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Hu Y, Liu G, Yu E, Wang B, Wittenbecher C, Manson JE, Rimm EB, Liang L, Rexrode K, Willett WC, Hu FB, Sun Q. Low-Carbohydrate Diet Scores and Mortality Among Adults With Incident Type 2 Diabetes. Diabetes Care 2023; 46:874-884. [PMID: 36787923 PMCID: PMC10090909 DOI: 10.2337/dc22-2310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE The current study aims to prospectively examine the association between postdiagnosis low-carbohydrate diet (LCD) patterns and mortality among individuals with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS Among participants with incident diabetes identified in the Nurses' Health Study and Health Professionals Follow-up Study, an overall total LCD score (TLCDS) was calculated based on the percentage of energy as total carbohydrates. In addition, vegetable (VLCDS), animal (ALCDS), healthy (HLCDS), and unhealthy (ULCDS) LCDS were further derived that emphasized different sources and quality of macronutrients. Multivariable-adjusted Cox models were used to assess the association between the LCDS and mortality. RESULTS Among 10,101 incident T2D cases contributing 139,407 person-years during follow-up, we documented 4,595 deaths of which 1,389 cases were attributed to cardiovascular disease (CVD) and 881 to cancer. The pooled multivariable-adjusted hazard ratios (HRs, 95% CIs) of total mortality per 10-point increment of postdiagnosis LCDS were 0.87 (0.82, 0.92) for TLCDS, 0.76 (0.71, 0.82) for VLCDS, and 0.78 (0.73, 0.84) for HLCDS. Both VLCDS and HLCDS were also associated with significantly lower CVD and cancer mortality. Each 10-point increase of TLCDS, VLCDS, and HLCDS from prediagnosis to postdiagnosis period was associated with 12% (7%, 17%), 25% (19%, 30%), and 25% (19%, 30%) lower total mortality, respectively. No significant associations were observed for ALCDS and ULCDS. CONCLUSIONS Among people with T2D, greater adherence to LCD patterns that emphasize high-quality sources of macronutrients was significantly associated with lower total, cardiovascular, and cancer mortality.
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Affiliation(s)
- Yang Hu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Gang Liu
- Department of Nutrition and Food Hygiene, Huazhong University of Science and Technology School of Public Health, Wuhan, China
| | - Edward Yu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Biqi Wang
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | | | - JoAnn E. Manson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Eric B. Rimm
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Liming Liang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Kathryn Rexrode
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Walter C. Willett
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Frank B. Hu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Qi Sun
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Kim SJ, Witchell EC, Conklin AI. Therapeutic carbohydrate restriction pre-COVID pandemic: assessing registered dietitians' knowledge, use and perceived barriers in Canada. Eur J Clin Nutr 2023; 77:98-104. [PMID: 35945261 DOI: 10.1038/s41430-022-01193-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND/OBJECTIVES Evidence supports therapeutic carbohydrate restriction (TCR) for managing appropriate patients with chronic illness, but little is known about TCR prescribing among dietitians. This study evaluated dietitians' knowledge, information use and needs for TCR in Canada. METHODS Registered dietitians (RDs) were recruited (n = 274) from January to December 2020 to collect semi-structured data using an online needs assessment survey (French and English). Descriptive and inferential statistics were used to describe and assess which nine RD practice characteristics predicted TCR prescription in clinical practice. RESULTS Respondents were located in all provinces and territories in Canada, with few international responses in the sample (3.5%). We found statistically significant differences between RDs who have prescribed TCR or not in four practice characteristics studied: level of knowledge (p < 0.001), reviewing literature (p = 0.02), clinician referrals (p < 0.001) or personal experience (p < 0.001). Multivariable models showed that the odds of prescribing TCR was associated with intermediate/expert knowledge (OR 5.92 [95% CI: 2.26-17.77]), clinician's referral (OR 3.22 [1.73-6.14]) and personal experience, whether a former user (OR 2.24 [1.09-4.72]) or a current user of TCR (OR 9.09 [2.70-42.09]), compared to no knowledge, no referral or no experience. CONCLUSION There is a strong link between the use, or lack, of TCR in clinical practice among RDs and their knowledge level, personal experience and clinician referrals/support. Scope exists to develop novel educational tools and resources on scientific evidence for TCR, and increase multidisciplinary teams, so as to better support RDs in Canada to safely implement TCR in appropriate patients with chronic illness.
