Reversing Diabetes with

Medical Nutrition Therapy:

Therapeutic Effects of A

Vegan Lifestyle

Jen King

Outline

Background

Review Articles

Article 1

Article 2

Article 3

Conclusions

Suggestions for Future Research

Questions

Significance of Type 2

Rising health epidemic in U.S.

Most common form of diabetes; 90-95% of DM

Preventable

23.6 million Americans with DM

165% projected increase by 2050

5th leading cause of death

Type 2 Diabetes

Diabetes Mellitus (DM)

Combination of insulin resistance and beta cell failure

“Non-insulin dependent”

Progressive disease

Risk factors: obesity, or have abdominal obesity; age, lack of physical activity

“Normal” Actions of Insulin

Secreted by the pancreas

Effects:

Increase uptake of glucose into skeletal muscle and adipose tissue

Decrease hepatic glucose production

Decrease release of NEFAs from adipose tissue

Diabetes: defective insulin production and/or action (IR). Above effects of insulin do not occur

Obesity and Insulin Resistance

Obesity (abdominal visceral)

Increased release of FFAs from adipocytes

Increases FFA flux to the liver, which causes an increase in hepatic glucose production, and a decrease in glucose utilization.

RESULT: Increase Blood Glucose Levels

*Defects in insulin signaling, so insulin does not effectively facilitate glucose entry into cells

Signs and Symptoms

Hyperglycemia

Glycosuria

Polyuria

Polydipsia

Dehydration

Related Health Complications

Hypoglycemia

Hyperglycemia

Ketoacidosis

Long-term damage

Eye complications (diabetic

retinopathy)

Kidney disease

Nerve Damage/Neuropathy

Heart disease and stroke

Methods of Diagnosis

Fasting plasma glucose (FPG)

Casual plasma glucose (any time of day)

Oral glucose tolerance test (OGTT)

Due to ease and cost, FPG tests is

recommended

Diagnosis

Diabetes Management

Intensive glycemic control

Balanced diet, proper nutrition

Regular exercise or physical activity

Smoking cessation

Specifically to type 2:

Monitor and treat risk factors and associated

conditions:

Hyperlipidemia

Hypertension

Obesity

Traditional Therapies

Testing blood sugar levels

A1C test

Blood glucose meter

Exercise and diet

Oral pill therapies

biguanides, thiazolidinediones

Insulin

Current Nutrition Therapies

General: Low-carb/low sugar/low glycemic index

Low-fat diet

Mediterranean diet slow digested foods leading to even blood sugar

Low-fat Vegetarian Diet Same benefits above

Decrease saturated fat Effect on insulin signaling

Note: Traditional and nutrition therapies have been used to reduce symptoms, not cure.

Emergence of Vegan Therapy

Dr. Barnard

Vegan: only current

therapy that is proving

not only to reduce

symptoms, but to

actually to reverse the

disease

Former Research Statements

“Plant-based diets rich in legumes and slowly

digested grains may improve glucose

tolerance, insulin sensitivity, and the

successful management of type 2 diabetes.”

“Diabetes and a Vegetarian Diet”, www.vrg.org

Former Research Statements

Vegetarian diets reduce: some cancers, heart

disease, obesity, and type 2 diabetes

Vegan diets reduce: prostate cancer, weight,

heart disease, cholesterol

Vegetarian vs. Vegan

Vegetarians

-avoid meat and/or animal products. Vegetarian diet includes only foods from plants: like fruits, vegetables, whole grain products, nuts, seeds, and legumes

Vegans-strict vegetarian; eliminating all animal products

-*no dairy

Despite such dietary restrictions, a balanced vegan diet is perfectly healthy

What about dairy?

Dairy elimination is the key difference

between vegetarian and vegan lifestyles

Bovine protein

Bovine serum lactobumin = triggers diabetes

Terminology

HbA1c (A1c): test that measures the amount of blood glucose within the last 3 months

glycemic index: a numerical index given to a carbohydrate-rich food that is based on the average increase in blood glucose levels occurring after

Low density lipoprotein (LDL)-cholesterol: “bad cholesterol”; low-density lipoproteins transport cholesterol from the liver to the tissues of the body

Polyunsaturated fatty acids (PUFA): fatty acids that have more than one double or triple bond per molecule; good fat

Affinity chromatography: a method of separating and identifying the components of a complex mixture; one such substance being immobilized and acting as the sorbent

A Low-Fat Vegan Diet Improves

Glycemic Control and

Cardiovascular Risk Factors in a

Randomized Clinical Trial in

Individuals With Type 2 Diabetes

Article 1Barnard N, Cohen J, Jenkins D, Turner-

McGrievy G, Gloede L, Jaster B, Siede K,

Green A, Talpers S

Objective

Objective

To investigate whether a low-fat vegan diet

improves glycemic control and cardiovascular risk

factors in individuals with Type 2 diabetes.

