) dietary pattern

Grade B, Level 2 (glycemic control)Grade D, Level 4 (CV risk)Grade C, Lavel 3 (LDL-C)Ungraded (CRP)

Low-Moderate-quality ⊕⊕⊕ (CV risk)Moderate-quality ⊕⊕⊕ (LDL-C)

[pending]

What is the Glycemic index (GI)? A physiological basis for carbohydrate exchange

Jenkins DJA. Am J Clin Nutr 2002;76(1):266S-273S

https://www.diabetes.ca/getmedia/e3c78c79-9b1b-4823-896d-7daae1726b02/glycemic-index.pdf.aspx

David Jenkins, OC, MD, PhD, DSc, FRCP, FRCPC, FRSC

Livesey et al. Nutrients. 2019;11(6). pii: E1280Livesey et al. Nutrients. 2019;11(6). pii: E1436

1.26 [1.15, 1.37] per 80g/d GL1.89 [1.66 2.16]

High-GI/GL diets are associated with increased incidence of diabetes:

SRMA of prospective cohort studies, 24 studies, FU=4-22y

Glycemic load (GL)Glycemic index (GI)

1.27 [1.15, 1.40] per 10 unit GI1.87 [1.56, 2.25]

High-GI/GL diets are associated with increased incidence of coronary heart disease (CHD):

SRMA of prospective cohort studies using truly validated dietary instruments (Corr>0.55), 11 studies (n=350,000;10,400 events), FU=11.4y

Livesey et al. Mayo Clin Proc Innov Qual Outcomes. 2019;3:52-69

Glycemic load (GL)Glycemic index (GI)

1.24 [1.12, 1.38] per 10 units GI2.71 [1.47, 4.40]

Diabetes and Nutrition Study Group

1.44 [1.25, 1.65] per 65 g/d GL5.5 [3.1, 9.8]

ResultsLow-GI (GI≤55) diets improve glycemic control and cardiometabolic risk factors in diabetes:

SRMA of 30 RCTs, n>1,500 (DM2, DM1), FU=12wk (3-52wk)

Cardiometabolic Risk Factor

No. Participants MD (95% CI) SMD (95% CI) P

GLYCEMIC CONTROL

HbA1c (%) 22 1,437 -0.31 [-0.47, -0.16] -0.84 [-1.27, -0.43] <0.00001 73% <0.00001

Glucose (mmol/L) 26 1,392 -0.39 [-0.49, -0.30] -1.58 [-1.98, -1.21] <0.00001 0% 0.46

Insulin (pmol/L) 12 756 -0.87 [-7.01, 5.27] -0.08 [-0.65, 0.49] 0.78 52% 0.02

BLOOD LIPIDS

LDL-C (mmol/L) 25 1,293 -0.18 [-0.30, -0.05] -0.56 [-0.94, -0.16] 0.006 70% <0.00001

Non-HDL-C (mmol/L) 24 1,273 -0.20 [-0.33, -0.08] -0.63 [-1.03, -0.25] 0.002 71% <0.00001

HDL-C (mmol/L) 25 1,293 0.02 [-0.01, 0.05] 0.26 [-0.13, 0.65] 0.14 52% 0.002

TG (mmol/L) 26 1,396 -0.08 [-0.17, 0.00] -0.36 [-0.77, 0.00] 0.06 50% 0.002

ApoB (umol/L) 5 161 -0.03 [-0.11, 0.04] -0.35 [-1.29, 0.47] 0.35 0% 0.49

ADIPOSITY

Body weight (kg) 25 1,341 -0.64 [-0.96, -0.33] -0.80 [-1.19, -0.41] <0.0001 0% 0.87

BMI (kg/m2) 9 261 -0.65 [-1.01, -0.30] -1.08 [-1.68, -0.50] 0.0003 0% 0.89

Waist circumference (cm) 11 884 -0.94 [-2.15, 0.27] -0.46 [-1.05, 0.13] 0.13 79% <0.0001

