The evolution of the nutritional management of diabetes

Low-Carbohydrate Diets in Children and Adolescents With or at Risk for Diabetes

Carbohydrate restriction is increasingly popular as a weight loss strategy and for achieving better glycemic control in people with diabetes, including type 1 and type 2 diabetes. However, evidence to support low-carbohydrate diets in youth (children and adolescents 2-18 years of age) with obesity or diabetes is limited. There are no guidelines for restricting dietary carbohydrate consumption to reduce risk for diabetes or improve diabetes outcomes in youth. Thus, there is a need to provide practical recommendations for pediatricians regarding the use of low-carbohydrate diets in patients who elect to follow these diets, including those with type 1 diabetes and for patients with obesity, prediabetes, and type 2 diabetes. This clinical report will: Provide background on current dietary patterns in youth, describe how moderate-, low-, and very low-carbohydrate diets differ, and review safety concerns associated with the use of these dietary patternsReview the physiologic rationale for carbohydrate reduction in youth with type 1 diabetes and for youth with obesity, prediabetes, and type 2 diabetesReview the evidence for low-carbohydrate diets in the management of youth with type 1 diabetesReview the evidence for low-carbohydrate diets in the management of youth with obesity, prediabetes, and type 2 diabetesProvide practical information for pediatricians counseling families and youth on carbohydrate recommendations for type 1 diabetes and for obesity, prediabetes, and type 2 diabetes.

Efficacy of Dietary and Supplementation Interventions for Individuals with Type 2 Diabetes

The prevalence of Type 2 diabetes (T2D) is increasing, which creates a large economic burden. Diet is a critical factor in the treatment and management of T2D; however, there are a large number of dietary approaches and a general lack of consensus regarding the efficacy of each. Therefore, the purpose of this narrative review is twofold: (1) to critically evaluate the effects of various dietary strategies on diabetes management and treatment, such as Mediterranean diet, plant-based diet, low-calorie and very low-calorie diets, intermittent fasting, low-carbohydrate and very low-carbohydrate diets, and low glycemic diets and (2) to examine several purported supplements, such as protein, branched-chain amino acids, creatine, and vitamin D to improve glucose control and body composition. This review can serve as a resource for those wanting to evaluate the evidence supporting the various dietary strategies and supplements that may help manage T2D.

Islet Health, Hormone Secretion, and Insulin Responsivity with Low-Carbohydrate Feeding in Diabetes

Exploring new avenues to control daily fluctuations in glycemia has been a central theme for diabetes research since the Diabetes Control and Complications Trial (DCCT). Carbohydrate restriction has re-emerged as a means to control type 2 diabetes mellitus (T2DM), becoming increasingly popular and supported by national diabetes associations in Canada, Australia, the USA, and Europe. This approval comes from many positive outcomes on HbA1c in human studies; yet mechanisms underlying their success have not been fully elucidated. In this review, we discuss the preclinical and clinical studies investigating the role of carbohydrate restriction and physiological elevations in ketone bodies directly on pancreatic islet health, islet hormone secretion, and insulin sensitivity. Included studies have clearly outlined diet compositions, including a diet with 30% or less of calories from carbohydrates.

Sustaining Effect of Intensive Nutritional Intervention Combined with Health Education on Dietary Behavior and Plasma Glucose in Type 2 Diabetes Mellitus Patients

Diabetes mellitus is very common in elderly Chinese individuals. Although nutritional intervention can provide a balanced diet, the sustaining effect on at-home dietary behavior and long-term plasma glucose control is not clear. Consequently, we conducted a long-term survey following one month of experiential nutritional intervention combined with health education. Based on the Dietary Guidelines for a Chinese Resident, we found that the food items met the recommended values, the percentages of energy provided from fat, protein, and carbohydrate were more reasonable after one year. The newly formed dietary patterns were “Healthy”, “Monotonous”, “Vegetarian”, “Japanese”, “Low energy”, and “Traditional” diets. The 2h-PG of female participants as well as those favoring the “Japanese diet” decreased above 12 mmol/L. Participants who selected “Japanese” and “Healthy” diets showed an obvious reduction in FPG while the FPG of participants from Group A declined slightly. “Japanese” and “Healthy” diets also obtained the highest DDP scores, and thus can be considered suitable for T2DM treatment in China. The results of the newly formed dietary patterns, “Japanese” and “Healthy” diets, confirmed the profound efficacy of nutritional intervention combined with health education for improving dietary behavior and glycemic control although health education played a more important role. The present study is encouraging with regard to further exploration of comprehensive diabetes care.