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Affiliation(s)
- Son Jun Kim
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Eliana C Witchell
- Institute for Personalized Therapeutic Nutrition, Vancouver, BC, Canada
| | - Annalijn I Conklin
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
- Centre for Health Evaluation and Outcome Sciences, Providence Health Research Institute, University of British Columbia, Vancouver, BC, Canada.
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Mayr HL, Savill H, Law L, Campbell KL, Hill J, Palmer M, Hickman IJ, Kelly JT. ‘We work in silos’: Exploring clinicians' perspectives on the dietary management of coronary heart disease and type 2 diabetes in an Australian public hospital and community health service. Nutr Diet 2022. [DOI: 10.1111/1747-0080.12789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Hannah L. Mayr
- Department of Nutrition and Dietetics Princess Alexandra Hospital Brisbane Queensland Australia
- Faculty of Health Sciences and Medicine, Bond University Nutrition and Dietetics Research Group Bond University Gold Coast Queensland Australia
- Greater Brisbane Clinical School, Faculty of Medicine The University of Queensland Brisbane Queensland Australia
- Centre for Functioning and Health Research Metro South Hospital and Health Service Brisbane Queensland Australia
| | - Holly Savill
- Faculty of Health Sciences and Medicine, Bond University Nutrition and Dietetics Research Group Bond University Gold Coast Queensland Australia
| | - Lynette Law
- Faculty of Health Sciences and Medicine, Bond University Nutrition and Dietetics Research Group Bond University Gold Coast Queensland Australia
| | - Katrina L. Campbell
- Greater Brisbane Clinical School, Faculty of Medicine The University of Queensland Brisbane Queensland Australia
- Metro North Hospital and Health Service Brisbane Queensland Australia
| | - Jan Hill
- Department of Nutrition and Dietetics Princess Alexandra Hospital Brisbane Queensland Australia
| | - Michelle Palmer
- Department of Nutrition and Dietetics Logan Hospital Brisbane Queensland Australia
| | - Ingrid J. Hickman
- Department of Nutrition and Dietetics Princess Alexandra Hospital Brisbane Queensland Australia
- Greater Brisbane Clinical School, Faculty of Medicine The University of Queensland Brisbane Queensland Australia
| | - Jaimon T. Kelly
- Centre for Online Health, Faculty of Medicine The University of Queensland Brisbane Queensland Australia
- Centre for Health Services Research, Faculty of Medicine The University of Queensland Brisbane Queensland Australia
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Mellos I, Probst Y. Evaluating augmented reality for 'real life' teaching of food portion concepts. J Hum Nutr Diet 2022; 35:1245-1254. [PMID: 35419898 PMCID: PMC9790224 DOI: 10.1111/jhn.13016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 04/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Estimation of food portions is a vital skill for dietitians, which is developed during formal nutrition training. Skill development is often accomplished by training with food portion estimation tools. These tools can vary in design but evaluations often reveal them to be limited in their effectiveness and generally impractical for everyday use. The aim of this study was to develop and evaluate an augmented reality (AR) tool for the estimation food portions. METHODS An online, quasi-experimental, randomised pre-test post-test study was conducted to evaluate the effectiveness of three food portion tools with nutrition students. These tools consisted of an online, AR, and an infographic tool (control). Students tested 10 different food images and were asked to estimate food portion sizes with and without assistance of a portion tool to determine absolute error, relative error, and overall improvement in estimation. RESULTS A total of 33 participants enrolled in the study with 26 (72.0%) completing the study. The mean absolute error was lowest in the online group (53.0%), followed by AR (59.5%) and control (64.0%). Relative error scores revealed higher accuracy for the AR group (45.5%) followed by online (43.5%), and control group (29.0%). Overall improvement in estimation was highest in the AR group (+12.2%) followed by the online (+11.6%) tool with a decrease seen for the infographic (-1.7%) tool. CONCLUSIONS The use of technology, notably AR technology, may provide some advantage when training nutrition students in food portion estimation, although further investigation is advised.