BLOOD PRESSURE

Systolic (mmHg) 8 839 0.30 [-1.45, 2.05] 0.12 [-0.57, 0.81] 0.74 12% 0.33

Diastolic (mmHg) 7 736 0.16 [-1.76, 2.08] 0.06 [-0.68, 0.80] 0.87 39% 0.13

INFLAMMATION

CRP (nmol/L) 5 542 -8.68 [-14.91, -2.45] -1.22 [-2.10, -0.34] 0.006 31% 0.21

Benefit Harm

No. Trial Comparisons

HeterogeneityI2 P

-4.00 -2.00 0.00 2.00

Chiavaroli et al., unpublished


Laura Chiavaroli, PhD

~5% ↓LDL-C~5% ↓ non-HDL-c

~0.3% ↓ HbA1c~0.4 ↓ FPG

~9nnmol/L ↓CRP

~0.6kg ↓body wt

Diabetes Canada:



Diabetes Canada:



Mediterranean dietary pattern

Grade A, Level 1 (CV risk)Grade B, Level 2 (glycemic control)Ungraded (Blood pressure)Ungraded (CRP)Ungraded (retinopathy risk)

High-Quality ⊕⊕⊕⊕ (CV risk)

[pending]

What is the Mediterranean Diet? A traditional plant-based diet

https://oldwayspt.org/traditional-diets/mediterranean-diet

“A Mediterranean diet primarily refers to a plant-based diet first described in the 1960s (136). General features include highconsumption of fruits, vegetables, legumes, nuts, seeds, cereals and whole grains; moderate-to-high consumption of olive oil (as the principal source of fat); low-to-moderateconsumption of dairy products, fish and poultry; low consumption of red meat; and low-to-moderate consumption of wine, mainly during meals (136,137).”


Mediterranean diet supplemented with tree nuts (30g/day) reduces major cardiovascular events:

PREDIMED trial, N=7,447 (288 events), FU=4.8y

Estruch et al. N Engl J Med 2018;378:e34

Mediterranean diet supplemented with tree nuts (30g/day) reduces incident diabetes:

PREDIMED (Reus) trial, N=418, 54 cases, FU=4y

Salas-Salvado et al. Diabetes Care 2011;34:14–19Salas-Salvado et al. Diabetes Care 2018 Oct; 41(10): 2259-2260

a, EVOO: RR=0.47 (0.23-0.97)b, Nuts: RR=0.47 (0.23-0.98)

Diabetes Canada:



Diabetes Canada:



DASH dietary pattern

Grade B, Level 3 (CV risk)Grade B, Level 2 (glycemic control)Grade D, Level 4 (Blood pressure)Grade B, Level 2 (LDL-C)Ungraded (CRP)Ungraded (weight loss)

Moderate-Quality ⊕⊕⊕ (CV risk)Moderate-Quality ⊕⊕⊕ (LDL-C)

Grade B

[pending]

https://www.nhlbi.nih.gov/files/docs/public/heart/new_dash.pdf

Food Group DailyServings

Grains 6–8

Meats, poultry, and fish 6 or less

Vegetables 4–5

Fruit 4–5

Low-fat or fat-free dairy products

2–3

Fats and oils 2–3

Food Group Weekly Servings

Nuts, seeds, dry beans, and peas

4–5

Sweets 5 or less

What is the DASH Diet? A dietary portfolio of blood pressure-lowering foods

Portfolio Diet and Cardiometabolic risk: Umbrella review of prospective cohorts and randomized trials

Chiavaroli et al. Nutrients. 2019 Feb 5;11(2). pii: E338.



DASH diet reduces incident CVD, CHD, stroke, and diabetes:

Umbrella review 3 SRMAs, 22 cohorts, N=1,241,668 (13,212 cases), FU=12-16y

0 0.5 1 1.5 2

CardiometabolicDisease Risk SRMA No.

Studies NPooled Effect Estimates

I2RR (95% CI) RR (95% CI)

CVD RISK Schwingshackl et al. 2015 11 783 732 0.80 (0.76, 0.85) 30%

CHD RISK Salehi-Abargouei et al. 2013 3 144 337 0.79 (0.71, 0.88) 0%

STROKE RISK Salehi-Abargouei et al. 2013 3 150 191 0.81 (0.72, 0.92) 0%

DIABETES RISKJannasch et al. 2017 5 158 408 0.82 (0.74, 0.92) 62%

Favours DASH Favours Control

0 0.5 1 1.5 2




DASH diet reduces cardiometabolic risk: Umbrella review 3 SRMAs, 112 trial comparisons, N=12,518, FU=4-16wk

CardiometabolicRisk Factor SRMA No.