Low Carbohydrate Diets and Type 2 Diabetes: What is the Latest Evidence?

INTRODUCTION

Low carbohydrate diets are again in the spotlight and have been identified as particularly appropriate for people with type 2 diabetes. There is confusion amongst both health professionals and people with diabetes about the suitability of these diets. This review aims to provide an overview of the latest evidence and to explore the role of low carbohydrate diets for people with type 2 diabetes.

METHODS

An electronic search of English language articles was performed using MEDLINE (2010-May 2015), EMBASE (2010-May 2015), and the Cochrane Central Register of Controlled Trials (2010-May 2015). Only randomized controlled trials comparing interventions evaluating reduced carbohydrate intake with higher carbohydrate intake in people with diagnosed type 2 diabetes were included. Primary outcomes included weight, glycated hemoglobin, and lipid concentrations.

RESULTS

Low carbohydrate diets in people with type 2 diabetes were effective for short-term improvements in glycemic control, weight loss, and cardiovascular risk, but this was not sustained over the longer term. Overall, low carbohydrate diets failed to show superiority over higher carbohydrate intakes for any of the measures evaluated including weight loss, glycemic control, lipid concentrations, blood pressure, and compliance with treatment.

CONCLUSION

Recent studies suggest that low carbohydrate diets appear to be safe and effective over the short term, but show no statistical differences from control diets with higher carbohydrate content and cannot be recommended as the default treatment for people with type 2 diabetes.

Periodic 48 h feed withdrawal improves glucose tolerance in growing pigs by enhancing adipogenesis and lipogenesis

Background

Adipocyte numbers and peroxisome proliferators activated receptorγ (PPARγ) expression of retroperitoneal tissue increased while area under the curve (AUC) during the glucose tolerance test (GTT) was reduced in rats subjected to certain feed withdrawal (FW) regimens. Thus, using pigs as the experimental model, the hypothesis that FW regimens influence glucose tolerance by influencing fat cell function was evaluated with the objective of determining the effect of a single (FWx1; at age of 19 wk for 48 h) or periodic, multiple (FWx4; 24 h FW at 7 and 11 wk of age and 48 h FW at 15 and 19 wk of age) FW on AUC of glucose and insulin during the GTT relative to pigs that did not experience FW (Control).

Methods

Growth, body composition, adipocyte numbers, PPARγ expression, lipogenic potential as glucose uptake into fat of adipocytes of varying diameter in omental (OM) and subcutaneous (SQ) fat as affected by FW regimens were determined in pigs initiated into the study at 5 wk of age and fed the same diet, ad libitum.

Results

Blood glucose concentrations for prior to and 120 min post glucose meal tended to be lower (p = 0.105 and 0.097, respectively) in pigs in FW treatments. In OM fat; cell numbers, glucose Universal¹⁴C [U¹⁴C] incorporation into fat and rate of incorporation per 10⁴ cells was greatest for cells with diameters of 90-119 μm. Pigs undergoing FWx4 tended to have greater (p = 0.0685; by 191%) number of adipocytes, increased (p = 0.0234) glucose U¹⁴C incorporation into adipocytes and greater (p = 0.0872) rate of glucose uptake into cells of 119-150 μm diameter than of cells from control or FWx1 pigs. Subcutaneous adipocyte numbers in 22-60 and 61-90 μm diameter ranges from pigs in FWx1 tended to be greater (p = 0.08 and 0.06, respectively) than for those in FWx4 treatment, yet PPARγ expression and total cell number were not affected by treatment.

