Research Article The Transcultural Diabetes Nutrition Algorithm: A Canadian ... - Semantic Scholar

12 Pages·2014·0.68 MB·English

Hindawi Publishing Corporation
International Journal of Endocrinology
Volume 2014, Article ID 151068, 12 pages
http://dx.doi.org/10.1155/2014/151068
Research Article
The Transcultural Diabetes Nutrition Algorithm:
A Canadian Perspective
RéjeanneGougeon,1,2JohnL.Sievenpiper,3,4DavidJenkins,5,6Jean-FrançoisYale,7
RhondaBell,8Jean-PierreDesprés,9,10ThomasP.P.Ransom,11,12KathrynCamelon,13
JohnDupre,14CyrilKendall,15,16,17RefaatA.Hegazi,18AlbertMarchetti,19,20
OsamaHamdy,21andJeffreyI.Mechanick22
1CrabtreeNutritionLaboratories,McGillUniversityHealthCentre/RoyalVictoriaHospital,Montreal,
QC,CanadaH3H1A1
2CrabtreeNutritionLaboratories,McGillUniversityHealthCentre/RoyalVictoriaHospitalH6.90,687PineAvenueWest,
Montreal,QC,CanadaH3A1A1
3DepartmentofPathologyandMolecularMedicine,FacultyofHealthSciences,McMasterUniversity,Hamilton,ON,
CanadaL8N3Z5
4Toronto3DKnowledgeSynthesisandClinicalTrialsUnit,ClinicalNutritionandRiskFactorModificationCentre,
St.Michael’sHospital,Toronto,ON,CanadaM5C2T2
5DepartmentofNutritionalSciencesandMedicine,FacultyofMedicine,UniversityofToronto,
Toronto,ON,CanadaM5S3E2
6ClinicalNutritionandRiskFactorModificationCenter,DivisionofEndocrinologyandMetabolism,
andLiKaShingKnowledgeInstituteofSt.Michael’sHospital,Toronto,ON,CanadaM5C2T2
7McGillUniversityHealthCentre/RoyalVictoriaHospital,Montreal,QC,CanadaH3A1A1
8DivisionofHumanNutrition,DivisionofAgriculture,FoodandNutritionalScience,andtheAlbertaDiabetesInstitute,
UniversityofAlberta,Edmonton,AB,CanadaT6G2E1
9CentredeRecherchedeL’InstitutUniversitairedeCardiologieetdePneumologiedeQue´bec,Que´bec,QC,Canada
10DepartmentofKinesiology,FacultyofMedicine,Universite´Laval,Que´bec,QC,CanadaG1V4G5
11DivisionofEndocrinologyandMetabolism,CapitalHealth,Halifax,NS,CanadaB3H2Y9
12DalhousieUniversity,Canada
13DepartmentofAlliedHealth,ClinicalNutrition,UniversityHealthNetwork,Toronto,
ON,CanadaM5G2C4
14RobartsResearch,UniversityofWesternOntario,London,ON,CanadaN6A5B7
15ClinicalNutritionandRiskFactorModificationCenter,StMichael’sHospital,Toronto,ON,CanadaM5S3E2
16DepartmentofNutritionalSciences,FacultyofMedicine,UniversityofToronto,Toronto,ON,Canada
17CollegeofPharmacyandNutrition,UniversityofSaskatchewan,Saskatoon,SK,Canada
18AbbottLaboratories,AbbottPark,43219,USA
19MedicalEducationandResearchAlliance(Med-ERA),NewYork,NY10019,USA
20DepartmentofPreventiveMedicineandCommunityHealth,UniversityofMedicineandDentistryofNewJersey,
Newark,NJ07101,USA
21JoslinDiabetesCenter,HarvardUniversity,Boston,MA02215,USA
22DivisionofEndocrinology,Diabetes,andBoneDisease,IcahnSchoolofMedicineatMountSinai,
NewYork,NY10029,USA
CorrespondenceshouldbeaddressedtoRe´jeanneGougeon;[email protected]
Received19June2013;Accepted8December2013;Published16January2014
AcademicEditor:AnnabelE.Barber
Copyright©2014Re´jeanneGougeonetal. This is an open access article distributed under the Creative Commons Attribution
License,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperly
cited.
2 InternationalJournalofEndocrinology
The Transcultural Diabetes Nutrition Algorithm (tDNA) is a clinical tool designed to facilitate implementation of therapeutic
lifestylerecommendationsforpeoplewithoratriskfortype2diabetes.Culturaladaptationofevidence-basedclinicalpractice
guidelines(CPG)recommendationsisessentialtoaddressvariedpatientpopulationswithinandamongdiverseregionsworldwide.
TheCanadianversionoftDNAsupportsandtargetsbehaviouralchangestoimprovenutritionalqualityandtopromoteregular
dailyphysicalactivityconsistentwithCanadianDiabetesAssociationCPG,aswellaschannellingtheconcomitantmanagement
ofobesity,hypertension,dyslipidemia,anddysglycaemiainprimarycare.Assessingglycaemicindex(GI)(therankingoffoods
byeffects onpostprandialbloodglucoselevels)andglycaemic load(GL)(theproductofmeanGIandthetotalcarbohydrate
contentofameal)willbeacentralpartoftheCanadiantDNAandcomplementnutritiontherapybyfacilitatingglycaemiccontrol
using specific food selections. This component can also enhance other metabolic interventions, such as reducing the need for
antihyperglycaemicmedicationandimprovingtheeffectivenessofweightlossprograms.ThistDNAstrategywillbeadaptedtothe
culturalspecificitiesoftheCanadianpopulationandincorporatedintothetDNAvalidationmethodology.