Trials NPooled Effect Estimates

I2MD (95% CI) SMD (95% CI) SMD (95% CI)

BLOOD PRESSURE

Systolic (mmHg) Siervo et al. 201519 1 918 -5.20 (-7.00, -3.40) -1.30 (-1.75, -0.85) 76%

19 1 918 -2.60 (-3.50, -1.70) -1.30 (-1.75, -0.85) 49% Diastolic (mmHg)

BLOOD LIPIDS

Total-C (mg/dL)

Siervo et al. 2015

13 1 673 -7.90 (-12.00, -3.80) -1.05 (-1.59, -0.50) 52%

13 1 673 -4.00 (-7.70, -0.30) -0.59 (-1.13, -0.04) 37%LDL-C (mg/dL)

HDL-C (mg/dL) 15 1 749 0.10 (-2.00, 2.10) 0.10 (-2.00, 2.10) 76%

14 1 654 -0.40 (-5.60, 4.70) -0.40 (-5.60, 4.70) 0%Triglycerides (mg/dL)

GLYCEMIC CONTROL

Glucose (mg/dL) Siervo et al. 2015 10 826 -3.40 (-7.10, 0.30) -0.57 (-1.19, 0.05) 59%

Fasting Insulin (uU/mL)Shirani et al. 2013

11 760 -0.15 (-0.22, -0.08) -1.27 (-1.86, -0.68) 0%HOMA-IR 8 603 -0.05 (-0.15, 0.05) -0.35 (-1.04, 0.35) 16%

BODY WEIGHTBody Weight (kg) Soltani et al. 2016 11 1 211 -1.42 (-2.03, -0.82) -1.39 (-1.98, -0.80) 71%

INFLAMMATIONCRP (mg/L) Soltani et al. 2017 6 451 -0.41 (-0.98, 0.17) -0.57 (-1.36, 0.24) 97%

Favours DASH Favours Control

-6 -4 -2 0 2 4




Diabetes Canada:



Diabetes Canada:



Portfolio dietary pattern

Ungraded (CV risk)Ungraded (LDL-C)Ungraded (Blood pressure)Ungraded (CRP)

Moderate-Quality ⊕⊕⊕ (CV risk)High-Quality ⊕⊕⊕⊕ (LDL-C)

[pending]

What is the Portfolio Diet? A dietary portfolio of cholesterol-lowering foods

45g/dayPeanuts, tree nuts

45g/daySoy products, pulses

20g/dayOats, barley, psyllium, pulses, eggplant, okra, temperate climate fruit

2g/dayPlant sterol margarine/oil/supplements

Current approved health claims:Cholesterol and CHD risk reduction

1. Nuts (peanuts, 9 tree nuts)2. Plant protein (soy, ?pulses) 3. Viscous Fibres (oat, barley, psyllium, PGX)4. Phytosterols (plant sterols and stanols)

NCEP Step II diet ↓10%

↓5%

↓5%

↓5%

↓5%

↓30%

Portfolio Diet: From efficacy to effectiveness

Jenkins DJ et al. JAMA 2003; 290(4):502-10

-40

-35

-30

-25

-20

-15

-10

-5

0

5

10 LDL Cholesterol

Control ♦

PortfolioStatin

Wk 0 Wk 2 Wk 4

% C

hang

e Fr

om B

asel

ine

Multicentre Canadian trial: N=345, FU=6 mo

Single centre trial: N=46, FU=1 mo

Jenkins DJ et al. JAMA 2011;306(8):831-9

David Jenkins, OC, MD, PhD, DSc, FRCP, FRCPC, FRSC

Cyril Kendall, PhD

Portfolio Diet and Cardiometabolic risk: SRMA 7 controlled trial, N=439, FU=1-6mo

Chiavaroli et al. Prog Cardiovasc Dis 2018;61:43-55



Portfolio Diet and cardiometabolic risk: SRMA 7 controlled trial, N=439, FU=1-6mo

Chiavaroli et al. Prog Cardiovasc Dis 2018;61:43-55

“The combination of a Portfolio dietary pattern and NCEP Step II diet significantly lowered the primary outcome LDL-C by 17% (21% in efficacy and 12% in effectiveness trials)… suggesting that the benefit of the intended combination… would result in LDL-C reductions of ~27% (32% in efficacy and 15% in effectiveness trials) in clinical practice.”

