Diete a diverso contenuto di carboidrati

Diete a diverso contenuto di
carboidrati
Giuseppe Fatati
Ilenia Grandone
Struttura Complessa di Diabetologia, Dietologia e Nutrizione
Clinica. Azienda Ospedale S.Maria, Terni
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Klein S, Sheard NF, Pi-Sunyer X, et al.; American Diabetes Association; North American
Association for the Study of Obesity; American Society for Clinical Nutrition. Weight
management through lifestyle modification for the prevention and management of
type 2 diabetes: rationale and strategies. A statement of the American Diabetes
Association, the North American Association for the Study of Obesity, and the
American Society for Clinical Nutrition. Diabetes Care 2004;27:2067–2073
Norris SL, Zhang X, Avenell A, et al. Efficacy of pharmacotherapy for weight loss in
adults with type 2 diabetes mellitus: a meta-analysis. Arch Intern Med 2004;164:1395–
1404
Wolf AM, Conaway MR, Crowther JQ, et al.; Translating lifestyle intervention to
practice in obese patients with type 2 diabetes: Improving Control with Activity and
Nutrition (ICAN) study. Diabetes Care 2004;27:1570–1576
Manning RM, Jung RT, Leese GP, Newton RW. The comparison of four weight
reduction strategies aimed at overweight patients with diabetes mellitus: four-year
follow-up. Diabet Med 1998;15:497–502
Pi-Sunyer X, Blackburn G, Brancati FL, et al.; Look AHEAD Research Group. Reduction in
weight and cardiovascular disease risk factors in individuals with type 2 diabetes: oneyear results of the look AHEAD trial. Diabetes Care 2007; 30:1374–1383
Wing RR; Look AHEAD Research Group. Long-term effects of a lifestyle intervention on
weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: fouryear results of the Look AHEAD trial. Arch Intern Med 2010;170:1566–1575
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Klein S, Sheard NF, Pi-Sunyer X, et al.; American Diabetes Association; North American
Association for the Study of Obesity; American Society for Clinical Nutrition. Weight
management through lifestyle modification for the prevention and management of
type 2 diabetes: rationale and strategies. A statement of the American Diabetes
Association, the North American Association for the Study of Obesity, and the
American Society for Clinical Nutrition. Diabetes Care 2004;27:2067–2073
Norris SL, Zhang X, Avenell A, et al. Efficacy of pharmacotherapy for weight loss in
adults with type 2 diabetes mellitus: a meta-analysis. Arch Intern Med 2004;164:1395–
1404
Wolf AM, Conaway MR, Crowther JQ, et al.; Translating lifestyle intervention to
practice in obese patients with type 2 diabetes: Improving Control with Activity and
Nutrition (ICAN) study. Diabetes Care 2004;27:1570–1576
Manning RM, Jung RT, Leese GP, Newton RW. The comparison of four weight
reduction strategies aimed at overweight patients with diabetes mellitus: four-year
follow-up. Diabet Med 1998;15:497–502
Pi-Sunyer X, Blackburn G, Brancati FL, et al.; Look AHEAD Research Group. Reduction in
weight and cardiovascular disease risk factors in individuals with type 2 diabetes: oneyear results of the look AHEAD trial. Diabetes Care 2007; 30:1374–1383
Wing RR; Look AHEAD Research Group. Long-term effects of a lifestyle intervention
on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus:
four-year results of the Look AHEAD trial. Arch Intern Med 2010;170:1566–1575
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Changes in Weight, HbA1c, Blood Pressure, HDL-C, Triglycerides, and LDL-C
(unadjusted and adjusted for medication use).
the Intensive lifestyle intervention (ILI) and diabetes support and
education (DSE)
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Le persone affette da alterazioni glicemiche o diabete devono
ricevere, preferibilmente da un dietologo o da un dietista, esperti in
terapia medica nutrizionale (MNT) del diabete e quindi inseriti nel
team diabetologico, una terapia medica nutrizionale individualizzata
al fine di raggiungere gli obiettivi terapeutici. (Livello della prova III,
Forza della raccomandazione B). AMD-SID: Standard italiani per la
cura del Diabete Mellito 2009-2010.
