To Be or Not To Be On Low Carb Diet

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To Be or Not To Be On Low Carb Diet
Naomi Wedel, M.S., R.D., C.D., C.D.E. Dean
Medical Center, Madison naomi.wedel_at_deancare.com
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Background on Food Guide Pyramid

• Introduced in 1992 by the USDA to replace Basic
  4 food groups.
• Graphic representation of food guidance to suit
  Americans food consumption, nutrient
  composition, and individual nutrient needs.

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Goals of Food Guide Pyramid

• Focus on overall health, not suggest diets to
  prevent or treat specific diseases.
• Be based on the most recent, authoritative
  dietary standards, and food composition and
  consumption data.
• Address the total diet rather than the foundation
  diet targeting nutrient adequacy only, and
• Build on successful elements on the previous
  guides.

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Use of Food Guide Pyramid

• All foods fits.
• Pictorial Dietary Guidelines.
• Encourages variety of food consumption.
• Meets the need of well-balanced diet.
• Meets individual nutrient needs for diverse
  American population.
• Encourages people to eat less fat.

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Consumer Awareness

• 67 Americans aware of the Pyramid (1997).
• 75 somewhat or very familiar with the
  Pyramid (2000).
• 43 72 failed to meet dietary recommendations
  for the Pyramid fruit and dairy groups.
• 30 of children and teens failed to meet fruit,
  grain, meat, and dairy groups, and 36 for
  vegetable group.
• Davis, Et al. JADA 1018, Pg. 881 - 885

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Controversies of Food Guide Pyramid

• Dr. Atkins Criticism
• Dr. Willetts Criticism
• FGP promotes a high carbohydrate diet which
  contributes to a increased risk of health
  problems and certain chronic diseases.
• No distinction between wild rice and a slice of
  Wonder Bread.
• No distinction between good fats and bad fats.
• Not culturally sensitive.
• Over simplified.

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Which One?
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Teaching Point

• Emphasize whole grains foods, fruits and
  vegetables.
• Use good fats.
• Incorporate nuts and legumes.
• Reduce foods high in saturated fats.
• Eat refined foods sparingly.
• Portion sizes.
• Emphasize physical activity and weight control.

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Enter the Zone
Protein Power
Sugar Busters!
Dr. Atkins New Diet Revolution
The Anti-Aging Zone
The Cabbage Soup Diet
Dr. Bob Arnots Revolutionary Weight Control
Program
Source Wheat Foods Council www.wheatfoods.org
Faddiets.ppt
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Researches on Low Carbohydrate Diets

• Efficacy and Safety of Low-Carbohydrate Diet.
  Bravata, et al JAMA 28914, pp.1837 1850, 2003.
• Review of 107 articles of low-carbohydrate diets
  published between Jan. 1 1966 to Feb. 15, 2003.
• 94 dietary interventions.
• 3268 participants, 663 received diets carb./d (71

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Findings

• Only 5 studies evaluated diets 90 days.
• No studies evaluated participants with a mean age
  older than 53.1 years.
• Weight loss associated with longer diet duration,
  restriction of calorie intake among the obese
  patients.
• Low carbohydrate diets had no significant adverse
  effect on serum lipid, fasting serum glucose, and
  fasting serum insulin levels or blood pressure.

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Conclusions

• Insufficient evidence to make recommendation for
  or against the use of low-carbohydrate diets
  (particularly among participants older than age
  50).
• Among the published studies, participants weight
  loss while using low-carbohydrate diet was
  principally associated with decreased caloric
  intake and increased diet duration, but not with
  reduced carbohydrate content.

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Evidence-Based Nutrition Principles and
Recommendations for the Treatment and Prevention
of Diabetes and Related Complications
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Evidence Based Principles

• Problems with the previous recommendations
• Many nutrition recommendations had no scientific
  supporting evidence.
• Goal
• Improve the quality of clinical judgments and
  facilitate cost-effective care.

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Evidence Based Principles

• Recommendations are classified according to level
  of evidence available using the American Diabetes
  Association evidence grading system.

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Evidence Grading System
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Goals of Medical Nutrition Therapy for Diabetes

• Attain and maintain optimal metabolic outcomes
  including
• Blood glucose levels in the normal range or as
  close to normal as is safely possible to prevent
  or reduce the risk for complications of diabetes.
• A lipid and lipoprotein profile that reduced the
  risk for macrovascular disease.
• Blood pressure levels that reduce the risk for
  vascular disease.

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Goals of Medical Nutrition Therapy for Diabetes

• Prevent and treat the chronic complications of
  diabetes. Modify nutrient intake and lifestyle
  as appropriate fo the prevention and treatment of
  obesity, dyslipidemia, cardiovascular disease,
  hypertension, and nephropathy.