1.Introduction theoptimizationofnutritionalcareinprediabetesandT2D
on a global scale with the intention that provided infor-
Type 2 diabetes (T2D) is a chronic disease with hypergly- mation will suit geographic and ethnocultural factors for
caemia as its characteristic feature, resulting from defects individualization and implementation at regional and local
in insulin secretion and/or insulin action [1]. The disorder levels worldwide. It is anticipated that tDNA will increase
is associated with adiposity, particularly central abdominal awareness of the benefits of dietary behaviour changes,
adiposity [2], and multiple metabolic abnormalities that which can be better achieved when recommended dietary
increase the risk of mortality from cardiovascular diseases patternsandfoodchoicesaccommodateregionaldifferences
(CVD) by two- to fourfold [3], the leading cause of death ingeneticfactors,foodavailabilityandpreferences,lifestyles,
[4],shorteninglifeby5to15years.InCanada,theprevalence and cultures. Thereafter, a task force was selected among
ofT2Disincreasingatepidemicproportions,affectingmore Canadian health care experts in diabetes and nutrition to
than three million Canadians, with 6 million others at ele- adapttheglobaltDNAtemplatetoCanadianmores,norms
vated risk of developing the disease. Of particular concern andpopulationdemographics(Figure1).Theseexperts,who
arenon-Caucasianswhocomprisemorethan25%oftheCa- areauthorsofthispaper,arealsokeyregionalstakeholdersin
nadian population (Figure1) and are highly susceptible theimplementationoftheCDACPG.
to T2D when adopting a Western lifestyle. Diabetes affects
economicprosperity,costingtheCanadianhealthcaresystem
$12.2 billion annually, a number that is projected to rise to
$16.9billionby2020[4]. 2.Methods
Canadiancensusdatashowthatmorethan200tongues
are spoken in Canada, 60 being aboriginal. The mother The process of modifying the tDNA to Canada involved a
tongue reported by 6.8 millionCanadians (21% of the pop- groupofexpertswhoreviewedandconsideredrevisingallof
ulation) differs from English or French, the two official thetopicsoutlinedintheglobaltemplate[5].Thesereviewers
languages of the country. Another 4.7 million Canadians alsodefinedavisionfortheCanadiantDNAandconsidered
speak a language at home by order of prevalence: Punjabi, factorsuniquetotheCanadianpopulationandtheguidelines
Chinese,Spanish,Italian,German,Cantonese,Tagalog,Ara- and recommendations put forth by CDA in their revision,
bic, and Mandarin (Statistic Canada). Challenged by this that is, ethnocultural lifestyle input; individual risk strati-
situation, the Canadian Diabetes Association (CDA) has fication with tables on classification by body composition;
begun to tailor its nutrition therapy tool, Just the Basics, general recommendations on physical activity and healthy
to the cultural and personal tastes of individuals of varied eating,withtherelatedtablesprovidingphysicalactivityand
ethnicitieswhohaveT2D(http://www.diabetes.ca/diabetes- nutritionalguidelines;specificrecommendationsforobesity,
and-you/nutrition/just-basics/AccessedJanuary24,2013). hypertension,anddyslipidemia;criteriaforbariatricsurgery;
ThroughthesupportoftheCDA,clinicalpracticeguide- descriptionofanantihypertensivedietandotherdietarypat-
lines(CPG)fornutritiontherapy[4]werepublishedin2003 terns;andtheglyceamicindicesandloadofcommonfoods.
and 2008 and updated in 2013, to provide evidence-based During development of the Canadian version of tDNA, the
recommendationsforhealthyfoodchoicesandlifestylesthat taskforceestablishedthattheirsharedvisionofthetDNAwas
improveglycaemic,metabolic,andweightcontrol.Included to enable sustainable healthy lifestyle behaviours amongst
in these guidelines is the recommendation to replace high- healthcare providers and people with diabetes. It became
glycaemic index (GI) carbohydrate foods by low GI carbo- evidentthatprimarycareproviderswouldbestbeimplicated
hydratefoodsinmixedmealsbecauselowGIintakeisasso- in promoting a healthy lifestyle in their patients with T2D
ciated with a lower glycaemic response and improvements if they believed in its positive impact on glycaemic and
in A1C [4]. A multitude of cultures and diverse geographic metaboliccontroltothepointthattheythemselvesadaptand
locationsacrossCanadahavechallengedtheeffectivenessof sustainahealthylifestyle,thelattermadeachievablethrough
nutrition therapy guidelines to promote sustained healthy resources and tools within the Canadian tDNA. There was
eatinghabitsinthediabeticpopulation.Inresponse,Mechan- alsoaneedfordefiningsimpleassessmentmeasuresforlife-
ick et al. [5] have designed a global tDNA template for stylebehaviourthatputCanadiansatriskofdevelopingT2D,
InternationalJournalofEndocrinology 3
Total population (%) by Yusuf et al. [3]. In Canada, however, the general recom-
mendations for counselling on care, physical activity, and
healthyeatinghabitsconformtoCDA2013CPG[4]andare
5.4 3.9 2.5 for all patients independent of the magnitude of their risk.
4
0.8 Furthermore,therecommendationsareextendedtoaddress
1
patients’ obesity, hypertension, dyslipidemia, and/or dysg-
0.9
0.5 lycaemia with specific dietary approaches and metabolic
targets. In all cases, follow-up evaluation is recommended
0.5
at1–3monthsinitiallyandat3–6monthsongoing.TheCa-
0.7 0.3 nadian tDNA, like other cultural versions, includes and
refers to tables that convey additional information adapted
according to national or regional recommendations, in this
case,CanadianCPGs.ExamplesaregiveninTables1–5.
78.4 SpecifictotheCanadiantDNA,Table1presentsdiabetes
nutritiontherapyinamannerthatfacilitatestheselectionof
astrategybasedonindividualizedtargetedoutcomes.Differ-
ent dietary patterns evaluated in T2D populations, popular
weightlossapproaches,specificfoods,variedmacronutrient
Aboriginal Ancestry Arab distributions,andmealreplacementsarelistedwiththeirspe-
Chinese West Asian cificeffectsonhemoglobinA1c(A1C),weight,bloodpressure,
South Asian Korean lipidriskfactors,inflammatorymarkers,hypoglycemia,and
Black Japanese otheradvantagesanddisadvantagesrelatedtotheirimpacton
Latin American Other nutrients,gastrointestinaltract,orrenalload.Thisapproach
Southeast Asian Caucasian
isalsopromotedintheCDACPGs[4].
Adapted from statistics Canada January22,2009 CertainapproachesfromtheglobaltDNA[5]wereadapt-
ed to the many ethnicities in the Canadian population.
Figure1:CanadianPopulationDemographics.
