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Lines to legumes & back again? Charaka, Sushruta and Vagbhata (9(((((6th century AD)

Nutrional approaches to diabetes prevenon & management during the past 100 years

Jim Mann

WHO Collaborating Centre for

Schnée

A warm climate: Riviera in the winter, Zurich in the summer

Muscular activity: Starting with billiards, graduating to rowing and splitting wood

Diet: easily digested animal and vegetable food, no starch or

Other: light Moselle wines, old Claret and good cigars in moderation

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RD Lawrence: A Diabetic Diet: The Line Ration Scheme Modern history of high /high fibre diets Br Med J. 1925 1 (3345): 261-262

1935 Himsworth High CHO diet increased insulin sensitivity (Clin Sci 2: 67-94)

1958 Kempner et al Rice diet (Postgrad Med 24:359)

1963 Stone & Connor High CHO diet & serum lipids in diabetes (Diabetes 12: 127-132)

1975 Trowell Little diabetes in East Africa & high fibre diets (Diabetes 24: 762-765)

1976 Kiehm et al Uncontrolled experiments of high fibre diets in type 2 patients, insulin treated. (Am J Clin Nutr 29:895-899)

1939:

Case Control study of newly diagnosed T2DM

Mann, J, Pyörälä, K, Teuscher, Diabetes in Epidemiological Perspective, Churchill Livingstone Inc, 1983

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Diabetes mellitus death-rates for adult civilian males 1940-1970

Trowell H. Lancet, 1974

Insulin requirements of diabetic men on low doses of insulin Definition of Dietary fibre

Trowell: 1976

Dietary fibre:

! residue derived from plant cell walls that is resistant to hydrolysis by human alimentary enzymes

! contains cellulose, hemicellulose, and lignin.

Codex 2009

Anderson & Ward, 1978

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Simpson R et al, 1979: High carbohydrate diets & maturity-onset diabetics (BMJ 1: 1753-1756) Twenty-four-hour Plasma Concentrations

Simpson R et al, 1979: High carbohydrate diets & insulin- dependent diabetics (BMJ 2: 523-525)

HIGH CHO LOW CHO 60% CHO 40% CHO *

25% Fat (P:S,1:1) 38% Fat (P:S,1:3)

*Cereal containing foods * Very low free (“wholegrain”) Tuberous vegetables Very low free sugars

Mean (± SE of mean) total serum cholesterol & triglyceride & lipoprotein cholesterol concentraons with the two diets Low - High - carbohydrate Significance carbohydrate diet diet Jenkins, D.J.A., T.M.S. Wolever, T.D.R. Hockaday, Serum triglycerides 1.20 ± 0.13 1.09 ± 0.08 NS A.R. Leeds, R. Haworth, S. Bacon, E.C. Apling and (mmol/l) J. Dilawari

Total cholesterol 4.9 ± 0.2 4.4 ± 0.2 P < 0.001 (mmol/l) Treatment of diabetes with guar gum: reduction of HDL cholesterol 1.6 ± 0.1 1.6 ± 0.1 NS (mmol/l) urinary glucose loss in diabetes.

LDL cholesterol 3.2 ± 0.2 2.4 ± 0.3 P< 0.02 Lancet 2: 779, 1977 (mmol/l) VLDL cholesterol 0.2 ± 0.1 0.5 ± 0.2 NS (mmol/l)

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Plasma glucose values during 24h profiles of type Measures of diabec control on type 2 paents 1 patients on HL & LC diets Index LC HL P Blood glucose (mmol/l) Basal 6.7 ± 1.5 5.7 ± 1.4 0.001 Preprandial 7.3 ± 2.1 6.2 ± 1.5 <0.01 2 h postprandial 9.1 ± 2.3 8.1 ± 1.6 <0.05 Daily 7.9 ± 1.8 6.9 ± 1.1 <0.01 Mean postprandial 9.0 ± 1.9 7.6 ± 1.2 <0.001 24 h urine glucose (mmol) 31 ± 51 2 ± 3 0.05

HbA1c 9.6 ± 2.3 8.6 ± 1.6 <0.02

Plasma insulin values during 24 h profiles of type 2 Trigylyceride values during 24 h profiles of type paents 2 patients on HL & LC diets

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Simpson HCR et al, 1982 Plasma glucose levels during high CHO and low CHO 24 hr profiles Digestible carbohydrate - an independent effect on diabetic control in type 2 diabetic patients? Diabetologia 23: 235-239

Diet CHO FAT (%) Protein (%) Total dietary fibre (%) (g/24h)

High CHO 60 22 18 16

Low CHO 35 47 18 14

------high CHO low CHO

Insulin levels during high CHO and low CHO 24 hr Plasma triglyceride levels during high CHO and low CHO 24 profiles hr profiles