Individuals who have prediabetes or diabetes should receive
individualized MNT as needed to achieve treatment goals, preferably
provided by a registered dietitian familiar with the components of
diabetes MNT. (A) American Diabetes Association. Standards of
medical care in diabetes--2013. Diabetes Care. 2013 Jan; 36 Suppl
1:S11-66. doi: 10.2337/dc13-S011.
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A full review of the evidence regarding nutrition in preventing and
controlling diabetes and its complications and additional nutritionrelated recommendations can be found in the ADA position statement
“Nutrition Recommendations and Interventions for Diabetes” (114),
which is being updated as of 2013.
114. Bantle JP, Wylie-Rosett J, Albright AL, et al.; American Diabetes
Association. Nutrition recommendations and interventions for diabetes:
a position statement of the American Diabetes Association. Diabetes
Care 2008;31(Suppl. 1):S61– S78
Clinical trials/outcome studies of MNT have reported decreases in A1C
at 3–6 months ranging from 0.25 to 2.9% with higher reductions seen in
type 2 diabetes of shorter duration. Multiple studies have demonstrated
sustained improvements in A1C at 12months and longer when a
registered dietitian provided follow-up visits ranging from monthly to 3
sessions per year (115–122).
115. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary
freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE)
randomised controlled trial. BMJ 2002;325:746
116. Franz MJ, Monk A, Barry B, et al. Effectiveness of medical nutrition therapy provided by
dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized,
controlled clinical trial. J Am Diet Assoc 1995;95:1009– 1017
117. Goldhaber-Fiebert JD, Goldhaber-Fiebert SN, Trist
an ML,NathanDM. Randomized
controlled community-based nutrition and exercise intervention improves glycemia and
cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica. Diabetes Care
2003;26:24–29
118. Lemon CC, Lacey K, Lohse B, Hubacher DO, Klawitter B, Palta M. Outcomes monitoring of
health, behavior, and quality of life after nutrition intervention in adults with type 2 diabetes. J
Am Diet Assoc 2004;104:1805–1815
119. Miller CK, Edwards L, Kissling G, Sanville L. Nutrition education improves metabolic
outcomes among older adults with diabetes mellitus: results from a randomized controlled trial.
Prev Med 2002;34:252–259
120. Wilson C, Brown T, Acton K, Gilliland S. Effects of clinical nutrition education and educator
discipline on glycemic control outcomes in the Indian Health Service. Diabetes Care 2003;
26:2500– 2504
121. Graber AL, Elasy TA, Quinn D, Wolff K, Brown A. Improving glycemic control in adults with
diabetes mellitus: shared responsibility in primary care practices. South Med J 2002;95:684–690
122. Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a
registered dietitian improves short-term clinical outcomes for rural Kentucky patients with
chronic diseases. J Am Diet Assoc 2006;106:109–112
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Cumulative Incidence of Diabetes According to Study Group: the lifestyle intervention reduced the
incidence by 58 percent (95 percent confidence interval, 48 to 66 percent) and metformin by 31
percent (95 percent confidence interval, 17 to 43 percent), as compared with placebo
Diabetes Prevention Program Research Group. N Engl J Med
2002;346:393-403.
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Mann JI, De Leeuw I, Hermansen K, Karamanos B, Karlström B, Katsilambros
N, Riccardi G, Rivellese AA, Rizkalla S, Slama G, Toeller M, Uusitupa M, Vessby B;
Diabetes and Nutrition Study Group (DNSG) of the European Association.
Evidence-based nutritional approaches to the treatment and prevention of
diabetes mellitus. Nutr Metab Cardiovasc Dis. 2004 Dec;14(6):373-94. J Am Diet
Assoc. 2007 Oct;107(10):1755-67.
Franz MJ, VanWormer JJ, Crain AL, Boucher JL, Histon T, Caplan W, Bowman
JD, Pronk NP: Weight-loss outcomes: a systematic review and meta-analysis of
weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc.