Table2isanexamplethatshowsalistofcommonfoodsand
theirGI.OthermodificationstotheglobaltDNAwerebased
ontherecommendationsfromCDACPG[4].Forexample,
or associated complications, and also measures of lifestyle
Table3 summarizes those for physical activity in the man-
behaviouralchange.
agementofdiabetes[4]andTable4theDietaryApproaches
ChangesbroughttotheglobaltDNAtemplateanddiffer-
toStopHypertension(DASH)indiabetesadaptedaccording
entpointsofsignificancearehighlightedintheresultssection
to CDA CPG. Table5 summarizes CDA CPG for bariatric
ofthisreport.
surgery,whichmaybeconsideredinpatientswithT2Dand
aBMI≥35kg/m2 whenlifestyleinterventionshavefailedto
3.Results achieveandmaintainweightgoals.Minimallyinvasivesurgi-
calapproachesshouldbeusedbyawell-establishedsurgical
As a result of our revision, the modified algorithm focused team that includes experts in nutritional and psychological
on the process of adapting healthy behaviours rather than support.Bariatricsurgeryisnowbecominganacceptedop-
weightloss;behaviourleadingtoimproveddietandregular tionforthemanagementofT2Dandhasbeenshowntobe
physicalactivitybecametheinterventionaltarget.Emphasis superiortomedicalmanagementforitstreatment[6].Pres-
wasplacedalsoonincreasingpatientandproviderawareness ently there is no overall consensus as to what kind of pro-
of the process of change and of improvements to lifestyle cedure is most effective, be it malabsorptive, restrictive, or
behaviourovertime.TheresultantobjectiveoftDNACanada combinationsurgery.
became support of behavioural change through simple and
effective dietary and physical activity advice at the primary
carelevel.Additionally,aquick,simple,pragmatic,validated
4.Discussion
questionnaire to assess combined work and leisure time
physical activityshown to be associated with mortalityin a Adopting healthy behaviour rather than only attaining sus-
prospectivepopulationstudywasfoundtobefeasibleforuse tained weight loss was defined as the main objective of
inclinicalpractice[6].Thealgorithmwasmodifiedtobetter the Canadian tDNA. This objective is consistent with CDA
assist physicians in improving lifestyle habits of Canadian CPG, which recommend that self-management education
patientswhopresentwithdiverseethnicbackgrounds,based incorporating knowledge and skill development, as well as
ontheexistingCanadianguidelinesforpreventionandtreat- cognitivebehaviouralinterventions,shouldbeimplemented
ment of T2D. The global tDNA [5] adapted to fit current forpeoplewithdiabetes(CDACPG2008)[4].Tooptimize
CanadianguidelinesispresentedinFigure2. change,messagesregardingnutritionrecommendationsand
As in the global tDNA, initially, ethnooncultural iden- lifestylemodificationshouldaccommodateaperson’sculture
tification and geographic location are assessed concur- [7].TheethnicmosaicoftheCanadianpopulationprovides
rentlywithindividualriskstratification,thelatterdescribed arichtestinggroundforlearninghowtoadapteducational
4 InternationalJournalofEndocrinology
Ethno-cultural assessment Individual risk stratification
- Geographic location and - Anthropometrics (BMI/waist circumference/waist-hip ratio) (Tables1and25)
- Hypertension, Dyslipidemia, and/or Dysglycemia
- Ethno-cultural classification and
- Any cardiovascular event, any liver disease, microalbuminemia
identification
- Family history of high-risk dietary pattern and premature cardiovascular disease
- Insufficient physical activity (<30min/day and/or<5days/week)
- Risky alcohol intake (>2drink in men,>1drink in women)
- Any sleep disturbance; any chronic illness
General recommendations
Counseling, physical activity, and healthy eating consistent with current clinical practice guidelines or evidence (Tables1–4)
Overweight/obesity Hypertension Dyslipidemia Dysglycemia
- Weight loss (Tables1–5) (>130/80mmHg) - Lipid-modifying diet Prediabetes Diabetes
- Waist circumference reduction - Antihypertension diet (Table1) FPG mg/dL 6.1–6.9 ≥7.0
- Physical activity. Tremendous consistent with DASH
benefits are seen as a result of - Sodium restriction of 2hOGTT 7.8–11.0 11.1
exercise that reduces WC, 1.5g/day or A1C (%) 6.0–6.4 6.5
irrespective of weight loss. -3.7g salt or
- Nutrition therapy -2/3teaspoon salt
- Formula/caloric (Table3) Carbohydrate intake and spacing for
supplementation or glycemic control.
replacement
- Consider bariatric surgery
Follow-up evaluation (1–3months initially,3–6months ongoing)
History, physical (anthropometrics, blood pressure); chemistries (glucose, A1C, lipids, urinary albumin/creatinine, liver enzymes); urinalysis;
dietary assessment; physical activity monitoring.
If not at goal, intensify physical activity, meal plan, and nutrition therapy; consider pharmacologic therapy
Figure2:CanadianTransculturalDiabetesNutritionAlgorithm(tDNA)forprediabetesandtype2diabetes.
toolstovariouscultures.Atthistime,thedietaryeducation they provide the groundwork for creating tools tailored to
tool,JusttheBasics,hasbeencreatedforSouthAsian,Latin otherhigh-riskpopulations.
American,andtheAboriginalcommunitiesinCanada,using TheCanadiantDNAistopromotelow-GIcarbohydrate
a consultative process within the respective cultural groups foods within a healthy dietary pattern. GI provides an
[8]. These tools were developed by reaching out to the eth- assessment of the quality of carbohydrate-containing foods
niccommunitiesthroughprofessionalandcommunitygroup basedontheireffectonpostprandialbloodglucose[10].To
networks to identify persons who could contribute to the decrease the glycaemic response to dietary intake, low-GI
adaptationoftheeducationalmaterials.Peoplewithdiabetes carbohydratefoodscanreplacehigh-GIcarbohydratefoods.
andtheirfamilymembers,aswellasAboriginal,LatinAmeri- MoredetailedlistscanbefoundintheInternationalTables
can,orSouthAsiandietitians,otherdietitiansexperiencedin of Glycaemic Index and Glycaemic Load Values [11]. Meta-
workingwithculturalgroups,andanadvisorygroupofdieti- analyses of controlled dietary trials of replacing high-GI
tianswithexpertiseindiabetesmanagement,participatedin carbohydrates with low-GI carbohydrates in the context of
focusgroupdiscussionsandpilot-testedthetools.Thefocus mixedmealshaveshownclinicallysignificantimprovements
groupsexploredtopicssuchasdietarypatternspracticedin in glycaemic control over 2 weeks to 6 months in people
Canada, meaningful expressions of portion sizes, cultural with type 1 diabetes (T1D) or T2D [12–14]. Replacing high-
holidays and values, preferred teaching and learning meth- GIcarbohydrateswithlow-GIcarbohydratesinmixedmeals
ods,classificationoffoodsintofoodgroups,andbarriersto alsohasbeenshowntoreducetotalcholesterolover2to24
education[9].JusttheBasicsprovidesclearinitialmessagesto weeksinpeoplewithandwithoutdiabetes[13],postprandial
patientsabouthealthyeatingandphysicalactivityfordiabetes glycaemia and high-sensitivity C-reactive protein (hsCRP)
preventionandmanagement,usingculturallydistinctfoods over 1 year in people with T2D [15], and the number of
and languages. Although these culturally adapted tools for hypoglycaemic events over 24 to 52 weeks in adults and
theSouthAsian,LatinAmerican,andAboriginalpopulations children with T1D [14]. Similar benefits have been shown
needongoingassessmentoftheirabilitytopromotesustained whenlow-GIdietsarecomparedwithdifferentcontroldiets.