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Affiliation(s)
- Ioannis Mellos
- Smart Foods Centre, School of Medicine, Science Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Yasmine Probst
- Smart Foods Centre, School of Medicine, Science Medicine and HealthUniversity of WollongongWollongongAustralia
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Newson L, Parody FH. Investigating the experiences of low-carbohydrate diets for people living with Type 2 Diabetes: A thematic analysis. PLoS One 2022; 17:e0273422. [PMID: 35994442 PMCID: PMC9394793 DOI: 10.1371/journal.pone.0273422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Low-Carbohydrate Diets (LCDs) are becoming increasingly popular to manage Type 2 diabetes mellitus (T2DM). However, there is a need to identify people with T2DM’s understanding of LCDs, their reasons for engaging in such a diet, how they sustain it and any challenges they face. This study aimed to assess the experience of adhering to a LCD within a sample of individuals with T2DM. Ten participants with T2DM were recruited using a self-selecting sampling method from an online diabetes community that promotes LCDs. Participants completed one-to-one digitally recorded semi-structured interviews, which were later transcribed verbatim and data subjected to Thematic Analysis. Five core themes and twelve subthemes were developed during the analysis: (1) Lack of professional guidance; (2) Fear of complications & long-term medication use; (3) Dietary control as motivation; (4) Positive health outcomes; and (5) Social support. The findings are discussed with reference to a psychological model of behaviour, COM-B. Participants reported gaining knowledge and skills to increase their Capability to engage in LCDs, Motivation to manage diabetes outcomes influenced adherence. However, challenges were reported with the Opportunity to engage in behaviour, mainly influenced by social support. Health professionals and significant others may benefit from resources to help build knowledge and understanding and assist with maintaining a LCD long-term.
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Affiliation(s)
- Lisa Newson
- School of Psychology, Faculty of Health, Liverpool John Moores University, Liverpool, United Kingdom
- * E-mail:
| | - Francesca Helen Parody
- School of Psychology, Faculty of Health, Liverpool John Moores University, Liverpool, United Kingdom
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Moutou KE, England C, Gutteridge C, Toumpakari Z, McArdle PD, Papadaki A. Exploring dietitians' practice and views of giving advice on dietary patterns to patients with type 2 diabetes mellitus: A qualitative study. J Hum Nutr Diet 2021; 35:179-190. [PMID: 34370332 DOI: 10.1111/jhn.12939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dietary guidelines for type 2 diabetes mellitus (T2DM) emphasise weight management and individualised total carbohydrate intake. Evidence on the most effective dietary patterns (DPs) for T2DM management is mixed, potentially leading to variations in the advice that dietitians provide. The present study aimed to explore dietitians' practice of DP advice provision to adults with T2DM, as well as understand their views when advising their patients on the DPs deemed effective for glycaemic management or recommended by current guidelines. METHODS Semi-structured interviews were conducted with 12 UK-registered dietitians, with experience in consulting adults with T2DM. Dietitians were asked for their views on five DPs recommended for glycaemic management of T2DM. Interview transcripts were analysed using deductive and inductive thematic analysis. RESULTS Nine themes were identified that draw attention to DP advice provision practices, the five DPs (low-carbohydrate, low-fat, low-glycaemic index, Mediterranean diet and Dietary Approaches to Stop Hypertension diet), other DPs, the barriers and facilitators to DP advice provision and following this advice, and the factors affecting the provision of DP advice. Participants' current practice of DP advice provision to patients with T2DM was perceived to be individualised and patient-centred. Participants discussed their current practice and perceptions of available evidence and how patients respond to advice on the DPs shown to be effective for glycaemic management. Several barriers to providing advice on specific DPs, including safety and compliance challenges, were identified. Participants also highlighted factors that would facilitate the provision of advice on specific DPs and would help patients to follow this advice, including social support, educational resources and more robust scientific evidence. CONCLUSIONS The findings of the present study provide important insights regarding dietitians' views of promoting whole DPs to patients with T2DM. Emerged barriers and facilitators should be considered when developing future guidance for dietetic practice to support patients with following whole DPs for T2DM management.