Main outcomes

Glycemic, plasma lipid, and weight control

Subjects

99 individuals with type 2 diabetes

49 followed low-fat vegan diet

22 m, 27 f

50 followed control diet*

17 m, 33 f

A1c was determined and volunteers were

ranked in order of concentrations

Randomly assigned in sequential pairs

Interventions

Vegan group 10% fat, 15% protein, 75% CHO

Include vegetables, fruits, grains, legumes

Avoid animal products and added fats

*Portion sizes, energy intake, and CHO intake were unrestricted

Control group American Diabetes Association (ADA) guidelines

15-20% protein, <7% saturated fat, 60-70% CHO, cholesterol and saturated fat <200 mg/day

*Individualized based on body weight and plasma lipid concentrations

Both groups asked to not alter exercise habits

Research Design

Randomized control trial

Each met with RD for 1 hr initially

Met weekly for 1 hr with assigned groups throughout study

Unannounced phone calls for dietary recall

In addition, 3-day dietary records were completed

Physical activity was assessed over a 3-day period (pedometer)

Lab Measurement Tools

Laboratory measurements by blind technicians

Abbott Spectrum Analyzer

plasma glucose, plasma cholesterol, triglycerides

Friedewald equation

LDL cholesterol

Urinary albumin measured using anionic dye-binding assay

Bouchard 3-Day Physical Activity Record

Statistical Methods

Abbott IMx analyzer

T-tests

Regression analyses

Pearson correlations

Interim analysis

Results

Both groups reduced energy intake and

protein intake

CHO intake increased in the vegan group

Fat intake fell in both groups

Pedometer readings had no significant

interest/difference between groups

Results: Dietary effects on

clinical measures

43% of the vegan group and 26% of the ADA group participants reduced diabetes medications.

Including all participants, A1c decreased 0.96 percentage points in the vegan group and 0.56 points in the ADA group.

Excluding those who changed medications, A1c fell 1.23 points in the vegan group compared with the 0.38 points in the ADA group.

Body weight decreased 6.5 kg in the vegan group and 3.1 kg in the ADA group.

Among those who did not change lipid-lowering medications, LDL cholesterol fell 21.2% in the vegan group and 10.7% in the ADA group.

Urinary albumin reductions were greater in the vegan group (15.9 mg/24 h) than in the ADA group (10.9 mg/24 h)

A1c at baseline, 11, & 22 wks

Conclusion

Both a low-fat vegan diet and a diet based on

ADA guidelines improved glycemic and lipid

control in type 2 diabetic patients.

These improvements were greater with a low-

fat vegan diet.

Pros and Cons

Pros:

Clear and easy to read

Keeping exercise at a constant to isolate diet

Applicability outside the research setting

Cons:

Diversity was limited among subjects

Many study participants were taking antihypertensive medications which may have blunted the effect of diet on blood pressure.

All participants had access of group support

Dietary intake was based on self-report, which is vulnerable to distortion

Changes in Nutrient Intake and Dietary

Quality among Participants with Type

2 Diabetes Following a Low-Fat Vegan

Diet or a Conventional Diabetes Diet

for 22 Weeks

Article 2Turner-McGrievy G, Barnard N, Cohen J,

Jenkins D, Gloede L, Green A

Objective

Assess the changes in nutrient intake

and dietary quality among participants

following a low-fat vegan diet or the 2003

ADA dietary recommendations.

Subjects

99 participants with type 2 diabetes in a free-

living setting

49 followed low-fat vegan diet

22 m, 27 f

50 followed control diet

17 m, 33 f

Intervention

Vegan diet

Grains, fruits, vegetables, and legumes

Avoid animal products, limit high-fat foods, and favor foods

with low glycemic index value

No restrictions on portion sizes or energy intake

Control diet

2003 ADA guidelines

Exchange system used to provide recommended energy and

carbohydrate and saturated fat grams each participant

required

Individualized based on body weight and lipid profile

Design

Randomized, controlled clinical trial

22-week trial examining changes in nutrient

intake and diet quality

Before randomization, participants completed a

practice 3-day weighed dietary record

Participants then completed a baseline food

record

Design cont.