Portfolio dietary pattern is associated with decreased incidence and mortality of CVD outcomes:

Women’s Health Initiative (WHI), n= 107,387, mean FU=14.9y

Glenn AJ et al., submitted

OUTCOME # CASES Q1HR [95% CIs]

Q2HR [95% CIs]

Q3HR [95% CIs]

Q4HR [95% CIs]

Total CVD 11,370 1.0 (Ref) 0.98 [0.93-1.03]

0.92 [0.87-0.97]

0.89 [0.84-0.95]

CHD 5, 739 1.0 (Ref) 0.92 [0.86-0.99]

0.86 [0.79-0.93]

0.87 [0.79-0.95]

Stroke 4, 451 1.0 (Ref) 1.03 [0.94-1.13]

0.99 [0.89-1.09]

0.97 [0.87-1.08]

Heart Failure 1, 946 1.0 (Ref) 1.06 [0.87-1.28]

0.85 [0.74-0.98]

0.83[0.70-0.98]

Andrea Glenn, MSc, RD

Simin Liu,MD, ScD

How do you prescribe diet?

Case

Case of a 74-year old man with mixed dyslipidemia & MetS

ID: 74 year old, male, Caucasian

RFR: Hyplidipidemia w/ inability to meet targets

PMH: OW, HTN, Colon CA (remission), hypothyroidism

Meds: Atorva 80mg1, Eze 10mg1, Amlodipine 5mg1, Synthroid 0.025mg1

HPI: Dx 2010 on routine work-upNo 20 causes identifiedNo CHD, stroke, PVD -tve stress test, -tve 24h-holter

CV risk factors: Visceral obesity Ex-15 pack year smoker HTNNo DM (pre-DM)No FHx of premature CVD

Diet & Lifestyle: High red meatHigh refined starch, low fibreLow fruit & veg

O/E: No stigmataBMI 29.8, WC >102cmBP 154/91 mmHgOtherwise unremarkable

Labs: Nov 2014 (“off”) Jan 2015 (“on”) Total-C 8.81 → 5.45TGs 2.56 → 2.29HDL-C 1.40 → 1.23 LDL-C 6.25 → 3.18 Non-HDL-C 7.41 → 4.22Apo B 1.79

HbA1c: 6.1%

Normal thyroid, liver, renal tests

FRS: >30%

A/P: Mixed dyslipidemiaMetS 4/5 (WC, TG, BP, Pre-DM)Lipids not at target of ≤2mmol/L or ≥50% ↓ LDL-COn max dual therapy - ? approachHTN – started ramipril 10mg1

Importance of vales, preferences, and treatment goals

“Values and preferences. Adherence is one of the most important determinants for attaining the benefits of any diet. High food costs (e.g. fresh fruits and vegetables), allergies (e.g. peanut and tree nut allergies), intolerances (e.g. lactose intolerance), and gastrointestinal (GI) side effects (e.g. flatulence and bloating from fibre) may present as important barriers to adherence. Other barriers may include culinary (e.g. ability and time to prepare foods), cultural (e.g. culturally specific foods), and ecological/environmental (e.g. sustainability of diets) considerations. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long term.”

Anderson JT et al. Can J Cardiol. 2016 Jul 25. pii: S0828-282X(16)30732-2.Sievenpiper et al. Can J Diabetes. 2018;42 (Suppl 1):S64-S79.

What is the Portfolio Diet? A dietary portfolio of cholesterol-lowering foods

45g/dayPeanuts, tree nuts

45g/daySoy products, pulses

20g/dayOats, barley, psyllium, pulses, eggplant, okra, temperate climate fruit

2g/dayPlant sterol margarine/oil/supplements

https://www.ccs.ca/images/Images_2017/Portfolio_Diet_Scroll_eng.pdf

http://www.stmichaelshospital.com/media/hospital_news/2018/0706.phphttp://childnutrition.utoronto.ca/news/quick-visual-portfolio-diet-and-cholesterol

PortfolioDiet.app

http://www.portfoliodiet.app/

Case of a 74-year old man with mixed dyslipidemia & MetS:4 years of follow-up on Portfolio diet + exercise & dual max therapy