Conclusions

Results suggest that FW regimens influence fat cell function or lipogenesis rather than number, affecting glucose metabolism and may have implications in drug-free control of metabolic syndrome symptoms.

Health-related behaviours in adults with diabetes: associations with health care utilization and costs

OBJECTIVES

The primary objective of this study was to examine whether physical activity, diet, and smoking behaviours are associated with health resource utilization and costs in the Canadian context. A secondary objective was to evaluate demographic and health behavioural characteristics of the participants of the study to assess the degree of respondent bias.

METHODS

Self-reported physical activity, diet and smoking status were obtained from a large population-based sample of adults with diabetes (N = 2311). Resource utilization and cost information was obtained by linking these data to the provincial government's administrative database. Multiple regression models examined predictors of resource utilization and costs for individuals with type 1 (T1D) and type 2 (T2D) diabetes separately. To assess the degree of responder bias, characteristics of individuals who consented to link data were compared with those who did not consent.

RESULTS

Various measures of health care utilization and costs were negatively associated with physical activity behaviour in both T1D and T2D groups. Ever having smoked cigarettes was associated with higher resource utilization in individuals with T2D when controlling for demographic and health variables. Significant differences in demographic and health behavioural characteristics of the participants who provided consent for data linkage and those who did not were also found.

CONCLUSION

These findings are of interest considering that PA is a critical but understudied component of individuals with diabetes, and this appears to be one of the first studies to directly examine the relationship between health-related behaviours and health care utilization and costs. The findings may be useful in guiding targeted health promotion programs for individuals with diabetes. The results also indicate that studies involving linkage of administrative and survey data could be over-represented by healthy individuals.

Genes, diet and type 2 diabetes mellitus: a review

Diabetes mellitus is widely recognized as one of the leading causes of death and disability. While insulin insensitivity is an early phenomenon partly related to obesity, pancreatic beta-cell function declines gradually over time even before the onset of clinical hyperglycemia. Several mechanisms have been proposed to be responsible for insulin resistance, including increased non-esterified fatty acids, inflammatory cytokines, adipokines, and mitochondrial dysfunction, as well as glucotoxicity, lipotoxicity, and amyloid formation for beta-cell dysfunction. Moreover, the disease has a strong genetic component, although only a handful of genes have been identified so far. Diabetic management includes diet, exercise and combinations of antihyperglycemic drug treatment with lipid-lowering, antihypertensive, and antiplatelet therapy. Since many persons with type 2 diabetes are insulin resistant and overweight, nutrition therapy often begins with lifestyle strategies to reduce energy intake and increase energy expenditure through physical activity. These strategies should be implemented as soon as diabetes or impaired glucose homoeostasis (pre-diabetes) is diagnosed.

The diabetic surgical patient

PURPOSE OF REVIEW

This review summarizes the current progress in disease classification, pathophysiology and management of diabetes mellitus with a special focus on treatment modalities and recommendations for the practicing anesthesiologist.

RECENT FINDINGS

The revised classification of diabetes mellitus emphasizes disease cause and eliminates any reference to age-of-onset and insulin therapy. Hyperglycemia has emerged as an important marker of outcome in the operating room. Intensive insulin therapy promises to reduce health risk in the surgical and critical care setting. Perioperative beta-blocker and statin therapy are likely to reduce cardiac morbidity and mortality in diabetic patients. Promotility therapy (with metoclopromide) intended to reduce the aspiration risk of diabetic gastroparesis is likely over-utilized and may only be indicated for diabetics with poor glucose control and high hemoglobin A1c levels.

SUMMARY

According to World Health Organization projections, anesthesiologists can expect to care for more diabetic patients than ever before. Diabetes and its associated complications present unique challenges to the perioperative physician. As biomedical research continues to unravel the genetic, cellular and molecular mechanisms of this complex metabolic disease, our specialty must be prominently involved in the design and testing of innovative treatments to protect the diabetic patient from the risks of surgery and anesthesia.