After randomization, participants met individually with an

RD experienced in the use of the assigned diet to

develop individualized meal plans

Participants continued to meet with assigned diet

groups- 1/wk with RD and physicians

Adherence to diet was assessed based on 22-wk dietary

records and 24-hr recalls with unexpected phone calls

Quality control conducted by dietary records and recalls

by RD

Lab Measurement Tools

AHEI Scores

Alternate Healthy Eating Index

Calculated for each participant based on food

categories: vegetables, fruit, nuts and soy

protein, cereal fiber, trans fat, and ratio of

polyunsaturated to saturated fatty acids

Receives a score ranging from 0-10

Statistical Methods

T tests

Pearson's correlation

Results

The vegan group improved in every AHEI

food category

Increase in fruits, veg, nut, soy protein, and cereal

fiber; decrease in trans fat and increase in PUFA-

to-saturated fat ratio

The ADA group showed changes in one food

Increase PUFA-to-saturated fat

Clinical Data Results

Both groups reported significant decreases in energy,

protein, fat, cholesterol, and vitamin D

The vegan group significantly increased CHO, fiber,

vitamin A activity, beta carotene, vitamins A&K, folate,

magnesium, and potassium

Note: Vegan group significantly reduced intakes of vitamin B-12

and calcium

Clinical Data Results cont.

The vegan group significantly improved its

AHEI score, while the control diet group did

not.

With both groups combined, AHEI score was

negatively correlated with both changes in A1c

value and weight

Changes in AHEI Score

Conclusions

Vegan diets increase intakes of carbohydrate,

fiber, and several micronutrients, in contrast

with the ADA diet.

The vegan group improved its AHEI score

whereas the ADA diet group's AHEI scored

remained unchanged

Pros and Cons

Pros:

Clear and easy to read

Prospective design and

an intention-to-treat

analysis

Cons:

Not diverse group of

subjects

All participants had

access of group support

Dietary intake was based

on self-report, which is

vulnerable to distortion

A Low-Fat Vegan Diet Elicits Greater

Macronutrient Changes, but Is

Comparable in Adherence and

Acceptability, Compared with a More

Conventional Diabetes Diet among

Individuals with Type 2 Diabetes

Article 3Barnard N, Gloede L, Cohen J, Jenkins D,

Turner-McGrievy G, Green A, Ferdowsian H

Objective

To quantify adherence and acceptability for two types of diets for diabetes.

Main outcomes: Attrition, adherence, dietary behavior, diet acceptability, cravings

Subjects

99 individuals with type 2 diabetes

49 followed low-fat vegan diet

22 m, 27 f

50 followed control diet

17 m, 33 f

Interventions

Vegan diet 10% fat, 15% protein, 75% carbohydrate

Grains, fruits, vegetables, and legumes

Avoid animal products, fatty foods (avocadoes, fried foods, nuts/seeds), and favor foods with low glycemic index value

No restrictions on portion sizes or energy intake

Control diet 2003 ADA guidelines

15-20% protein, <7% saturated fat, 60-70% CHO, cholesterol and saturated fat <200 mg/day

Individualized based on body weight and lipid profile

All participants not to alter exercise habits.

Research Design

Controlled trial

Each participant met with RD for 1 hr prior to

discuss the assigned diet

Thereafter, attended weekly 1 hr meeting with

their diet groups for 22 weeks

Optional bi-weekly 1 hr meeting with their diet

groups for 52 weeks

Research Design cont.

3-day dietary records complete at weeks 0, 11, 22,

and 74

Diet records reviewed by RD

In addition, at several weeks throughout the study,

an RD made unannounced telephone calls to each

participant to administer a 24-hr diet recall using a

multi-pass approach

At weeks 0, 22, and 74 participants completed:

Eating Inventory, Food Acceptability Questionnaire,

Food-Craving Inventory Instruments

Lab Measurement Tools

Food scales used for dietary records

Nutrition Data System- used for diet analysis

At weeks 0, 22, and 74 participants

completed:

Eating Inventory

Food Acceptability Questionnaire

Food-Craving Inventory Instruments

Stastical Methods

T tests

Wilcoxon sum rank test

Mann-Whitney U test

Results

All participants completed the initial 22 weeks

90% of control group and 86% of the vegan diet

group participants completed 74 weeks.

