NUTRITIONAL ISSUES IN TYPE 1 DIABETES

2014 Diabetes Update; Whistler BC

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Rémi Rabasa-Lhoret M.D, Ph.D. Endocrinology J-A De Sève Chair , IRCM Associate professor nutrition departement , Université de Montréal Director PRO MD (Plateforme de Recherche en Obésité Métabolisme et Diabète), IRCM Endocrinology division CHUM Montreal Diabetes Research Center (MDRC)

Disclosure

1. Scholarship: FRQ-S senior

2. Research grants: Canadian Diabetes Association, CIHR, Astra-Zeneca/BMS, CQDM, Diabète Québec,E Lilly, Cystic Fibrosis Canada, Imunotec, JDRF, J-A De Sève, Merck, Novo-Nordisk, Sanofi-Aventis,

SFD.

3. Consulting /advisory panel : Astra-Zeneca/BMS, Boehringer, E Lilly, Medronic, Merck, Novartis, Neomed, Novo-Nordisk, Sanofi-Aventis, Takeda, Valeant, Roche, Janssen, Becton Dickinson & Co (BD)

4. Honoraria for conferences : Astra-Zeneca/BMS, E Lilly, Janssen, Medtronic, Merck, Novo-Nordisk, Sanofi-Aventis.

5. Consumable gift (in Kind): Medtronic, Novo-Nordisk, Paladin

6. Unrestricted grants for clinical and educational activities : Lifescan, Medtronic, Novo Nordisk

7. Research chair: J-A De Sève

Outline

2013 CDA CPG

Carbohydrate counting

Importance

Feasibility

When patients with T1D look like patients with T2D: double diabetes

Prevention of nocturnal hypoglycemia

Bedtime snack useful ?

Outline

2013 CDA CPG

Carbohydrate counting

Importance

Feasibility

When patients with T1D look like patients with T2D: double diabetes

Prevention of nocturnal hypoglycemia

Bedtime snack useful ?

DCCT : A1c, complications & hypoglycemia

DCCT Research Group. N Engl J Med. 1993;329:977-986.

Relative

risk

HbA1c, %

7 8 9 10 11 12

Retinopathy

Nephropathy

Neuropathy

Microalbuminuria

15

13

11

9

7

5

3

1

Severe

Hypos(

per 100

patient

years)

0

20

40

60

80

100

120

Severe Hypoglycemia

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Key numbers, type 1diabetes

~ 285 millions diabetic patients

Type1~ 5-15% of cases

Growing incidence +3%/year

DCCT : Landmark study but…

~ 75% do not reach A1c < 7% goal

Hypoglycemia remains # 1 barrier

1.2 severe-hypo/patient/yrs

2.7 non-severe/patient/week

After 40 yrs of T1D non-severe ~ 5.000 &

severe ~ 40

Weight gain

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W.H.O., Prevention of diabetes mellitus. Report of a WHO study group. 1994.

Diabetes Res Clin Pract. 87(1): p. 4-14.

Diabetologia, 1999. 42(12): p. 1395-403.

Canadian Journal of Diabetes, 2008. 32(Supp 1): p. S1-S201.

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright © 2013 Canadian Diabetes Association

Nutrition Checklist

REFER for nutrition counseling by a registered

dietitian

FOLLOW Eating Well with Canada’s Food Guide

http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-

eng.php

INDIVIDUALIZE dietary advice based on preferences

and treatment goals

CHOOSE low glycemic index carbohydrate food

sources

2013

CDA nutritional recommandations

Canadian Diabetes Association2013; Evert et al. Diabetes Care 2013

CHO

Proteins

Lipides

No specific nutritional profile

45-60%

<35%

15-20%

Fibers 25 to 50g/day

Saturated fat ≤7% of total energy intake

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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright © 2013 Canadian Diabetes Association

Nutrition Checklist (continued)

KNOW alternative dietary patterns for type 2 diabetes

ENCOURAGE nutritionally balanced, calorie-reduced

diet in overweight or obese patients

ENCOURAGE matching of insulin to carbohydrate in

type 1 diabetes

2013

Outline

2013 CDA CPG

Carbohydrate counting

Importance

Feasibility

When patients with T1D look like patients with T2D: double diabetes

Prevention of nocturnal hypoglycemia

Bedtime snack useful ?