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Affiliation(s)
- Konstantina E Moutou
- School for Policy Studies, Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK
| | - Clare England
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Callum Gutteridge
- School for Policy Studies, Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK
| | - Zoi Toumpakari
- School for Policy Studies, Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Paul D McArdle
- Birmingham Community Healthcare NHS Foundation Trust, Birmingham, UK
| | - Angeliki Papadaki
- School for Policy Studies, Centre for Exercise, Nutrition and Health Sciences, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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Sousa AA, Renke G, Leal A, Rassi MMB, Feuser CS, Cunha H, Silva FM, Arbex A. Current Evidence Regarding Low-carb Diets for The Metabolic Control of Type-2 Diabetes. Curr Diabetes Rev 2021; 17:e112220188254. [PMID: 33231159 DOI: 10.2174/1573399816666201123104358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/13/2020] [Accepted: 08/20/2020] [Indexed: 11/22/2022]
Abstract
The management of diabetes requires a medical nutrition therapy as an essential part of this treatment. There should be no "one-size-fits-all" eating pattern for different patient´s profiles with diabetes. It is clinically complex to suggest an ideal percentage of calories from carbohydrates, protein and lipids recommended for all patients with diabetes. Among the eating patterns that have shown beneficial effects on metabolic control of patients with type 2 diabetes is the lowcarb diet, since the carbohydrate ingestion is viewed as the most important determinant of postprandial glucose and insulin response. In this context, theoretically, it could make sense to reduce the daily amount of carbohydrates ingested, to achieve lower levels of HbA1c. There could be risks associated to this approach. The adherence to a low-carb diet is here also discussed. This narrative review shows on the current evidence for answering these questions regarding low-carb diet as a possible alternative eating pattern for type 2 diabetes.
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Affiliation(s)
- Adriana Andrade Sousa
- Department of Endocrinology IPEMED Medical School / AFYA Educational, São Paulo, Brazil
| | - Guilherme Renke
- Department of Endocrinology IPEMED Medical School / AFYA Educational, São Paulo, Brazil
| | - Aluysio Leal
- Department of Endocrinology IPEMED Medical School / AFYA Educational, São Paulo, Brazil
| | | | | | - Heber Cunha
- Department of Endocrinology IPEMED Medical School / AFYA Educational, São Paulo, Brazil
| | - Flávia Moraes Silva
- Department of Nutrition and Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Alberto Arbex
- Department of Endocrinology IPEMED Medical School / AFYA Educational, São Paulo, Brazil
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Investigating Whether the Mediterranean Dietary Pattern Is Integrated in Routine Dietetic Practice for Management of Chronic Conditions: A National Survey of Dietitians. Nutrients 2020; 12:nu12113395. [PMID: 33158299 PMCID: PMC7694348 DOI: 10.3390/nu12113395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 01/13/2023] Open
Abstract
Evidence supports recommending the Mediterranean dietary pattern (MDP) in the management of cardiovascular disease (CVD), type 2 diabetes (T2D), non-alcoholic fatty liver disease (NAFLD) and solid organ transplant (SOT). However, the evidence-practice gap is unclear within non-Mediterranean countries. We investigated integration of MDP in Australian dietetic practice, and barriers and enablers to MDP implementation for chronic disease management. Dietitians managing CVD, T2D, NAFLD and/or SOT patients (n = 182, 97% female) completed an online survey in November 2019. Fewer than 50% of participants counsel patients with CVD (48%), T2D (26%), NAFLD (31%) and SOT (0–33%) on MDP in majority of their practice. MDP principles always recommended by >50% of participants were promoting vegetables and fruit and limiting processed foods and sugary drinks. Principles recommended sometimes, rarely or never by >50% of participants included limiting red meat and including tomatoes, onion/garlic and liberal extra virgin olive oil. Barriers to counselling on MDP included consultation time and competing priorities. Access to evidence, professional development and education resources were identified enablers. An evidence-practice gap in Australian dietetic practice exists with <50% of participants routinely counselling relevant patient groups on MDP. Strategies to support dietitians to counsel complex patients on MDP within limited consultations are needed.
