Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
NUTRITIONAL ISSUES IN TYPE 1 DIABETES
2014 Diabetes Update; Whistler BC
1
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
6
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
6
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
8
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
6
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
20
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
21
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
22
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
23
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.
26
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.
27
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
28
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