behaviour change associated with optimal diabetes control, Dietary advice to consume a low-GI diet compared with
InternationalJournalofEndocrinology 5
Disadvantage ↓VitaminB12 ↑↓↓LDL,micN,adh↓↓↑micN,adh,RL↔↓FPG,adh↔↓FPG,adh↔↓↑FPG,adh,RL GIsideeffects ↓HDL,GIsideeffects ↓↑micN,RL↓↑micN,RLCH–Hgexposure,EI3Temporaryintervention Wgt);bloodpressure(BP);(FPG);CreactiveproteinHg(M-Hg);environmental
ht(cosehyl-
OtherAdvantages∗Ratio ↓↓↓↓CRP,Hypos,Rx ↓↓↓CRP,FPG,Rx,↓↓CVevents↓CRP ↓ ↓↓↓ ↓ Preserveleanmass oStopHypertension(DASH);weigotein-B(apo-B);fastingplasmagluutrient(micN);renalload(RL);met
ntherapies. Non-HDL-C ∗∗↓ etaryApproachestHDL-C);apolipoprence(adh);micron
fordiabetesnutritio LipidRiskFactorsHDL-CTG ↑ ↑↓ ↑ ↑↑↓↓ ↓ ↓↓↓↔↓ ds(LC-N3-PUFAs);DiHDLcholesterol(non-vegetarian(veg);adher
le1:Dietarystrategies LDL-CApo-B ↓ ↓ ↓↓↓ ↓ ↔ polyunsaturatedfattyacitriglycerides(TG);non-Mediterranean(Mediter); poprotein-A1).
Tab BP ↔ ↓ ↓ ↓↔ hainn-3HDL-C);nts(Rx); A1(apoli
InterventionsHbA1c%Wgt Dietarypatterns↓Low-GI/GL0.3–0.5%↓↓Vegdiets0.3–0.5% ↓Mediterdiets0.3–0.5% ↓↓DASH0.5–1.0%Wgtlossdiets↔↓Atkins↓↓Proteinpower0.5–1.0%↓Omish↓Wgtwatchers↓ZoneSpecificfoods↓Dietary0.3–0.5%↓<Treenuts0.3%Macronutrient↓Hi-CHOhifiber0.3–0.5%↓<Hi-MUFA0.3%↔Lo-CHO↔Hi-protein↔LC-N3-PUFAs ↓↓Mealreplacements0.3–0.5% Adaptedfrom[4].Glycaemicindex(GI);monounsaturatedfattyacids(MUFA);long-ctotalcholesterol(TC);LDLcholesterol(LDL-C);HDLcholesterol((CRP);hypos(hypoglycaemicepisodes);oralantihyperglycaemicageimpact(EI);gastrointestinal(GI).∗LipidratiosincludeTC:HDL-C,LDL-C:HDL-C,andapo-B:apo-∗∗Adjustedformedicationchanges.
6 InternationalJournalofEndocrinology
Table2:Commoncarbohydratefoodsandtheirglyceamicindices Table2:Continued.
(GI).
Food GI
Food GI Vegetables
Cereals Potato,boiled 78
Biscuits 69 Potato,fried 63
Cornflakes 81 Potato,instantmash 87
Instantoatmeal 79 Sweetpotato 63
Ricecongee 78 Carrots,boiled 39
Rolledoatmeal 55 Pumpkin,boiled 64
Milletporridge 67 Plantain 55
Muesli 57 Taro,boiled 53
Commonitems Vegetablesoup 48
Brownrice 68 Glyceamicindex(GI)rankscarbohydratesaccordingtotheirabilitytoraise
Barley 28 bloodglucoselevels,withthefollowingcut-offs:low-GI≤55,medium-GI
56–69,andhigh-GI≥70.AdaptedfromMechanicketal.[5].
Chapati 52
Corn 52
Corntortilla 46 Table3:CanadianDiabetesAssociationPhysicalActivityRecom-
Couscous 65 mendationsfordiabetesmanagement.
Multigrainbread 53
(1)Patientswithdiabetesshouldaccumulateaminimumof150
Ricenoodles 53 minutesofmoderate-to-vigorousintensityaerobicexerciseeach
Spaghetti 49 week,spreadoveratleast3daysoftheweek,withnomorethan2
Udonnoodles 55 consecutivedayswithoutexercise.
Wheatroti 62 (2)Peoplewithdiabetes(includingelderlypeople)shouldalsobe
encouragedtoperformresistanceexercise3timesperweek,in
Whiterice 73
additiontoaerobicexercise.Initialinstructionandperiodic
Whitewheatbread 75
supervisionbyanexercisespecialistarerecommended.
Wholewheatbread 74
(3)AnexerciseECGstresstestshouldbeconsideredforpreviously
Dairyproducts sedentaryindividualswithdiabetesathighriskforCVDwhowish
Icecream 51 toundertakeexercisemorevigorousthanbriskwalking(GradeD
Skimmilk 37 LOE).
Soymilk 37 AdaptedfromtheCanadianDiabetesAssociationClinicalPracticeGuide-
linesExpertCommittee.
Ricemilk 86
Canadian Diabetes Association 2008 clinical practice guidelines for the
Wholemilk 39
preventionandmanagementofdiabetesinCanada.CanJDiabetes.2008;32
Yogurt 41 (suppl1):S1-S201.
Fruits
Apple 36
Banana 51 ahigh-cerealfibredietinpeoplewithT2Dhasbeenshown
Dates 42 to improve glycaemic control and HDL cholesterol over 6
Mango 51 months [16]. In another trial in which dietary pulses (e.g.,
Orange 43 beans,chickpeas,lentils,andpeas)wereemphasizedtolower
the GI of the diet, significant improvements in glycaemic
Peach 43
control and blood pressure were reported over 3 months
Pineapple 59
[17].Alow-GIdietcomparedwithalow-carbohydrate,high
Watermelon 76
mono-unsaturatedfatdiet,hasbeenshowntoimprovebeta-
Legumes
cellfunctionoveroneyearinpeoplewithT2D[18].Moreover,
Chickpeas 28
low-GI diets compared with dietary advice based on the
Kidneybeans 24 nutrition recommendations of varied diabetes associations
Lentils 32 havebeenshowntohaveadvantages.Forexample,(a)dietary
Soybeans 16 advicetoconsumealow-GIdietimprovedglycaemiccontrol
Snacks over 3 months in Japanese people with impaired glucose
Chocolate 40 tolerance(IGT)orT2Dwhencomparedwiththenutritional
recommendationsoftheJapaneseDiabetesSociety[19],and
Popcorn 65
(b) the need for antihyperglycaemic medications over one
Potatochips 56
year was decreased in people with poorly controlled T2D
Ricecrackers 87
whencomparedwiththenutritionalrecommendationsofthe
Soda 59
AmericanDiabetesAssociation[20].