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Winham DM, Nikl RR, Hutchins AM, Martin RL, Campbell CG. Dietitians vary by counseling status in bean promotion with type 2 diabetes clients: A pilot study. Food Sci Nutr 2020; 8:2839-2847. [PMID: 32566201 PMCID: PMC7300060 DOI: 10.1002/fsn3.1578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/03/2020] [Accepted: 03/22/2020] [Indexed: 11/30/2022] Open
Abstract
Beans are noted for their beneficial effects on blood glucose for persons with type 2 diabetes mellitus (T2DM). However, little is known about dietitian attitudes and perceptions, self-efficacy, or counseling practices about beans in T2DM management. Through an online survey, the attitudes and perceptions dietitians have toward the role of beans in managing T2DM were examined. The practice intentions for advising T2DM clients about beans, perceived self-efficacy for counseling on general nutrition topics and specifically on beans, were evaluated. While the target population was dietitians, all persons on the Arizona Dietetic Association and the Arizona School Nutrition Association listservs received a direct email invitation for an online survey on foods and chronic disease. There was no mention of beans or pulses to reduce bias toward bean advocates. Of the 302 dietitian respondents, over 66% counseled clients with T2DM. Fewer clinical counseling dietitians recommended beans to control blood glucose (p = .041) or to increase fiber (p < .05), and more of them promoted beans as being the same as other carbohydrates (p = .002). Higher mean self-efficacy scores for general nutrition counseling were observed for T2DM counseling RDs (p < .001). Counseling dietitians in nonclinical settings had the highest bean self-efficacy score (p < .001). Findings suggest clinical counseling dietitians are aware of bean health benefits, but do not consistently suggest beans to improve nutrition for those with T2DM in contrast to dietitians who counsel in other settings.
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Affiliation(s)
- Donna M. Winham
- Food Science & Human NutritionIowa State UniversityAmesIAUSA
| | - Rebecca R. Nikl
- Food Science & Human NutritionIowa State UniversityAmesIAUSA
- UnityPoint Health Des MoinesDes MoinesIAUSA
| | - Andrea M. Hutchins
- Human Physiology and NutritionUniversity of Colorado Colorado SpringsColorado SpringsCOUSA
| | - Rose L. Martin
- Food Science & Human NutritionIowa State UniversityAmesIAUSA
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Low-Carbohydrate Diets in the Management of Obesity and Type 2 Diabetes: A Review from Clinicians Using the Approach in Practice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17072557. [PMID: 32276484 PMCID: PMC7177487 DOI: 10.3390/ijerph17072557] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/14/2022]
Abstract
Low-carbohydrate diets are increasingly used to help patients with obesity and type 2 diabetes. We sought to provide an overview of the evidence for this treatment approach, considering the epidemiology and pathophysiology of obesity and diabetes in terms of carbohydrate excess. We describe the mechanistic basis for the clinical benefits associated with nutritional ketosis and identify areas of practice where the evidence base could be improved. We summarize the key principles which inform our approach to treating patients with low-carbohydrate diets. The scientific controversy relating to these diets is real but is consistent with the known challenges of any dietary interventions and also the limitations of nutritional epidemiology. Secondly, notwithstanding any controversy, international guidelines now recognize the validity and endorse the use of these diets as a therapeutic nutritional approach, in appropriate patients. Thirdly, we have found that early de-prescription of diabetes medications is essential, in particular insulin, sulphonylureas, and sodium-glucose cotransporter (SGLT2) inhibitors. Fourthly, we encourage patients to eat ad libitum to satiety, rather than calorie counting per se. Furthermore, we monitor cardiovascular risk factors frequently, as with all patients with obesity or diabetes, but we do not necessarily consider an increase in low-density lipoprotein (LDL)-cholesterol as an absolute indication to stop these diets, as this is usually related to large LDL particles, which are not associated with increased cardiovascular risk. In the absence of large randomized controlled trials with cardiovascular and other hard endpoints, adopting a low-carbohydrate diet is a legitimate and potentially effective treatment option for patients with diabetes or obesity.