Lipids Nov 2014

Jan 2015

Jun 2015

Jan 2016

Jul2016

Dec2017

Aug2018

Apr 2019

Delta %

Total-C 8.81 5.45 3.74 3.24 3.15 3.03 3.52 3.85 -57%

TAGs 2.56 2.29 1.11 1.36 0.97 0.61 0.94 1.19 -54%*

HDL-C 1.40 1.23 1.36 1.22 1.26 1.08 1.38 1.54 +10%

LDL-C 6.25 3.18 1.88 1.40 1.45 1.67 1.71 1.77 -72%**

Non-HDL-C

7.41 4.22 2.38 2.02 1.89 1.95 2.14 2.31 -69%***

Weight loss (baseline, 96.3kg): 7.2kg or 8% (lowest) to 4.1kg or 4.3% (present)

* -48%** -44% *** -45%

additional lowering beyond dual max therapy

Off Rx On Rx “Rx + Portfolio”

Conclusions

Conclusions

1. Dietary guidelines have moved away from “nutrient-based recommendations” (“low fat”, “low carb”, “high protein”) to more “food- and dietary pattern-based recommendations”.

2. Comprehensive dietary patterns that combine the advantages of different foods (e.g. Med diet, DASH diet, Portfolio Diet,) result in clinically meaningful improvements in cardiometabolic risk factors and associated reductions in cardiovascular disease comparable to those seen with medications.

3. Physicians (with the assistance of a registered dietitian where possible) have an important opportunity to make an impact prescribing diet and exercise to their patients.

Practice Applications1. Use food and dietary pattern-based strategies such as

Mediterranean, Portfolio, Low glycemic index, Vegetarian, or DASHdietary patterns to modify cardiometabolic risk factors and reduce disease risk as 1st-line therapy in your patients

2. To achieve the greatest benefit in those already treated with medications, consider food and dietary pattern-based strategies as add-on therapy.

3. Help your patient (with the assistance of a registered dietitian) to choose the dietary pattern that best aligns with their values, preferences and treatment goals to ensure the greatest adherence over the long term

Acknowledgements

Acknowledgements

Current lab membersDr. Sonia Blanco Mejia, MD, MSC (Research Associate)Ms. Maxine Seider, RD, MSc (Research Coordinator)Dr. Tauseef Khan, MBBS, PhD (PDF)Dr. Laura Chiavaroli, PhD (PDF)Ms. Stephanie Nishi, MSc, RD (PhD student)Mr. Rodney Au Yeung, MSc (PhD student)Ms. Andrea Glenn, MSc, RD (PhD student)Ms. Nema McGlynn, HBASc, RD (MSc student)Ms. Sabrina Ayoub-Charette, HBSc (MSc student)Ms. Annette Cheung, HBASc, RD (MSc student)Ms. Qi “Annie” Liu (HBSc project student)Ms. Danielle Lee (HBSc project student)Ms. Amna Ahmed (HBSc project student)

Former lab membersMs. Catherine Braustein, MScMr. Jarvis Nooranha, MScMs. Effie Viguiliouk, MScMs. Vivian Choo, MSc (MD student)Mr. Viranda Jayalath, MAN (MD student)Dr. Vanesa Ha, PhD, (MD student)Ms. Christine Tsilas, HBSc, (RD intern)Ms. Shana Kim, MSc (PhD student)Dr. Adrian Cozma, MD (Resident)Dr. Shari Li, MD (Resident)Dr. Arash Mirrahimi, MD, MSc (Resident)Dr. David Wang, MD (Resident)Mr. Simon Chiu, HBScMs. Reem Tawfik, HBScMs. Sara Rehman, HBScDr. Matt E Yu, HBSc, DDS

CollaboratorsDr. David JA Jenkins, MD, PhD, DScDr. Cyril Kendall, PhDDr. Lawrence A Leiter, MD, FRCPCDr. Thomas MS Wolever MD, PhDDr. Elena Comelli, PhDDr. Richard Bazinet, PhDDr. Anthony Hanley, PhDDr. Ahmed El-Sohemy, PhD

CollaboratorDr. Vasanti Malik, PhD

CollaboratorDr. Jordi Salas-Salvado, MD, PhD

CollaboratorsDr. Russell J de Souza, RD, ScDDr. Joseph Beyene, PhD

CollaboratorDr. Simin Liu, MD, ScD

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Evidence Behind Dietary Intervention in Diabetes in 2020. Dr. John Sievenpiper_Archive.pdfEvidence Behind Dietary Intervention in . Diabetes in 2020. ... Review current and evolving