Fat and cholesterol intake fell more and CHO and

fiber intake increased more in the vegan group.

At 22 weeks, group specific diet adherence criteria

were met by 44% of members of the control and

67% of the vegan group participants

Results cont.

Control group reported a greater increase in dietary restraint; this difference was not significant at 74 weeks

Both groups reported reduced hunger and reduced disinhibition.

Questionnaire responses rated both diets as satisfactory, with no significant difference except ease of preparation

Cravings for fatty foods diminished more in the vegan group at 22 weeks with no significant difference at 74 weeks.

FA Questionnaire

Symptoms and Benefits

Conclusions

Despite its greater influence on macronutrient

intake, a low-fat, vegan diet has an

acceptability similar to that of a more

conventional diabetes diet.

Acceptability appears to be no barrier to its

use in medical nutrition therapy.

Pros and Cons

Pros

Clear and easy to read

Sample size that was

adequate to compare

differences

Appropriate follow-up

period

.

Cons

All self-selected research volunteers: well educated

All participants had access of group support

Dietary intake was based on self-report, which is vulnerable to distortion

Summary and Conclusion

Both a low-fat vegan diet and the ADA diet improved glycemic and lipid control in type 2 diabetic patients. These improvements were greater with a low-fat vegan diet.

Vegan diets increase intakes of carbohydrate, fiber, and several micronutrients, in contrast with the ADA diet.

Summary and Conclusion

cont.

The vegan group improved its AHEI score

whereas the ADA diet group’s AHEI scored

remained unchanged.

Despite its greater influence on macronutrient

intake, a low-fat vegan diet has an

acceptability similar to that of a more

conventional diabetes diet.

Acceptability appears to be no barrier to its use

in medical nutrition therapy.

Suggestions for Future

Research

Research on body’s

response if transitioning

back to a healthy diet (but

including healthy fats, lean

meats, lean dairy)

Diagnosis at earlier age

Extend research on

satiation/acceptability over

longer period of time

More diverse subjects

Research on vegan diets

and other chronic conditions

Questions

References

1. Davy B: Medical Nutrition Therapy for Diabetes Mellitus and Related Disorders. Medical Nutrition Therapy. 2009

2. Zimmet P, Alberti KG, Shaw J. "Global and societal implications of the diabetes epidemic". Nature. 2003; 414 (6865): 782–7.

3. Eberhart, M. S.; Ogden, C, Engelgau, M, Cadwell, B, Hedley, A. A., Saydah, S. H. "Prevalence of Overweight and Obesity Among Adults with Diagnosed Diabetes ---United States, 1988--1994 and 1999--2002". Morbidity and Mortality Weekly Report(Centers for Disease Control and Prevention). 2004;53 (45): 1066–8.

4. Camastra S, Bonora E, Del Prato S, Rett K, Weck M, Ferrannini E. "Effect of obesity and insulin resistance on resting and glucose-induced thermogenesis in man. EGIR (European Group for the Study of Insulin Resistance)". Int. J. Obes. Relat. Metab. Disord. 1999;23 (12): 1307–13.

5. Jack L, Boseman L, Vinicor F. "Aging Americans and diabetes. A public health and clinical response". Geriatrics 2004;59 (4): 14–7.

6. Lovejoy JC. "The influence of dietary fat on insulin resistance". Curr. Diab. Rep.2002;2 (5): 435–40.

7. Barnard ND, Scialli AR, Turner-McGrievy G, Lanou AJ, Glass J: The effects of low-fat plant-based dietary intervention on body weight, metabolism, and insulin sensitivity. Am J Med. 2005;118:991-997.

8. Scott FW. Cow milk and insulin-dependent diabetes mellitus: is there a relationship? Am J Clin Nutr 1990;51:489-91.

9. Lovejoy JC, Windhauser MM, Rood JC, de la Bretonne JA: Effect of a controlled high-fat vs. low-fat diet on insulin sensitivity and leptin levels in African American and Caucasian women. Metabolism. 1998;47: 1520-1524.

10. Jenkins DJA, Kendall CWC, Marchie A, Jenkins AL, Augustin LSA, Ludwig DS, Barnard ND, Anderson JW: Type 2 diabetes and the vegetarian diet. Am J Clin Nutr.2003;78:610S-616S.