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Allmark G, Calder PC, Marino LV. Research identified variation in nutrition practice by community prescribing dietitians with regards to the identification and management of malnutrition amongst community dwelling adults. Nutr Res 2019; 76:94-105. [PMID: 31837829 DOI: 10.1016/j.nutres.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/30/2019] [Accepted: 10/15/2019] [Indexed: 01/29/2023]
Abstract
To improve nutritional outcomes of community dwelling adults with malnutrition we identified three related hypotheses to be tested: i) Southampton Community Prescribing Support Service dietitians achieve 100% compliance with selected standards of the National Institute for Health and Clinical Excellence Clinical Guideline (CG) 32, ii) patient service satisfaction amongst community dwelling adults accessing the prescribing support service is high (90%), and iii) nationally, dietitians use weight gain goal >10% and BMI >18.5 kg/m2 as outcome measures from the service phases of prescribing support. A retrospective audit of records of 100 community-dwelling adults accessing local services considered CG32 "Indications for nutrition support in hospital and community standard 1.3.1" and CG32 "Monitoring of nutrition support in hospital and community standard 1.5.6". A questionnaire was distributed to community-dwelling adults (n = 52) accessing the service, in addition to a national survey of dietetic practice. Compliance with standard 1.3.1 was 46% and with standard 1.5.6 it was 82%. The majority of patients (86%; n = 13) reported satisfaction with the support service. Nationally, 89% (n = 51) of dietitians use weight and 87% (n = 50) use BMI as an outcome measure for success of nutritional intervention. All research hypotheses were rejected. These results suggest there is considerable variation in the identification and management of malnutrition amongst community dwelling adults, which may impact on clinical and nutritional outcomes. Future work should consider quality improvement projects to address potential barriers to achieving best practice by community prescribing dietitians through the use of nutrition pathways to support older adults with malnutrition.
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Affiliation(s)
- Grace Allmark
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - Philip C Calder
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Luise V Marino
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom; Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
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12
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Dyson P, McArdle P, Mellor D, Guess N. James Lind Alliance research priorities: what role do carbohydrates, fats and proteins have in the management of Type 2 diabetes, and are there risks and benefits associated with particular approaches? Diabet Med 2019; 36:287-296. [PMID: 30264442 DOI: 10.1111/dme.13826] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2018] [Indexed: 12/12/2022]
Abstract
AIMS To assess the role played by carbohydrates, fat and proteins in the management of Type 2 diabetes. BACKGROUND Diabetes research tends to reflect the interests of academics or the pharmaceutical industry, rather than those of people living with Type 2 diabetes. The James Lind Alliance and Diabetes UK addressed this issue by defining the research priorities of people living with Type 2 diabetes. Three of the top 10 research priority questions focused on lifestyle. METHODS A narrative review was undertaken with a structured search strategy using three databases. Search terms included the three macronutrients and Type 2 diabetes. No restrictions were placed on macronutrient quantity or length of study follow-up. Outcomes included changes in HbA1c , body weight, insulin sensitivity and cardiovascular risk. RESULTS There is no strong evidence that there is an optimal ratio of macronutrients for improving glycaemic control or reducing cardiovascular risk. Challenges included defining the independent effect of macronutrient manipulation and identifying the effects of macronutrients, independent of foods and dietary patterns. Extreme intakes of macronutrients may be associated with health risks. CONCLUSIONS It is challenging to formulate food-based guidelines from studies based on macronutrient manipulation. Structured education should be offered to support individuals in discovering their optimal, individual dietary approach. Recommendations for dietary guidelines should be expressed in terms of foods and not macronutrients.