------high CHO low CHO ------high CHO

low CHO

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Riccardi, Rivellese et al, 1984 Blood glucose control at the end of each dietary period

Separate influence of dietary carbohydrate and fibre on the metabolic control in diabetes

Low CHO/low fibre High CHO/low fibre High CHO/high fibre Protein 21% 17% 17%

CHO

Total 252g 42% 318g 53% 321g 53%

Simple 108g 111g 112g

Complex 144g 207g 209g

Fibre 20g 16g 54g

Composition of major lipoprotein classes at end of each dietary period Aro, Uusitupa & colleagues

Hermansen, Rasmussen & colleagues

Jenkins & colleagues

Karamanos & colleagues

Karlstrom, Vessby & colleagues

Katsilambros & colleagues

Nurses & Health Professional Cohort Studies

Rizkalla, Slama & colleagues

Toeller, Heitkamp & colleagues

Vuksan, Sievenpiper & colleagues

Wolever & colleagues

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Intervention Studies on Fibre Intake and Diabetes Dietary carbohydrate recommendations: (DNSG, 2004)

• Wide range of total CHO acceptable: 45 – 60% total energy

• People with T1DM and T2DM should be encouraged to consume naturally occurring foods which are rich in dietary fibre (non-starch polysaccharide). Grade A

• Dietary fibre intake should ideally be >40g/day, half of which should be soluble. Beneficial effects also obtained with lower, and for some, more acceptable amounts. Grade A

• Daily consumption of at least 5 servings of fibre-rich vegetables or fruit and at least 4 servings of legumes/week will help to provide minimum requirements for fibre intake Grade C • Cereal-based foods should, whenever possible, be wholegrain and high in fibre. Grade B Chandalia et al. NEJM 2000

ADA (2016)

“Carbohydrate intake from wholegrains, vegetables, fruits, legumes & dairy products with an emphasis on foods higher in fiber & lower in glycemic load should be advised over other sources, especially those containing sugars”

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Nutrion 31 (2015)1 -13 Points of Evidence:

Point 2. During the epidemics of obesity and , caloric increases have been due amost entirely to increased

Point 3. Benefits of dietary carbohydrate restriction do not require weight loss

Point 4. Although weight loss is not required for benefit, no dietary intervention is better than carbohydrate restriction for weight loss

Point 7. Dietary total and saturated fat do not correlate with risk for

Point 10. Dietary carbohydrate restriction is the most effective method (other than Global Dairy Platform starvation) of reducing serum TGs and increasing high-density lipoprotein McDonalds Atkins Foundation Atkins Nutritionals Inc Feinman et al, Nutrion 2015

Am J Clin Nutr (2015) doi: 10.3945/ajcn.115.112581.

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Macronutrient intakes at 37- 52 weeks

LC HC

T CHO (% En) 17 49 T fat (% En) 53 26 SFA (% En) 11 9 Dietary fibre (g) 26 31 T CHO (g) 74 218

Fibre/ 50g CHO 18 7 Tay et al, 2014. Diabetes Care

U.S.A. WHO TR 916 Nordic U.S.A. Proportion of subjects without diabetes during trial 1977 2003 2013 2015 Fat

Total (% Energy) 30 15-30 25-40 25-35

SAFA 10 <10 ≤10 ≤10

cis-PUFA 10 6-10 -

cis –MUFA 10 By diff 10.20

trans - <1% As low as possible

Carbohydrate

Total (% Energy) 55-60* 55-75 45-60 45-65 (50-75)

Sugars (% Energy) 15% <10% <10 -

Dietary Fibre - From food 25-35 14g/ (g/day) 1000kcal

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Dietary carbohydrate recommendations: (DNSG, 2004) Definions of Dietary fibre • Wide range of total CHO acceptable: 45 – 60% total energy

• People with T1DM and T2DM should be encouraged to consume naturally occurring foods which are rich in dietary fibre (non-starch polysaccharide). Codex 2009 Grade A Carbohydrate polymers of ≥10 monomeric units not hydrolysed by endogenous enzymes in the small intesne • Dietary fibre intake should ideally be >40g/day, half of which should be soluble. Beneficial effects also obtained with lower, and for some, more acceptable amounts. • Occur naturally in the food as consumed Grade A

• Extracted from food, synthec carbohydrate polymers where • Daily consumption of at least 5 servings of fibre-rich vegetables or fruit and competent authories recognise a health benefit based on at least 4 servings of legumes/week will help to provide minimum requirements for fibre intake generally accepted scienfic evidence. Grade C

• Cereal-based foods should, whenever possible, be wholegrain and high in fibre. May or may not include oligosaccharides 3-9 units in length. Grade B

Adding Fibre to Foods

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