InternationalJournalofEndocrinology 7
Table4:DietaryApproachestoStopHypertension(DASH)fordiabetesnutritiontherapy.
Servingsperday
Foodgroups Servingsize
1600kcal/day 2600kcal/day 3600kcal/day
1slicebread;1ozdrycereal;1/2cup
Grains 6 10-11 12-13
cookedrice,pasta,cereal
Vegetables 3-4 5-6 6 1cuprawleafy;1/2cupcutraworcooked
1mediumpiece;1/4cupdried;1/2cup
Fruits 4 5-6 6
fresh,frozen,canned;1/2fruitjuice
Low/nonfatdairy 2-3 3 3-4 1cupmilkoryogurt;1.5ozcheese
Leanmeat,poultry,andfish 3–6 6 6–9 1ozcooked,meats,fish;1egg
1/3cupnuts;2tbsppeanutbutter;2tbsp
Nuts,seeds,andlegumes 3/week 1 1
seeds;1/2cupcookedlegumes
1tspsoftmargarine(nonhydrogenated);1
FatsandOils 2 3 4 tspvegoil;1tbspmayonnaise;2tbsp
saladdressing
Sweets,addedsugars 0 ≤2 ≤2 1tbspsugar;1tbspjellyorjam;1/2cup
sorbet,gelatin;1cuplemonade
AdaptedfromtheCanadianDiabetesAssociation.
CanadianDiabetesAssociation,DASHdietsummary,accessedathttp://www.diabetes.ca/documents/about-diabetes/DASHDietSummary.pdfon11,01,2012.
Table5:CDA’sClinicalPracticeGuidelinesSuggestionsforbariatric reduced risk of developing T2D [27–30]. The relationship
surgery. betweenlevelofphysicalactivityandmortality/morbidityis
semi-independent from the concomitant influence of well-
(1)Adultswithclinicallysevereobesity(BMI≥40kg/m2or
established CVD risk factors such as lipids, blood pressure,
≥35kg/m2withseverecomorbiddisease)maybeconsideredfor
diabetes, and smoking [28, 31]. Thus, even among individ-
bariatricsurgerywhenlifestyleinterventionisinadequateto
uals who are abdominally obese with other features of the
achievehealthyweightgoals.
metabolic syndrome, those who reported being very active
(2)Bariatricsurgeryinadolescentsshouldbelimitedto
exhibita50%reductionincoronaryriskcomparedtosimi-
exceptionalcasesandperformedonlybyexperiencedteams.
larlymatchedindividualswhoreportedbeingverysedentary
(3)Aminimallyinvasiveapproachshouldbeconsideredfor
[32].Theseresultsshowthatregularphysicalactivitynotonly
weightlosssurgerywhenanappropriatelytrainedsurgicalteam
reduces the risk of developing T2D [33, 34] but also pro-
andappropriateresourcesareavailableintheoperatingtheatre.
videsclinicalbenefitsamongpatientswithT2Dorwiththe
featuresofthemetabolicsyndrome.Somestudieshaveused
cardiorespiratoryfitness(CRF)asanobjectivephysiological
TheproductofmeanGIandtotalcarbohydrateintakeis markerofparticipationinvigorousphysicalactivityandhave
known as glycaemic load (GL) and has also been explored shownthatahighlevelofCRFisassociatedwithasubstan-
in therapeutic studies. A low GL was found to improve the tially reduced risk of premature mortality, CVD mortality,
efficiency of weight loss advice over 4 weeks [21] and im- and CVD morbidity [35–37]. The substantial cardioprotec-
proveriskfactorsforcoronaryheartdiseaseincludinghigh- tionconferredbyahighlevelofCRFhasevenbeenreported
density lipoprotein cholesterol (HDL-C), triglycerides, and amongpatientswithT2D[38].Forinstance,Churchandcol-
C-reactiveprotein(CRP)over4weeksto6months[21–23] leagues[38]haveshownthatoverweight/obesebutfitpatients
comparedwithalow-fatdiet,inyoungoverweightandobese withdiabeteswereatlowermortalityriskthannonobesebut
adultswithoutdiabetes.AlowGLdiethasalsobeenshown unfitpatientswithdiabetes.Alltheaboveobservationsclearly
tohaveadvantagesforcoronaryheartdiseaseinasystematic highlight the critical importance of recommending regu-
reviewandmeta-analysisofprospectivecohortstudies[24] lar physical activity and better cardiorespiratory fitness in
and for diabetes management itself in different analyses of patients with T2D. In addition, regular physical activity
theNursesHealthStudy[25,26].Thesuccessofweightloss produces substantial benefits in high-risk individuals with
strategies using low-GL diets appears to be related to the prediabetes,reducingtheirriskofconvertingtoT2Dandde-
degreeofinsulinresistanceasassessedbythe30-minpost- velopingdetrimentalcardiovascularoutcomes[33,34].
prandialinsulinloads[23]. Inadditiontoaerobictraining,moderate-to-highinten-
TheCanadiantDNAintegratesandemphasizesphysical sityresistancetrainingisbeneficialinordertomaintainlean
activity. The recommendations are based on evidence from body mass, particularly in the aging population of patients
prospective observational studies showing that individuals with T2D [39–41]. As there is a dose-response relationship
who perform such levels of activity have reduced risk of between level of physical activity and clinical outcomes,
premature total and cardiovascular mortality as well as guidelinesfromtheCanadianSocietyofExercisePhysiology
8 InternationalJournalofEndocrinology
haveemphasizedthegreaterhealthbenefitsthatareexpected that were consumed. The age-adjusted relative risk for all-
fromagreatervolumeofweeklyphysicalactivity[27].Inline cause mortality in persons in the upper quartile was 0.69
withtheCanadianrecommendations,itishereinproposedto (95% confidence interval 0.61–0.78); for the second and
reducethetimedevotedtosedentarybehaviour,toincrease third quartiles the relative risks were 0.82 (95% confidence
the level of moderate-to-vigorous physical activities and interval 0.73–0.92) and 0.71 (95% confidence interval 0.62–
exercise,andalsotoperformresistanceexercisetrainingfor 0.81),respectively.Thestudydemonstratedthatasthequality
all major muscle groups. Unfortunately, accelerometer data of the dietary pattern improved (on the basis of current
obtained from the 2007–2009 Canadian Health Measures dietary guidelines) an associated health benefit was gained.