2007 Oct;107(10):1755-67.
Gary D. Foster, Holly R. Wyatt, James O. Hill, Angela P. Makris, Diane L.
Rosenbaum, Carrie Brill, Richard I. Stein, B. Selma Mohammed, Bernard Miller,
Daniel J. Rader, Babette Zemel, Thomas A. Wadden, Thomas Tenhave, Craig W.
Newcomb, and Samuel Klein: Weight and Metabolic Outcomes After 2 Years
on a Low-Carbohydrate Versus Low-Fat Diet. A Randomized Trial. Ann Intern
Med. 2010 August 3; 153(3): 147–157.
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Gary D. Foster: Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate
Versus Low-Fat Diet. A Randomized Trial. Ann Intern Med. 2010 August 3; 153(3): 147–157.
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Gary D. Foster, Holly R. Wyatt, James O. Hill, Angela P. Makris, Diane L.
Rosenbaum, Carrie Brill, Richard I. Stein, B. Selma Mohammed, Bernard
Miller, Daniel J. Rader, Babette Zemel, Thomas A. Wadden, Thomas
Tenhave, Craig W. Newcomb, and Samuel Klein: Weight and Metabolic
Outcomes After 2 Years on a Low-Carbohydrate Versus Low-Fat Diet. A
Randomized Trial. Ann Intern Med. 2010 August 3; 153(3): 147–157.
Conclusion: Successful weight loss can be achieved with either a low-fat
or low-carbohydrate diet when coupled with behavioral treatment. A
low-carbohydrate diet is associated with favorable changes in
cardiovascular disease risk factors at 2 years.
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Original Article
Weight Loss with a Low-Carbohydrate,
Mediterranean, or Low-Fat Diet
Iris Shai,
Dan Schwarzfuchs, Yaakov Henkin, Danit R. Shahar, Shula Witkow, Ilana Greenberg, Rachel Golan, Drora
Fraser, Arkady Bolotin, Hilel Vardi, Osnat Tangi-Rozental, B.A., Rachel Zuk-Ramot, Benjamin Sarusi, Dov Brickner, Ziva
Schwartz, Einat Sheiner, Rachel Marko, Esther Katorza, Joachim Thiery, Georg Martin Fiedler, Matthias Blüher, Michael
Stumvoll, Meir J. Stampfer for the Dietary Intervention Randomized Controlled Trial (DIRECT)
Group. N Engl J Med Volume 359(3):229-241 July 17, 2008
Study Overview
This 2-year trial, which took place in an isolated workplace that facilitated retention in the
study, randomly assigned 322 moderately obese subjects to one of three diets: a low-fat,
restricted-calorie diet; a Mediterranean, restricted-calorie diet; or a low-carbohydrate, non–
restricted-calorie diet.
The results suggest that the Mediterranean and low-carbohydrate diets are effective
alternatives to low-fat diets and that personal preferences and metabolic considerations
might inform individualized tailoring of dietary interventions.
Weight Changes during 2 Years According to Diet Group.
Shai I et al. N Engl J Med 2008;359:229-241
Changes in Cholesterol and Triglyceride Biomarkers According to Diet Group during the
Maximum Weight-Loss Phase (1 to 6 Months) and the Weight-Loss Maintenance Phase (7 to
24 Months) of the 2-Year Intervention.
Shai I et al. N Engl J Med 2008;359:229-241
Changes in Biomarkers According to Diet Group and Presence or Absence of Type 2
Diabetes.
Shai I et al. N Engl J Med 2008;359:229-241
Conclusions
• Mediterranean and low-carbohydrate diets may be effective alternatives
to low-fat diets.
• The more favorable effects on lipids (with the low-carbohydrate diet) and
on glycemic control (with the Mediterranean diet) suggest that personal
preferences and metabolic considerations might inform individualized
tailoring of dietary interventions.
In conclusion, a 2-year
workplace
intervention
trial involving healthy
dietary
changes
had
longlasting,
favorable
postintervention effects,
particularly
among
participants receiving the
Mediterranean and lowcarbohydrate
diets,
despite a partial regain of
weight.
