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New "Lifestyle" Guidelines for Type 2 Diabetes: A Newsmaker Interview With Osama Hamdy, MD, PhD, FACE
Laurie Barclay, MD
April 8, 2005 —
The Joslin Diabetes Center at Harvard Medical School in Boston, Massachusetts, has issued new guidelines specifically targeting people with type 2 diabetes or prediabetes who are overweight or obese. The new dietary guidelines have been posted to the center's Web site [see link at the end of this article].
Hoping to draft guidelines that would provide clear and easily followed recommendations to improve insulin sensitivity and cardiovascular health while reducing body fat, Joslin's clinical guidelines committee spent months reviewing the scientific literature.
In the new recommendations, 40% of daily calories come from carbohydrates; 20% to 30% from protein (except in the presence of renal disease); 30% to 35% from fat, (mostly mono- and polyunsaturated fats); and the diet consists of a minimum of 20 to 35 g of fiber. By reducing daily caloric intake by 250 to 500 calories, individuals should be able to lose one pound every one to two weeks. Total daily caloric intake should be at least 1,000 to 1,200 for women and 1,200 to 1,600 for men. To maintain or increase lean body mass, the guidelines recommend a target of 60 to 90 minutes of moderate intensity physical activity, including cardiovascular, stretching, and resistance activities most days of the week, with a minimum of 150 to 175 minutes weekly.
To find out how these guidelines differ from those of other national organizations such as the American Diabetes Association and how they might best be implemented in clinical practice, Medscape's Laurie Barclay interviewed guidelines cochair Osama Hamdy, MD, PhD, FACE, director of the Obesity Clinical Program at the Joslin Diabetes Center.
Medscape: What was the impetus behind development of new guidelines for people with
type 2 diabetes or prediabetes who are overweight or obese?
Dr. Hamdy: With nearly 80% of type 2 diabetic patients either overweight or obese, it became quite clear that obesity and type 2 diabetes are two sides of the same coin, and you cannot improve one of them without improving the other. Our understanding of the goals of nutrition therapy for this population is much more global than it was before; overweight people with type 2 diabetes or prediabetes need to lose weight to improve all the metabolic and vascular complications of diabetes.
Joslin's new nutrition guidelines answer many of the controversial questions and make it clear that we need a newer pathway if we are serious about the obesity and diabetes problems, which means for us that we have to tackle the two problems at the same time. Clinical research over the last few years has shown that what you can achieve by effective nutrition can sometimes be better than what you may achieve by medications. The key is to find a logical and easy-to-use plan for people to follow, supported by strong evidence. That is what we have now in the new Joslin guidelines.
Medscape: What evidence was considered when drafting these guidelines?
Dr. Hamdy: We are always guided by evidence-based medicine for development of all our disease management guidelines. We reviewed all of the randomized clinical trials that were conducted over the last few years to formulate these new guidelines. At least 50% of the references included in these guidelines are between July 2003 and February 2005, so the guidelines reflect the cutting-edge knowledge in this field.
Medscape: How are the Joslin Diabetes Center guidelines different from those of other national guidelines, such as those from the American Diabetes Association?
Dr. Hamdy: The new Joslin guidelines are more specific in many areas. First, these guidelines are directed to overweight and obese subjects and are not directed to all diabetic patients. Second, the guidelines extend to cover the overweight and obese prediabetes population who are at very high risk for developing type 2 diabetes and cardiovascular disease; this is a population that has not been traditionally targeted. Cardiovascular risk often starts before diabetes is diagnosed. By the time type 2 diabetes is diagnosed, 17% of patients already have cardiovascular problems.
The new Joslin guidelines offer overweight individuals with type 2 diabetes or at risk for diabetes a practical package that is easy to use, affordable, and sustainable. The Joslin message is that we need a healthier lifestyle that combines an effective nutrition plan and exercise. The goal is to achieve slow, but steady, weight loss and to have better diabetes control and minimal or no complications, especially cardiovascular complications.
Medscape: What is the rationale behind the recommendation that approximately 40% of daily calories should come from carbohydrate, which is lower than in previous recommendations, and that the recommended percentage of calories from protein should be higher?
Dr. Hamdy: Over the last two years there has been a wealth of evidence from experimental studies and randomized controlled clinical trials in humans that support the concept that reducing energy intake from carbohydrates and increasing it from protein is effective in controlling diabetes, improving insulin sensitivity, reducing visceral fat, improving lipid profile and helping people to lose weight. Many recent studies also have shown that postprandial hyperglycemia and hypertriglyceridemia are significantly improved with the percentage of carbohydrates around 40%.
It is time to fix the problem. Americans have been eating too many carbohydrates for a long time, and this strategy has contributed to much more difficultly in controlling diabetes and obesity. Joslin Diabetes Center decided to be the leader in making that big move toward lowering the bar on carbohydrates and increasing the protein portion and the time spent for exercise to achieve and sustain gradual weight reduction and to better control diabetes and the associated lipid problems in such a high-risk population.
Medscape: What is the role of physical activity in these guidelines?
Dr. Hamdy: These are not just new nutrition guidelines; it is a whole lifestyle change. Exercise, especially the mix of resistance and cardiovascular, is very essential during weight reduction. Recent evidence has shown that people who exercise can maintain the achieved weight loss for longer period of time. Exercise also reduces the amount of visceral fat and improves vascular reactivity, as is evident by the improvement in endothelial function and blood flow. Exercise also reduces many of the harmful cytokines that contribute to insulin resistance and atherosclerosis. The new guidelines consider exercise as an integral component of any nutrition plan for overweight and obese patients with type 2 diabetes or at risk for diabetes.
Medscape: How likely are the recommendations in these guidelines to be followed by practitioners and their patients, and to achieve the goals of improved insulin sensitivity, cardiovascular health, and reduced body fat?
Dr. Hamdy: It has been always easy to tell people to go and lose weight to improve their health, but few were able to do it. Now, we have for them an easy and a potentially sustainable plan that works. The cut in caloric intake and portion control is small and easy to follow and may help them to lose one pound every one to two weeks. We think it is a more practical plan than cutting more on the energy intake that many people find difficult to sustain. We believe it is likely to be followed.
Medscape: What should individuals do to achieve these goals?
Dr. Hamdy: Eating smaller portions, modest carbohydrates, and slightly more protein with careful selection of fat, protein, and carbohydrate sources is the way to go if you are overweight or obese and have type 2 diabetes or prediabetes and normal kidney function. Add to this package a daily exercise routine and start counting the benefits.
Medscape: If these guidelines are widely implemented, what would be the public health implications?
Dr. Hamdy: These recommendations can help people lose weight, maintain weight loss, and have better diabetes control and may prevent or slow the development of many serious cardiovascular complications.
Disclosure: Dr. Hamdy is on the speaker's bureau for Takeda Pharmaceutical North America and KOS Pharmaceuticals.
Reviewed by Gary D. Vogin, MD