Rational for Carbohydrate counting

Carbohydate

Insulin

Halfon et al. Diabetes Care 1989, Rabasa-Lhoret Diabetes Care 1999; Marran KJ S Afr Med J 2013; 2013 CDA CPG

Despite numerous factors : - Glycemic index - Fiber content - Gastric empting - etc.

Better PPG Better A1c

Impact of Carbohydrate counting

Flexibility

Quality of life

Stable or Better A1c

Weight Stable, reduced, increased

Food quality Stable, improved, worse

Reduced insulin doses

Less hypoglycemia

In the top 5 problems

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7

8

9

10

11

12

Baseline 6 months

A1

c (%

)

CHC Conventional

Adapted from DAFNE Study Group BMJ 2002

Souto DL Nutrition 2014; Marigliano Acta Diabetol 2013; Laurenzi A Diab Care 2011; Dias VM Diab Met Sd 2010 Scavone G Diabetic med 2010; Trento M J Endo Invest 2011

Intergrating the impact of lipids & proteins?

Mean postprandial glucose excursions from 0 to 300 min for 33 subjects after test meals of LF/LP (●), LF/HP (♦), HF/LP (▲), and HF/HP () content.

Smart C E et al. Diab Care 2013;36:3897-3902; similar suggestion Bao J Diab care 2011 or Pamkowska E Diab Ther Thech 2012

Late PP effect

CHC + Porteins &/or lipids: Improved control or unwanted complexity?

Causes

Delayed gastric emptying

Increase FFA / insulin resistance

Impact on glucagon, GLP-1, GIP, etc.

Consequences

Postprandial glucose fluctuations

Imprecision = more hypo & hyper

Fat and lipids = more hypo (+ 33% in Diab Ther Tech 2012, 14:16-22)

Complexity of nutritional counseling

Maahs DM Diab Thech Ther 2012

Mean patients error for CHO estimation

15.4 g (20.9%)

Over 448 meals, the mean meal contains : 72.4 g

Brazeau A-S & al Diab Res Clin Pract, 2012 Smart CE Diab Med 2010

MAGE & SD

TIT & time > 10

mmol/L TIT : Time

In Target

In youth low impact of errors < 10-15 g

CHC: Feasible? How to improve accuracy?

102 youth (8.3-18.3 yrs)

73% error < 15 g

error: larger meal, longer Db, no label

No impact teaching in grams vs. portions

101 youth (12-18 yrs) with poor CHC accuracy

Control

Intervention: 90 min class + two 3-days food journal

No effect on A1c or CHC accuracy

Spiegel G J Acad Nutr Diet 2012; Mehta Diabtes Care 2009; Smart CE Diabet Med 2010

More intensive intervention

CHC counselling

1. Educate,

1. Start simple

2. CHC is probably the priority

3. Overall food quality

2. Test (SMBG, CGM)

3. Consistency probably more important than accuracy

4. Home = plan = weight food

5. Restaurant = improvise, investigate (web) and prudent

6. Consider technology

1. Check pump that carb factor is correct

2. Smart phone based app

3. Special meals : dual wave bolus for, 1-3 more U if rich prot and/or lipids

Smart CE Diabet Med 2010; Neithercott T Diab Forecast 2011; Rossi MC Diab Care 2010; Enander R Ped Daib 212

Outline

2013 CDA CPG

Carbohydrate counting

Importance

Feasibility

When patients with T1D look like patients with T2D: double diabetes

Prevention of nocturnal hypoglycemia

Bedtime snack useful ?

