EB 2016 - 4th Yogurt Summit - Constance Brown-Riggs

Healthy EatingAn Important Part of Diabetes Prevention

Constance Brown-Riggs, MSEd, RD, CDE, CDNAuthor: The African American Guide to Living Well With Diabetes

© CBR Nutrition Enterprises

Objectives

• Provide evidence on the importance of healthy eating—including yogurt, for the prevention and management of type 2 diabetes

• Highlight the International Diabetes Federation’s (IDF) proposed life course approach to diabetes prevention


Prediabetes

• A Global Health Crises 366 million people worldwide• An American Public Health Crises 86 million Americans• Nearly 90 percent of people with prediabetes

don’t know they have it.• IDF projects 471 million by 2035• Without intervention, 15 to 30 percent of

people with prediabetes will develop type 2 diabetes within five years.


Type 1β-cell destruction – Complete lack of insulin and amylin

Type 2 β-cell dysfunction and insulin resistance

Gestationalβ-cell dysfunction and insulin resistance during pregnancy

Prediabetes Insulin resistance – Increase insulin secretion

Classification of Diabetes Mellitus


Prediabetes

• People with prediabetes have impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) - blood glucose levels are higher than normal, but not high enough for a diagnosis of diabetes.

• Long term risk: type 2 diabetes, heart attack and stroke.

© CBR Nutrition Enterprises DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010

Diabetes and Prediabetes

Diagnosis Fasting Plasma BG 2-Hour OGTT A1C

No diabetes <100 mg/dL <140 mg/dL < 5.7%

Prediabetes 100 – 125 mg/dL 140 – 199 mg/dL 5.7 –6.4%

Diabetes ≥126 mg/dL ≥ 200 mg/dL ≥ 6.5%

Diagnosing Diabetes & Prediabetes

Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%

No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available

at http://www.cdc.gov/diabetes/statistics

2013

2013

© CBR Nutrition Enterprises Evert, et al. Diabetes Care 2014

Diabetes Risk Factors

• Overweight• 45 years or older• Parent or sibling type 2 diabetes• Physically active fewer than 3 times weekly• Gave birth to a baby weighing more than 9 lbs

(> 4 kg)• History of gestational diabetes

© CBR Nutrition Enterprises Evert, et al. Diabetes Care 2014

Diabetes Risk Factors

• Race and ethnicityAfrican Americans, Hispanic/Latino Americans, American Indians, Pacific Islanders and Asian Americans.

• Infants of women with gestational diabetes• Prenatal exposure to famine

© CBR Nutrition Enterprises www.eatingsoulfully.com

Diabetes PreventionLifestyle Intervention

• Da Qing Study

• Diabetes Prevention Program

• The Finnish Diabetes Prevention Study

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• 110,660 adults from 33 Da Qing, China, health care clinics screened in 1986 for impaired glucose tolerance, type 2 diabetes mellitus

• 577 adults with impaired glucose tolerance (WHO criteria) randomized to control (n=138) or one of three lifestyle interventions (n=438)

Diet onlyExercise onlyDiet + exercise

Follow-up at 2-year intervals over 6 years to identifythose who developed diabetes

Da Qing Study Methods

American Diabetes AssociationPan XR, et al. Diabetes Care. 1997;20:537-544.


• Cumulative incidence of diabetes at6 years was significantly decreased in the active intervention groups (P<0.05)

• When analyzed by clinic, each active intervention group differed significantly from the control (P<0.05)

Da Qing Study Results


Control 67.7% (95% CI, 59.8-75.2)

Diet 43.8% (95% CI, 35.5-52.3)

Exercise 41.1% (95% CI, 33.4-49.4)

Diet + exercise 46.0% (95% CI, 37.3-54.7)


• Active intervention with diet and/or exercise led to a significant decrease in incidence of diabetes over a 6-year period (1986-1992) among those with IGT

• Diabetes incidence (per 100 person years) per year

Control: 14.1 (95% CI 11.2-17.0)Lifestyle intervention: 7.9 (95% CI, 6.8-9.1)

Da Qing Study Conclusions



Finnish Diabetes Prevention Study Methods

• 522 subjects, 40-65 years of age BMI ≥25 kg/m2; IGT: 2-h PPG 140-200 mg/dL

• Control group: general oral and written information diet and exercise

• Intervention group: individualized- Reduce weight ≥5%- Decrease fat ≤30%, saturated fat ≤10% energy- Increase fiber to at least 15 g/1000 kcal- Moderate exercise ≥30 minutes/day

• Primary end point: diagnosis of diabetesAmerican Diabetes Association

Tuomilehto J, et al for the Finnish Diabetes Prevention Study Group.N Engl J Med. 2001;344:1343-1350.