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Affiliation(s)
- P Dyson
- OCDEM, University of Oxford, Churchill Hospital, Oxford, UK
| | - P McArdle
- Birmingham Community Nutrition, Birmingham, UK
| | - D Mellor
- School of Life Sciences, Coventry University, Coventry, UK
| | - N Guess
- Kings College London, London, UK
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Mellor DD, Langley-Evans S, Holt RIG. Update of Diabetes UK Evidence-Based Nutritional Guidelines for 2018: a celebration of two leading journals working together to improve nutritional science and dietetic care for people living with diabetes. J Hum Nutr Diet 2018; 31:289-291. [DOI: 10.1111/jhn.12564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mellor D, Langley-Evans S, Holt RIG. Update of Diabetes UK Evidence-Based Nutritional Guidelines for 2018: a celebration of two leading journals working together to improve nutritional science and dietetic care for people living with diabetes. Diabet Med 2018; 35:539-540. [PMID: 29658193 DOI: 10.1111/dme.13620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- D Mellor
- Journal of Human Nutrition and Dietetics, University of Canberra, ACT, Australia
| | - S Langley-Evans
- Journal of Human Nutrition and Dietetics, University of Nottingham, Nottingham, UK
| | - R I G Holt
- Diabetic Medicine, University of Southampton, Southampton, UK
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Taylor R, Barnes AC. Translating aetiological insight into sustainable management of type 2 diabetes. Diabetologia 2018; 61:273-283. [PMID: 29143063 PMCID: PMC6448962 DOI: 10.1007/s00125-017-4504-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 08/11/2017] [Indexed: 12/15/2022]
Abstract
Using a low-energy diet as a tool, it has been possible to elucidate the sequence of pathophysiological changes that lead to the onset of type 2 diabetes. Negative energy balance in type 2 diabetes causes a profound fall in liver fat content resulting in normalisation of hepatic insulin sensitivity within 7 days. As the period of negative energy balance extends and liver fat levels fall to low normal, the rate of export of triacylglycerol from the liver falls. Consequent to this, the raised pancreas fat content falls and in early type 2 diabetes, normal first-phase insulin secretion becomes re-established with normal plasma glucose control. This research, driven by the predictions of the 2008 twin cycle hypothesis, has led to a paradigm shift in understanding. Studying the reversed sequence of pathophysiological changes, the linked abnormalities in liver and pancreas have been revealed. Early type 2 diabetes is a potentially reversible condition. Surprisingly, it was observed that the diet devised as an experimental tool was actually liked by research participants. It was associated neither with hunger nor tiredness in most people, but with rapidly increased wellbeing. A defined period of weight loss followed by carefully planned weight maintenance-the 'One, Two' approach-has since been applied in clinical practice. Motivated individuals can reverse their type 2 diabetes and remain normoglycaemic over years. A large study is underway to evaluate the applicability of this general approach to routine primary care practice as a long-term management strategy.
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Affiliation(s)
- Roy Taylor
- Newcastle Magnetic Resonance Centre, Institute for Cellular Medicine, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, NE4 5PL, UK.
| | - Alison C Barnes
- Human Nutrition Research Centre, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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