Evolving weight & cardiometabolic profile

Since 1980 doubling the prevalence of overweight & obesity

Used to be -------------------------- to ---------------------------- current

Conway B. et al., Diabet Med., 2010 Purnell JQ. et al., JAMA, 1998

Lean T1D Overweight

Obese

• Insulin resistance • Dyslipidemia • Hypertension • Inflammation T2D familly history

Double diabetes

Purnell JQ et al. , Circulation 2013

Cardiometabolic profile

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Pub date # T1D Definition Prevalence of

Met Sd

DCCT (USA)1 1983 1337 IDF 22%

EDC (USA)2 1986 658 WHO; NCEP;

IDF 21%; 12%; 8%

FDS (Australia)3

1996 1426 WHO; NCEP;

IDF 45%; 42%; 39%

FinnDiane (Finland)4

1997 3783 WHO; NCEP;

IDF 44%; 38%♂ 40%♀; 36%

Scotland5 2008 365 WHO 31%

Brazil6 2010 45 ♀ WHO 45%

1Kilpatrick et al. Diabetes Care 2007; 2Pambianco et al. Diabetes Care 2007; 3Davis et al. Diab Res and clinical practice 2007; 4Thorn et al. Diabetes Care 2005; 5Ghosh et al. Int J of diabetes Mellitus 2010; 6Momesso et al. Diab Res and clinical practice 2011

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Defining double diabetes is problematic …

Double diabetes is associated with …

↑ A1c

↑ micro- et macrovascular complications

↑ Mortality

Double diabetes / Metabolic syndrome

Thorn LM. et al., Diabetes Care, 2005 Kilpatrick ES. et al., Diabetes Care, 2007

Thorn LM. et al., Diabetes Care, 2009 Pambianco G. et al., Diabetes Care, 2007

Major consequences

Patients with T1D face specific problems for lifestyle

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Even more sedentary than general population

Hypoglycemia is #1 barrier for physical activity

Sedentary = fatter

More atherogenic diet

Potential consequence of CHC complexity

At risk situation for increase caloric intake

Hypoglycemia: preventive & corrective snacks

Remaining high prevalence of smoking

Plotnitoff RC. et al. Med Sci Sports Exercise 2006 Brazeau AS. et al. Diabetes Care.2008

Brazeau AS. et al. Diabetic Medecine 2012 Snell-Bergeon JA. et al. Diabetologia 2009

Leroux C an J Diab 2014

Adapted from: Olsways 1993

Meditereanean diet

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1. Lipid profile

2. Blood pressure

3. Insulin sensitivity

4. Body composition

5. Inflammation

Benefits demonstrated even w/o weight loss Med diet do not imply higher costs

CV risk & mortality

Kastorini et al. J Am Coll Cardiol 2011; Panagiotakos et al. Nutr Metab Cardiovasc Dis 2006;

Goulet J et al. J Nutr 2008; Estruch R et al. N Engl J Med 2013

Know benefits of Med diet

General population

Outline

2013 CDA CPG

Carbohydrate counting

Importance

Feasibility

When patients with T1D look like patients with T2D: double diabetes

Prevention of nocturnal hypoglycemia

Bedtime snack useful ?

Are bedtime nutritional strategies effective in preventing nocturnal hypoglycaemia in patients with type 1 diabetes? Calibrated bedtime snack based on bedtime blood glucose (BG) level could be effective to reduce NH occurrence for patients treated with human or animal insulin (short-acting combined with lente, ultralente and/or intermediate-acting insulin).

There is no evidence for patients treated with insulin analogues as part of multiple daily injections or insulin pump regimen.

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Desjardins K & al Diab Obes Metab 2013

Are bedtime nutritional strategies effective in preventing nocturnal hypoglycaemia in patients with type 1 diabetes? (2) Some evidence suggests that including uncooked cornstarch or alanine in the bedtime snack composition could provide some benefits for the prevention of NH.

Individualized recommendations of a bedtime snack intake for patients or situations at high risk for NH (long standing diabetes, hypoglycaemia unawareness, prior physical activity, alcohol consumption, bedtime BG close to hypoglycaemia threshold) appear as a prudent recommendation.

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Desjardins K & al Diab Obes Metab 2013

Are bedtime nutritional strategies effective in preventing nocturnal hypoglycaemia in patients with type 1 diabetes? (3) On the basis of the available evidence, a bedtime snack cannot be recommended systematically but it might be useful if prescribed in an individualized fashion

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Desjardins K & al Diab Obes Metab 2013

Conclusion

CHC is an important part of T1D treatment

Mean error (20%) remain hard

Major educational component

Growing prevalence of obesity and cardio metabolic complications

Reduce: weight & smoking

Increase: food quality & physical activity

Low evidence that snack really prevent nocturnal hypoglycemia