Surveyhaverevealedthatonlyabout15%ofCanadianadults Other reviewed [44] dietary patterns associated with lower
accumulate 150 minutes of moderate-to-vigorous physical orhigherriskofchronicdisease(resp.)includethePrudent
activity per week, and this statistic is probably even worse Pattern compared to the Western Pattern, dietary patterns
amongpatientswithT2D[8].Becauselifestylemodification identified in the Nurse’s Health Study and the Physician’s
isacornerstoneofthemanagementofcardiometabolicrisk Health Study. The Prudent Pattern was characterized by a
inpatientswithT2D,itisproposedthateffortsandresources higherintakeofvegetables,fruits,legumes,wholegrains,and
should be devoted to help patients afflicted by a societal fishwhiletheWesternPatternbyahigherintakeofprocessed
metabolic disease recalibrate their nutritional and physical meat, red meat, butter, high-fat dairy products, eggs, and
activity/exercisehabits. refinedgrains.Relativeriskforcoronaryheartdisease(CHD)
Furthermore, interventions such as motivational inter- decreased from the lowest to highest quintiles of Prudent
viewing,whichisaspecificwayofhelpingpeoplerecognize Pattern score (relative risk 1.0 and 0.70, 95% confidence
and formulate an action plan to address specific lifestyle interval0.56–0.86;𝑃= 0.0009fortrend),whereasCHDrisk
changes, can be useful for clients who are reluctant or am- increasedwithincreasingquintileforWesternPatternscore
bivalentaboutchangingbehaviour[42].Thestrategiesused (relativerisk1.0and1.64,95%confidenceinterval1.24–2.17;
formotivationalinterviewingaremoresupportivethancon- 𝑃 < 0.0001 for trend). These analyses may provide useful
frontational, and the overall goal is to increase a person’s evidenceformakingspecificfood-baseddietaryrecommen-
intrinsicmotivationtochangeratherthanhavingchangeim- dationswithinthecontextoftheexistingdietaryguidelines;
posed by healthcare practitioners [42]. Motivational inter- however,theirimpactaspartofclinicaltreatmentfordiabetes
viewing,whenadministeredbygeneralpractitionerswhore- hasnotbeenstudied.
ceivedtraininginthistreatmentmodality,hasbeenshownto The Dietary Approaches to Stop Hypertension (DASH)
positivelyaffectattitudesforchangeinpeoplewithT2D[42]. Studydemonstratedthatadietarypatternhighinfruits,veg-
Indeed,itmustberememberedthatpatientsfindadher- etables, and low-fat dairy products, coupled with sodium
ence to appropriate dietary patterns exceptionally difficult restriction, reduced hypertension and, consequently, is in-
to maintain consistently and that recommended dietary cludedhereasadietaryinterventionforhypertensivepatients
patternsarenotwellfollowed.Furthermore,inthepast,dia- with T2D (Table1). Moreover, the Lyon Diet Heart Study
betesnutritiontherapyhasemphasizedindividualmacronu- showedthatdietarypatternshaveamarkedbeneficialimpact
trient and micronutrient components and their adequacy. onimportantriskfactorsforCVD,aswellasmorbidityand
Althoughstudyingindividualnutrientsmayleadtoanunder- mortalityend-points.Theseresultssupportthepotentialpos-
standing of important biological mechanisms, it has been itiveimplicationsforcliniciansandpatientsofusingadietary
recognized more recently that providing practical advice pattern approach that emphasizes “what to eat” (i.e., plant-
or identifing strategies on how people eat is not sufficient. basedfoods,selectedunsaturatedfats)ratherthan“whatto
Rather,assessmentofdietarypatternsoffersacomprehensive restrict”(i.e.,totalfat,saturatedfat,sodium,andsugars)and
andcomplementaryapproachtoapplynutritionalprinciples givemoreexplicitinstructionsthatcanbeputintopractice
to “real life” [43] and to identify and validate those that over the long term. Because evidence continues to emerge
support optimal glycaemic control in people with T2D, abouttheimportanceofregularlyincludingparticularfoods
regardlessofextantpharmacologicalmanagement.Suchas- (i.e., nuts, legumes, and vegetables) relative to the risk of
sessment has been suggested to be important for advance- developingdiabetesand/orotherchronicdiseases,especially
mentofefficaciousandeffectiveclinicalandpublichealthin- CVD, the Canadian tDNA makes reference to these items
terventions[43].Analysesoffoodpatternswouldincludethe (Table1)initsalgorithm.However,backgroundfoodintake
possibility that interactions or synergistic effects among in- patternsarenotusuallyreportedinstudiesinwhichoneor
dividualfoodsornutrientsareexamined[43]. twofoods/nutrientsaremanipulated,andthisinformationis
StudiesreviewedbyKris-Ethertonetal.provideevidence requiredinordertounderstandthepotentialforinteractions
thatfood-basedapproachesanddietarypatternsreducerisk betweenfoodsandnutrients.Furthermore,itisunlikelythat
forcardiovasculardisease[44].Forinstance,theBreastCan- emphasizing a single food or set of foods (e.g., only low
cer Detection Demonstration Project [45] evaluated 42,254 GIfoods)willsignificantlyandpositivelyimpactglycaemic
womenanddemonstratedthatall-causemortalitydecreased controlunlessthechangesintotalintakereflectasignificant
byquartileofrecommendedfoodscore.Therecommended changeinunderlyingregulardietarypatterns[46].Thus,an
food score was the sum of the number of foods as rec- emerging issue that must be resolved is that inclusion of
ommendedbycurrentdietaryguidelines(fruits,vegetables, particular foods is made within a diet that confers the op-
whole grains, low-fat dairy and lean meats, and poultry) timaldietarypatternforriskreductioninawaythatpromotes
InternationalJournalofEndocrinology 9
Physician buy-in on impact of healthy behavior requires the implementation of strategies to help change
thi behaviour in a sustainable manner. The foods in the
Meaningful, individual, Gradual, balanced environmentofCanadianswithT2Dshouldbenutritionally
reasonable goals Fun and individualized physical activity adequate,culturallyacceptablethroughappropriatefoodand
Structured dietary pleasure! Frequent participant distributionsystems,physicallyandeconomicallyaccessible
intervention contact
atalltimes,andsafeandsecureinordertoenableadoption
Strong individual Patient support network for ofbehaviourthatpromotesoptimaldiabetescareandmake
change readiness adapting healthy behaviour
healthy food choices the norm. Furthermore, simple tools
shouldbeputinplacetofirstevaluatesedentarybehaviour
and physical activity habits of patients and then support
Patient adherence
economicallyviablesolutionstohelppatientsincreasetheir
Figure3:DriversofadherencefortheCanadiantDNA. physical activity habits and regular exercise level. Above
all, primary care practitioners should buy-in on the impact
of healthy lifestyle behaviours on diabetes management by
adoptingthisbehaviourthemselves.TheCanadiantDNAis
ahealthybodyweight(i.e.,itdoesnotexceedenergyrequire-
afirststep.
ments).