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Goals of Medical Nutrition Therapy for Diabetes

• Improve health through healthy food choices and
  physical activity.
• Address individual nutritional needs taking into
  consideration personal and cultural preferences
  and lifestyle while respecting the individuals
  wishes and willingness to change.

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A-Level Evidence

• Foods containing carbohydrate from whole grains,
  fruits, vegetables, and low-fat milk should be
  included in a healthy diet.
• With regard to the glycemic effects of
  carbohydrates, the total amount of carbohydrate
  in meals or snacks is more important than the
  source or type.

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A-Level Evidence

• As sucrose does not increase glycemia to a
  greater extent than isocaloric amounts of starch,
  sucrose and sucrose-containing foods do not need
  to be restricted by people with diabetes
  however, they should be substituted for other
  carbohydrate sources or, if added, covered with
  insulin or other glucose-lowering medication.

22
A-Level Evidence

• Non-nutritive sweeteners are safe when consumed
  within the acceptable daily intake levels
  established by the Food and Drug Administration.

23
A-Level Evidence

• Less than 10 of energy intake should be derived
  from saturated fats. Some individuals (i.e.,
  persons with LDL cholesterol 100 mg/dl) may
  benefit from lowering saturated fat intake to 7 of energy intake.

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A-Level Evidence

• Dietary cholesterol intake should be day. Some individuals (i.e., persons with LDL
  cholesterol 100 mg/dl) may benefit from
  lowering dietary cholesterol to

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A-Level Evidence

• In insulin-resistant individuals, reduced energy
  intake and modest weight loss improve insulin
  resistance and glycemia in the short term.

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A-Level Evidence

• Structured programs that emphasize lifestyle
  changes, including education, reduced fat ( of daily energy) and energy intake, regular
  physical activity and regular participant
  contact, can produce long-term weight loss on the
  order of 5 7 of starting weight.

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A-Level Evidence

• Exercise and behavior modification are most
  useful as adjuncts to other weight loss
  strategies. Exercise is helpful in maintenance
  of weight loss.

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A-Level Evidence

• Standard weight reduction diets, when used alone,
  are unlikely to produce long-term weight loss.
  Structured intensive lifestyle programs are
  necessary.

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A-Level Evidence

• Energy requirements for older adults are less
  than for younger adults.
• Physical activity should be encouraged.

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A-Level Evidence

• Glucose is the preferred treatment for
  hypoglycemia, although any form of carbohydrate
  that contains glucose may be used.

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A-Level Evidence

• In both normotensive and hypertensive
  individuals, a reduction in sodium intake lowers
  blood pressure.
• A modest amount of weight loss beneficially
  affects blood pressure.

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B-Level Evidence

• Individuals receiving intensive insulin therapy
  should adjust their premeal insulin doses based
  on the carbohydrate content of meals.

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B-Level Evidence

• Although the use of low-glycemic index foods may
  reduce postprandial hyperglycemia, there is not
  sufficient evidence of long-term benefit to
  recommend use of low-glycemic index diets as a
  primary strategy in food/meal planning.

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B-Level Evidence

• As with the general public, consumption of
  dietary fiber is to be encouraged however, there
  is no reason to recommend that people with
  diabetes consume a greater amount of fiber than
  other Americans.

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B-Level Evidence

• In persons with controlled type 2 diabetes,
  ingested protein does not increase plasma glucose
  concentrations, although protein is just as
  potent a stimulant of insulin secretion as
  carbohydrate.

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B-Level Evidence

• For persons with diabetes, especially those not
  in optimal glucose control, the protein
  requirement may be greater than the Recommended
  Dietary Allowance, but not greater than usual
  intake.

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B-Level Evidence

• To lower LDL cholesterol, energy derived from
  saturated fat can be reduced if weight loss is
  desirable or replaced with either carbohydrate or
  monounsaturated fat when weight loss is not a
  goal.

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B-Level Evidence

• Intake of trans-unsaturated fatty acids should be
  minimized.
• Reduced-fat diets when maintained long-term
  contribute to modest loss of weight and
  improvement in dyslipidemia.

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B-Level Evidence

• For persons with elevated plasma LDL cholesterol,
  saturated fatty acids and trans-saturated fatty
  acids should be limited to 7 of energy.

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B-Level Evidence

• For persons with elevated plasma triglycerides,
  reduced HDL cholesterol and small dense LDL
  cholesterol (the metabolic syndrome), improved
  glycemic control, modest weight loss, dietary
  saturated fat restriction, increase physical
  activity, and incorporation of monounsaturated
  fats may be beneficial.