Finnish Diabetes Prevention Study Results

American Diabetes AssociationTuomilehto J, et al for the Finnish Diabetes Prevention Study Group.

N Engl J Med. 2001;344:1343-1350.

Weight Loss, KgMean ± SD

Cumulative Incidence of

DiabetesAfter 4 YearsYear 1 Year 2

Control 0.8±3.7 0.8±4.4 23%(95% CI, 17-29)

Intervention 4.2±5.1* 3.5±5.5* 11% (95% CI, 6-15)

Risk Reduction 58%*

*P<0.001

172 men, 350 women; mean age 55 yMean BMI 31 kg/m2

Mean duration of follow-up 3.2 years


Finnish Diabetes Prevention Study Conclusion

• Reduction in incidence of type 2 diabetes was directly associated with changes in lifestyles of high-risk subjects (ie, those with IGT)

- Modifiable risk factors such as obesity, physical inactivity, suggested as main nongenetic determinants of diabetes

American Diabetes AssociationTuomilehto J, et al for the Finnish Diabetes Prevention Study Group.

N Engl J Med. 2001;344:1343-1350.


• 3,234 nondiabetic persons in 27 clinical centers- BMI ≥24 kg/m2 (≥22 kg/m2 in Asians)- IGT: FPG 95-125 mg/dL or 2-h PPG 140-199

mg/dL• From 1996-1999, randomly assigned to

- Standard lifestyle + placebo (n=1082)- Standard lifestyle + metformin, initiated at 850

mg orally once daily; at 1 month, increased to 850 mg twice daily (n=1073)

- Intensive lifestyle intervention (n=1079)

Diabetes Prevention Program

American Diabetes AssociationKnowler WC, et al. for the Diabetes Prevention Program Research Group.

N Engl J Med. 2002;346:393-403.


Goals of intensive lifestyle intervention

• 7% loss of body weight- Dietary fat goal: 25% of calories from fat- Calorie intake goal: 1200-1800 kcal/day based on initial body

weight• >150 minutes of physical activities weekly

- Similar in intensity to brisk walking; at least 700 kcal/week• Group received 16-lesson curriculum



N Engl J Med. 2002;346:393-403.



• Results• Lifestyle intervention reduced risk of developing

diabetes by 58% vs 31% in metformin group • Those aged 60 and older, lifestyle intervention

reduced their risk by 71%- About 5% in lifestyle intervention vs 7.8% in

metformin group developed diabetes each year during the study period, compared with 11% of those in the placebo group.


N Engl J Med. 2002;346:393-403.


Lifestyle Interventions Sustained Effects

Da Qing Study 20-Year Follow-Up

• Combined lifestyle intervention vs control- 51% lower incidence of diabetes during

active intervention- 43% lower incidence over 20 years- 3.6 years fewer with diabetes

. American Diabetes AssociationPan XR, et al. Diabetes Care. 1997;20:537-544.


Diabetes Prevention Program Outcomes Study• After an average of 10 years follow up, intensive

lifestyle changes aimed at modest weight loss• Reduced rate of developing type 2 diabetes by 34%

vs placebo• Reduced rate of developing type 2 diabetes by 49%

in those age 60 and older compared with placebo• Delayed type 2 diabetes by approx 4 years

compared with placebo• Reduced cardiovascular risk factors

Diabetes Prevention Program Research Group, Lancet 2009, 374: 1677-1686Diabetes Prevention Program Research Group, Diabetes Care 2014, 37:2622-2631

Lifestyle Interventions Sustained Effects


International Diabetes Federation Prevention Strategies

“A life course approach is imperative to reduce the intergenerational transmission of diabetes”

- Epigenetic Process- Maternal Under or Over Nutrition- Low Birthweight- Newborn Over-Feeding

Encourage a healthy eating pattern across the lifespan. - During pregnancy- In fetal and early postnatal life


Lifestyle Interventions Including Yogurt

The 2015 Dietary Guidelines Advisory Committee concluded that “consumption of dairy foods provides numerous health benefits, including lower risk of diabetes, metabolic syndrome, cardiovascular disease and obesity.”