Validatedevaluationtoolsandsimple/efficientprocesses
Disclosure
for monitoring/surveillance are essential to the success of
tDNA.Establishingefficacyisimportant,butitisalsoessen-
Thepaperofthisarticlewascreatedandenrichedsolelyby
tial to identify techniques, tools, and environmental factors
task force members through a process of ongoing literature
thatcontributedto,ordetractedfrom,thesuccessofimple-
searches,independentcontributionsandreviews,andgroup
menting the intervention [47]. Nutrient intake, although
interactionsforconsensus.
important, does not capture the complexity of behavioural
changes that people make to implement the dietary advice
ConflictofInterests
they received. Details are critical so that programmes can
be expanded and adapted when warranted. For the field to
The authors declare that there is no conflict of interests re-
advance,wemustknowwhatstudyparticipantswereasked
gardingthepublicationofthispaper.
todoandwhattheyactuallydidandwemustmovebeyond
“intention to treat” analyses. Assessment of dietary and
Acknowledgments
physical activity behaviour and behaviour changes requires
evaluation tools that are validated, reliable, and easy to use
FinancialsupportwasprovidedbyAbbottNutritionInterna-
in various clinical practice settings [48]. The tools should
tional.Othersupportmayhavebeenprovidedtotaskforce
beadaptedtotheculturalspecificitiesoftheclientsandthe
membersasfollows.Jean-Franc¸oisYalehasreceivedfinancial
Canadian guidelines. An inventory of validated tools, their
support for advisory boards, lectures, and research from
selectionaccordingtoaccessibilityandappropriateness,their
Sanofi,EliLilly,NovoNordisk,Merck,Bristol-MyersSquibb,
adaptationtogeographicandethnoculturalspecificities,and
Astra Zeneca, Boehringer Ingelheim, Janssen, Medtronic,
their modification to improve clarity, simplicity, and user-
Abbott,Takeda,andGlaxoSmithKline.ThomasPPRansom
friendliness remain to be achieved before validation of the
has received financial support for advisory boards, lectures
tDNA is undertaken in a clinical setting. The tDNA and its
andresearchfromMerck&Co.,Novartis,BoehringerIngel-
toolscanonlybeofusewhenpatientsadoptandadhereto
heim, Bristal-Myers Squibb, AstraZeneca, Eli Lilly, Glaxo-
therecommendations.Thisisoptimizedifthephysiciansand
SmithKline, Novo Nordisk and Sanofi-Aventis. Jean-Pierre
theirpatientsbuy-inontheimpactofhealthybehaviouron
Despre´sdeclaresassociationswiththefollowingcompanies:
diabetesmanagementandpointstotheimportanceoftheir
Abbott, AstraZeneca, GlaxoSmithKline, Merck, Novartis,
involvementateachstepofthetDNA.Figure3summarizes
PfizerCanada,Sanofi,Theratechnologies,andTorrentPhar-
what is to be accomplished when primary caretakers adopt
maceuticals.CyrilKendallhasreceivedresearchgrants,travel
theCanadiantDNAanditstoolsinaclinicalpractice;atits
funding,consultantfees,andhonoraria,orhasservedonthe
core,wepromotetoalwaysaimatmakingtherelationshipto
scientificadvisoryboardforAbbottLaboratories,Advanced
foodandphysicalactivityfunandpleasurable.
FoodMaterialsNetwork,AgrifoodandAgricultureCanada
(AAFC), Almond Board of California, American Peanut
5.Conclusions Council, American Pistachio Growers, Barilla, California
StrawberryCommission,CalorieControlCouncil,Canadian
Adapting the global tDNA template to a Canadian society InstitutesofHealthResearch(CIHR),CanolaCouncilofCa-
led to the recognition that primary care practitioners need nada,TheCocaColaCompany(investigatorinitiated,unre-
toparticipateasactiveandkeypromotersofhealthylifestyle stricted), Danone, General Mills, Hain Celestial, Interna-
behaviour with other members of the health professional tionalTreeNutCouncil,Kellogg,Kraft,LoblawBrandsLtd,
team. Their involvement entails the development of sim- Nutrition Foundation of Italy, Oldways Preservation Trust,
ple, quick, and effective methods to assess nutritional and Orafti, Paramount Farms, Peanut Institute, Pepsi-Co, Pulse
physical activity behaviours that put patients at risk and Canada,SaskatchewanPulseGrowers,Solae,Sun-Maid,Tate
10 InternationalJournalofEndocrinology
& Lyle, and Unilever. David Jenkins has served on the Sci- [2] J.-P. Despres, A. Nadeau, A. Tremblay et al., “Role of deep
entificAdvisoryBoardofSanitariumCompany,Agriculture abdominalfatintheassociationbetweenregionaladiposetissue
andAgrifoodCanada(AAFC),CanadianAgriculturePolicy distributioinandglucosetoleranceinobesewomen,”Diabetes,
Institute(CAPI),LoblawSupermarket,HerbalLifeInterna- vol.38,no.3,pp.304–309,1989.
tional, Nutritional Fundamental for Health, Pacific Health [3] P.S.Yusuf,S.Hawken,S.Oˆunpuuetal.,“Effectofpotentially
Laboratories, Metagenics, Bayer Consumer Care, Orafti, modifiable risk factors associated with myocardial infarction
in52countries(theINTERHEARTstudy):case-controlstudy,”
Dean Foods, Kellogg’s, Quaker Oats, Procter & Gamble,
TheLancet,vol.364,no.9438,pp.937–952,2004.