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B-Level Evidence

• All individuals, especially family members of
  persons with type 2 diabetes, should be
  encouraged to engage in regular physical activity
  to decrease risk of developing type 2 diabetes..

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B-Level Evidence

• There is no clear evidence of benefit from
  vitamin or mineral supplementation in people with
  diabetes who do not have underlying deficiencies.
  Exceptions include folate for prevention of
  birth defects and calcium for prevention of bone
  disease.

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B-Level Evidence

• Routine supplementation of the diet with
  antioxidants is not advised because of
  uncertainties related to long-term efficacy and
  safety.

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B-Level Evidence

• If individuals choose to drink alcohol, dialy
  intake should be limited to one drink for adult
  women and two drinks for adult men. One drink is
  definced as 12 oz. of beer, 5 oz of wine, or 1.5
  oz of distilled spirits.
• To reduce risk of hypoglycemia, alcohol should be
  consumed with food.

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B-Level Evidence

• Ingestion of 15 20 g of glucose is an effective
  treatment, but blood glucose may only be
  temporarily corrected.
• During acute illnesses, testing blood glucose and
  blood or urine for ketones, drinking adequate
  amounts of fluids, and ingesting carbohydrate are
  important.

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C-Level Evidence

• Individuals receiving fixed daily insulin doses
  should try to be consistent in day-to-day
  carbohydrate intake.

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C-Level Evidence

• Polyunsaturated fat intake should be 10 of
  energy intake.

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C-Level Evidence

• In individuals with microalbuminuria, reduction
  of protein to 0.8 1.0 g/kg body wt. per day and
  in individuals with overt nephropathy, reduction
  to 0.8 g/kg body wt. per day may slow the
  progression of nephropathy.

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Expert Consensus

• Carbohydrate and monounsaturated fat together
  should provide 6070 of energy intake. However,
  the metabolic profile and need for weight loss
  should be considered when determining the
  monounsaturated fat content of the diet.

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Expert Consensus

• Sucrose and sucrose-containing foods should be
  eaten in the context of a healthy diet.

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Expert Consensus

• For persons with diabetes, there is no evidence
  to suggest that usual protein intake ( 15 20
  of total daily energy) should be modified if
  renal function is normal.

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Expert Consensus

• The long-term effects of diets high in protein
  and low in carbohydrate are unknown. Although
  such diets may produce short-term weight loss and
  improved glycemia, it not hat been established
  that weight loss in maintained long-term. The
  long-term effect of such diets on plasma LDL
  cholesterol is also a concern.

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Expert Consensus

• Individualized food/meal plans and intensive
  insulin regiments can provide flexibility for
  children and adolescents with diabetes to
  accommodate irregular meal times and schedules,
  varying appetite, and varying activity levels.

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Expert Consensus

• Nutrient requirements for children and
  adolescents with type 1 or type 2 diabetes appear
  to be similar to other same age children and
  adolescents.

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Expert Consensus

• Nutrition requirements during pregnancy and
  lactation are similar for women with and without
  diabetes.
• Medical nutrition therapy for gestational
  diabetes focuses on food choices for appropriate
  weight gain, normoglycemia, and absence of
  ketones.
• For some women with gestational diabetes, modest
  energy and carbohydrate restriction may be
  appropriate.

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Expert Consensus

• In the elderly, undernutrition is more likely
  than overnutrition, and therefore caution should
  be exercised when prescribing weight loss diets.

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Expert Consensus

• Initial response to treatment for hypoglycemia
  should be seen in 10 20 min however, blood
  glucose should be evaluated again in 60 min, as
  additional treatment may be necessary.

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Expert Consensus

• The goal should be to reduce sodium intake to
  2,400 mg (100 mmol) or sodium chloride (salt) to
  6,000 mg/day.

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Expert Consensus

• The energy needs of most hospitalized patients
  can be met by providing 25 35 kcal/kg body wt.
• Protein needs are between 1.0 1.5 g/kg body wt
  the higher end of the range beinf for more
  stressed patients.

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Dietary Reference Intakes for Energy,
Carbohydrate, Fiber, Fat, Fatty Acids,
Cholesterol, Protein, and Amino Acids
(Macronutrients) (2002) http//books.nap.edu/books
/0309085373/html/207.html
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Dietary Reference Intakes for Carbohydrates

• EAR (Estimated Average Requirement) 100 gram /
  day for men and women 19 years and older
• RDA (Recommended Dietary Allowance) 130 g / day
• MI for added sugar 25 of energy from added
  sugar

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Dietary Reference Intakes for Carbohydrates

• AI (Adequate Intake) of Fiber

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AMDR

• Acceptable Macronutrient Distribution Range
• Carbohydrate 45 65 of energy
• Fat 20 35 of energy
• Protein 10 35 of total energy