Dan Schwarzfuchs, Rachel
Golan,
Iris Shai, Ben
Gurion: Four-Year Followup after Two-Year Dietary
Interventions. N Engl J
Med 2012; 367:1373-1374
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Wheeler ML, Dunbar SA, Jaacks LM, et al. Diabetes Care 2012;35:
434–445
Summary of lower-carbohydrate research since 2002
In studies reducing total carbohydrate intake, markers of glycemic control
and insulin sensitivity improved, but studies were small, of short duration,
and in some cases were not randomized or had high dropout rates. Serum
lipoproteins typically improved with reduction of total carbohydrate
intake but, with the exception of HDL cholesterol, were not statistically
greater than with the comparison diet. The contribution of weight loss to
the results was not clear in some of these studies.
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It should be noted that the RDA for digestible carbohydrate is 130
g/day and is based on providing adequate glucose as the required fuel
for the central nervous system without reliance on glucose production
from ingested protein or fat. Although brain fuel needs can be met on
lower carbohydrate diets, long-term metabolic effects of very lowcarbohydrate diets are unclear and such diets eliminate many foods
that are important sources of energy, fiber, vitamins, and minerals and
are important in dietary palatability.
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La quantità ed il tipo di carboidrati (CHO) ingeriti sono il principale
determinante della glicemia postprandiale. Non ci sono, però, evidenze
scientifiche che permettano di consigliare una quantità ideale di CHO da
consigliare a tutti i pazienti diabetici. La quantità di carboidrati può variare in
base alle abitudini individuali e locali, ed in maniera complementare con il
consumo di grassi e proteine nell’intervallo tra il 45-60% dell’energia totale, ma
mai inferiori a 130 g/die(1-3). La quota del 60% dell’energia totale può essere
consigliata a patto che il consumo di carboidrati derivi principalmente da
alimenti ricchi in fibre idrosolubili (frutta, vegetali, legumi) e/o alimenti a basso
indice glicemico (pasta, legumi, riso parboiled). La dieta ricca in fibre idrosolubili
e/o con basso indice glicemico si è dimostrata efficace nel migliorare il controllo
glicemico e lipidico dei pazienti con Diabete Mellito, e utile nella prevenzione
del diabete. In particolare pazienti in sovrappeso od obesi possono beneficiare
dell’effetto saziante di alti apporti di carboidrati e fibre.
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Alla luce di quanto detto, considerato come nelle persone con
diabete siano disponibili dati solo nel breve periodo, e come sia
necessario da parte delle società scientifiche e dei sanitari traslare
le raccomandazioni in linee-guida appropriate alle diverse realtà
locali, si ritiene opportuno, in accordo con gli standard italiani, di
non proporre ai diabetici tipo 2 una dieta con apporto glucidico
inferiore al 45% delle calorie totali giornaliere.
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BMJ. 2008 Sep 11;337:a1344.
Sofi F, Cesari F, Abbate R, Gensini GF, Casini A.:
Adherence to Mediterranean diet and health status: meta-analysis.
E’ sufficiente migliorare lo score di aderenza di 2 punti per ottenere di:
a.
ridurre il rischio di mortalità per tutte le cause
b.
ridurre il rischio di mortalità da cause cardiovascolari
c.
ridurre il rischio di mortalità per cancro
d.
ridurre il rischio di malattie degenerative cerebrovascolari tipo la M. di
Parkinson.
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Estruch R et al. N Engl J Med 2013;368:1279-1290
Kaplan–Meier Estimates of the Incidence of
Outcome Events in the Total Study Population.
In nessun altro campo della medicina come nella dietetica clinica si
assiste alla ricerca dell’evento che esula dall’ordine necessario della
razionalità (miracolo) per ottenere un risultato visibile
(dimagrimento) seguendo un’improbabile teoria scientifica a
supporto (mito). Paradossalmente il mito della dieta amplificato dai
mass media assume un valore falso ma, non meno della scienza,
apparentemente fondato su presupposti logici e ontologici tanto che
la distinzione tra le due forme di sapere può sembrare solo storica e
non teoretica.
Giuseppe Fatati 2008
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Grazie