Coca-Cola, NuVal Griffin Hospital, Abbott, Pulse Canada,
[4] Committee.CDACPGE.CanadianDiabetesAssociation,“2008
SaskatchewanPulseGrowers,andCanolaCouncilofCanada;
clinicalpracticeguidelinesforthepreventionandmanagement
received honoraria for scientific advice from Sanitarium
ofdiabetesinCanada:self-managementeducation,”Canadian
Company,Orafti,theAlmondBoardofCalifornia,theAmer-
JournalofDiabetes,vol.32,supplement1,2008.
icanPeanutCouncil,InternationalTreeNutCouncilNutri-
[5] J.I.Mechanick,A.E.Marchetti,C.Apovianetal.,“Diabetes-
tion Research and Education Foundation and the Peanut
specific nutrition algorithm: a transcultural program to opti-
Institute,HerbalLifeInternational,PacificHealthLaborato-
mizediabetesandprediabetescare,”CurrentDiabetesReports,
ries,NutritionalFundamentalforHealth,Barilla,Metagenics, vol.12,no.2,pp.180–194,2012.
Bayer Consumer Care, Unilever Canada and Netherlands,
[6] G.Mingrone,S.Panunzi,A.deGaetanoetal.,“Bariatricsurgery
Solae, Oldways, Kellogg’s, Quaker Oats, Procter & Gamble, versusconventionalmedicaltherapyfortype2diabetes,”The
Coca-Cola,NuValGriffinHospital,Abbott,CanolaCouncil NewEnglandJournalofMedicine,vol.366,no.17,pp.1577–1585,
ofCanada,DeanFoods,CaliforniaStrawberryCommission, 2012.
HainCelestial,Pepsi,andAlproFoundation;hasbeenonthe [7] CommitteeCDACPGE,“Nutritiontherapy,”CanadianJournal
speakerspanelfortheAlmondBoardofCalifornia;received ofDiabetes,vol.32,supplement1,pp.S40–S45,2008.
researchgrantsfromSaskatchewanPulseGrowers,theAgri- [8] R. C. Colley, D. Garriguet, I. Janssen, C. L. Craig, J. Clarke,
cultural Bioproducts Innovation Program (ABIP) through and M. S. Tremblay, “Physical activity of canadian adults:
the Pulse Research Network (PURENet), Advanced Food accelerometer results from the 2007 to 2009 canadian health
Materials Network (AFMNet), Loblaw, Unilever, Barilla, measuressurvey,”HealthReports,vol.22,no.1,pp.7–14,2011.
AlmondBoardofCalifornia,Coca-Cola,Solae,HaineCeles- [9] S.I.MianandP.M.Brauer,“DietaryeducationtoolsforSouth
tial, Sanitarium Company, Orafti, International Tree Nut Asianswithdiabetes,”CanadianJournalofDieteticPracticeand
Research,vol.70,no.1,pp.28–35,2009.
CouncilNutritionResearchandEducationFoundationand
the Peanut Institute, the Canola and Flax Councils of Ca- [10] D.J.Jenkins,T.M.Wolever,R.H.Tayloretal.,“Glycemicindex
offoods:aphysiologicalbasisforcarbohydrateexchange,”The
nada, Calorie Control Council, Canadian Institutes of
AmericanJournalofClinicalNutrition,vol.34,no.3,pp.362–
Health Research, Canada Foundation for Innovation, and
366,1981.
the Ontario Research Fund; and received travel support to
[11] F.S.Atkinson,K.Foster-Powell,andJ.C.Brand-Miller,“Inter-
meetingsfromtheSolae,SanitariumCompany,Orafti,AFM-
national tables of glycemic index and glycemic load values:
Net, Coca-Cola, The Canola and Flax Councils of Canada,
2008,”DiabetesCare,vol.31,no.12,pp.2281–2283,2008.
OldwaysPreservationTrust,Kellogg’s,QuakerOats,Griffin
[12] J. Brand-Miller, S. Hayne, P. Petocz, and S. Colagiuri, “Low-
Hospital, Abbott Laboratories, Dean Foods, the California
glycemic index diets inthemanagement ofdiabetes: ameta-
StrawberryCommission,AmericanPeanutCouncil,Herbal
analysisofrandomizedcontrolledtrials,”DiabetesCare,vol.26,
Life International, Nutritional Fundamental for Health, no.8,pp.2261–2267,2003.
Metagenics, Bayer Consumer Care, AAFC, CAPI, Pepsi, [13] A.M.Opperman,C.S.Venter,W.Oosthuizen,R.L.Thompson,
Almond Board of California, Unilever, Alpro Foundation, and H. H. Vorster, “Meta-analysis of the health effects of
International Tree Nut Council, Barilla, Pulse Canada, and usingtheglycaemicindexinmeal-planning,”BritishJournalof
the Saskatchewan Pulse Growers. Dr Jenkins’ wife is a Di- Nutrition,vol.92,no.3,pp.367–381,2004.
rector of Glyceamic Index Laboratories, Toronto, Ontario, [14] D.E.ThomasandE.J.Elliott,“Theuseoflow-glycaemicindex
Canada.AlbertMarchettihasreceivedfinancialsupportfor dietsindiabetescontrol,”BritishJournalofNutrition,vol.104,
research and the development of educational materials in no.6,pp.797–802,2010.
diabetes from Eli Lilly, Takeda, GlaxoSmithKline, Bristol- [15] T.M.S.Wolever,A.L.Gibbs,C.Mehlingetal.,“TheCanadian
Myers Squibb, and Abbott Nutrition International. Osama TrialofCarbohydratesinDiabetes(CCD),a1-ycontrolledtrial
HamdyhasreceivedfinancialsupportasaConsultantfrom oflow-glycemic-indexdietarycarbohydrateintype2diabetes:
noeffectonglycatedhemoglobinbutreductioninC-reactive
AbbottNutritionandasaSpeakerfromAmylin/EliLillyand
protein,”AmericanJournalofClinicalNutrition,vol.87,no.1,
AbbottNutrition.JefferyIMechanickhasreceivedhonoraria
pp.114–125,2008.
forlecturesandprogramdevelopmentfromAbbottNutrition
[16] D.J.A.Jenkins,C.W.C.Kendall,G.McKeown-Eyssenetal.,
International.
“Effectofalow-glycemicindexorahigh-cerealfiberdieton
type 2 diabetes: a randomized trial,” Journal of the American
MedicalAssociation,vol.300,no.23,pp.2742–2753,2008.
References [17] D. J. Jenkins, C. W. Kendall, L. S. Augustin et al., “Effect of
legumesaspartofalowglycemicindexdietonglycemiccontrol
[1] R.A.DeFronzo,R.C.Bonadonna,andE.Ferrannini,“Patho- and cardiovascular risk factors in type 2 diabetes mellitus: a
genesisofNIDDM:abalancedoverview,”DiabetesCare,vol.15, randomizedcontrolledtrial,”ArchivesofInternalMedicine,vol.
no.3,pp.318–368,1992. 22,pp.1–8,2012.