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The intake of yogurt is consistently associated with lower incidence of diabetes mellitus

- Inverse association between yogurt intake and type 2 diabetes

incidence.

- One serving low fat yogurt is associated with a reduced risk of type 2

diabetes.

- Yogurt consumption associated with a healthy weight, decreased

waist circumference, healthy levels of circulating glucose within the

normal range and decreased blood pressure. • Mozaffarian, D.; Hao, T.; Rimm, E.B.; Willett, W.C.; Hu, F.B. Changes in diet and lifestyle and long-term weight gain in women and men. N. Engl. J. Med. 2011, 364, 2392–2404.• Wang, H.; Livingston, K.A.; Fox, C.S.; Meigs, J.B.; Jacques, P.F. Yogurt consumption is associated with better diet quality and metabolic profile in American men and women. Nutr. Res. 2013, 33, 18–26• Dairy Food Consumption is Associated with Reduced Risk of Type 2 Diabetes: Science Summary. (National Dairy Council. 2014.) • Tong, X.; Dong, J.Y.; Wu, Z.W.; Li, W.; Qin, L.Q. Dairy consumption and risk of type 2 diabetes mellitus: A meta-analysis of cohort studies. (Eur. J. Clin. Nutr. 2011)• O’Connor, L. M.; Lentjes, M. A. H.; Luben, R. N.; Khaw, K.;Wareham, N.J.; Forouhi, N. G. Dietary dairy product intake and incident type 2 diabetes:a prospective study using dietary data from a 7-day food diary. Diabetologia.DOI

10.1007/s00125-014-3176-1. • Mu Chen; Qi Sun; Edward Giovannucci; Dariush Mozaffarian; JoAnn E Manson; Walter C Willett; and Frank B Hu. Dairy consumption and risk of type 2 diabetes: 3 cohorts of US adults and an updated meta-analysis . BMC Medicine

2014, 12:215.• Díaz‐López, et al. Dairy product consumption and risk of type 2 diabetes in an elderly Spanish Mediterranean population at high cardiovascular risk. Eur J Nutr.DOI 10.1007/s00394-015-0855-8.

Health Benefit of Yogurt


Healthful Diet Patterns Include Yogurt

Dietary Approaches to Stop Hypertension (DASH)

Mediterranean Style Eating Pattern


Dietary Eating Patterns

Dietary Approaches to Stop Hypertension (DASH)

• Control Blood Pressure

• Lower Risk for CVD

• Recommended for General Public - 2015 DGAs

• Associated with Improved AIC

Emphasizes fruits, vegetables, and low-fat dairy products, including whole grains, poultry, fish, and nuts and is reduced in saturated fat, red meat, sweets, and sugar-containing beverages. The most effective DASH diet was also reduced in sodium.

Evert, et al. Diabetes Care 2014


Dietary Eating Patterns

Mediterranean Style Eating Pattern Diets

• Improve cardiovascular risk factor ( lipids, blood pressure and

triglycerides).

• Associated with reduced incidence of type 2 diabetes

• Recommended for General Public - 2015 DGAs

Emphasizes fruits, vegetables, beans, nuts and seeds; minimally processed, seasonally fresh, and locally grown foods; olive oil; dairy products (mainly cheese and yogurt) fewer than 4 eggs/week; red meat consumed in low frequency and amounts; and wine consumption in low to moderate amounts generally.

Evidence-based dietary priorities for cardiometabolic health.

Dariush Mozaffarian Circulation. 2016;133:187-225Copyright © American Heart Association, Inc. All rights reserved.


Conclusions

✓ Prevention of diabetes must start with a healthy pregnancy

✓ We must identify individuals at highest risk for prediabetes

✓ Modest dietary and lifestyle changes are most effective

✓ Yogurt can play a positive role in diabetes prevention✓ Delaying or preventing type 2 diabetes will help turn

the tide on the diabetes epidemic


Thank You For Your Attention

Constance Brown-Riggs, MSEd, RD, CDE, CDN

Nutrition Consultant – Certified Diabetes Educator

100 Veterans Blvd, Suite 15Massapequa, NY 11758

516.795.4288constance@eatingsoulfully.comwww.constancebrownriggs.com

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