1. Reversing Diabetes with
Medical Nutrition Therapy:
Therapeutic Effects of A
Vegan Lifestyle
Jen King

2. Outline
 Background
 Review Articles
 Article 1
 Article 2
 Article 3
 Conclusions
 Suggestions for Future Research
 Questions

3. Significance of Type 2
 Rising health epidemic in U.S.
 Most common form of diabetes; 90-95% of DM
 Preventable
 23.6 million Americans with DM
 165% projected increase by 2050
 5th leading cause of death

4. Type 2 Diabetes
 Diabetes Mellitus (DM)
 Combination of insulin
resistance and beta cell
failure
 “Non-insulin dependent”
 Progressive disease
 Risk factors: obesity, or
have abdominal obesity;
age, lack of physical
activity

5. “Normal” Actions of Insulin
 Secreted by the pancreas
 Effects:
 Increase uptake of glucose
into skeletal muscle and
adipose tissue
 Decrease hepatic glucose
production
 Decrease release of NEFAs
from adipose tissue
 Diabetes: defective insulin
production and/or action (IR).
Above effects of insulin do not
occur

6. Obesity and Insulin Resistance
 Obesity (abdominal visceral)
 Increased release of FFAs
from adipocytes
 Increases FFA flux to the
liver, which causes an
increase in hepatic glucose
production, and a decrease in
glucose utilization.
 RESULT: Increase Blood
Glucose Levels
 *Defects in insulin signaling,
so insulin does not effectively
facilitate glucose entry into
cells

7. Signs and Symptoms
 Hyperglycemia
 Glycosuria
 Polyuria
 Polydipsia
 Dehydration

8. Related Health Complications
 Hypoglycemia
 Hyperglycemia
 Ketoacidosis
Long-term damage
 Eye complications (diabetic
retinopathy)
 Kidney disease
 Nerve Damage/Neuropathy
 Heart disease and stroke

9. Methods of Diagnosis
 Fasting plasma glucose (FPG)
 Casual plasma glucose (any time of day)
 Oral glucose tolerance test (OGTT)
 Due to ease and cost, FPG tests is
recommended

10. Diagnosis

11. Diabetes Management
 Intensive glycemic control
 Balanced diet, proper nutrition
 Regular exercise or physical activity
 Smoking cessation
 Specifically to type 2:
 Monitor and treat risk factors and associated
conditions:
 Hyperlipidemia
 Hypertension
 Obesity

12. Traditional Therapies
 Testing blood sugar levels
 A1C test
 Blood glucose meter
 Exercise and diet
 Oral pill therapies
 biguanides, thiazolidinediones
 Insulin

13. Current Nutrition Therapies
 General:
 Low-carb/low sugar/low glycemic index
 Low-fat diet
 Mediterranean diet
 slow digested foods leading to even blood sugar
 Low-fat Vegetarian Diet
 Same benefits above
 Decrease saturated fat
 Effect on insulin signaling
 Note: Traditional and nutrition therapies have been used to
reduce symptoms, not cure.

14. Emergence of Vegan Therapy
 Dr. Barnard
 Vegan: only current
therapy that is proving
not only to reduce
symptoms, but to
actually to reverse the
disease

15. Former Research Statements
 “Plant-based diets rich in legumes and slowly
digested grains may improve glucose
tolerance, insulin sensitivity, and the
successful management of type 2 diabetes.”
 “Diabetes and a Vegetarian Diet”, www.vrg.org

16. Former Research Statements
 Vegetarian diets reduce: some cancers, heart
disease, obesity, and type 2 diabetes
 Vegan diets reduce: prostate cancer, weight,
heart disease, cholesterol

17. Vegetarian vs. Vegan
 Vegetarians
-avoid meat and/or animal products. Vegetarian diet includes
only foods from plants: like fruits, vegetables, whole grain
products, nuts, seeds, and legumes
 Vegans
-strict vegetarian; eliminating all animal products
-*no dairy
 Despite such dietary restrictions, a balanced vegan diet is
perfectly healthy

18. What about dairy?
 Dairy elimination is the key difference
between vegetarian and vegan lifestyles
 Bovine protein
 Bovine serum lactobumin = triggers diabetes

19. Terminology
 HbA1c (A1c): test that measures the amount of blood glucose within
the last 3 months
 glycemic index: a numerical index given to a carbohydrate-rich food
that is based on the average increase in blood glucose levels
occurring after
 Low density lipoprotein (LDL)-cholesterol: “bad cholesterol”; low-
density lipoproteins transport cholesterol from the liver to the tissues
of the body
 Polyunsaturated fatty acids (PUFA): fatty acids that have more than
one double or triple bond per molecule; good fat
 Affinity chromatography: a method of separating and identifying the
components of a complex mixture; one such substance being
immobilized and acting as the sorbent

20. A Low-Fat Vegan Diet Improves
Glycemic Control and
Cardiovascular Risk Factors in a
Randomized Clinical Trial in
Individuals With Type 2 Diabetes
Article 1
Barnard N, Cohen J, Jenkins D, Turner-
McGrievy G, Gloede L, Jaster B, Siede K,
Green A, Talpers S

21. Objective
 Objective
 To investigate whether a low-fat vegan diet
improves glycemic control and cardiovascular risk
factors in individuals with Type 2 diabetes.
 Main outcomes
 Glycemic, plasma lipid, and weight control

22. Subjects
 99 individuals with type 2 diabetes
 49 followed low-fat vegan diet
 22 m, 27 f
 50 followed control diet*
 17 m, 33 f
 A1c was determined and volunteers were
ranked in order of concentrations
 Randomly assigned in sequential pairs

23. Interventions
 Vegan group
 10% fat, 15% protein, 75% CHO
 Include vegetables, fruits, grains, legumes
 Avoid animal products and added fats
 *Portion sizes, energy intake, and CHO intake were
unrestricted
 Control group
 American Diabetes Association (ADA) guidelines
 15-20% protein, <7% saturated fat, 60-70% CHO,
cholesterol and saturated fat <200 mg/day
 *Individualized based on body weight and plasma lipid
concentrations
 Both groups asked to not alter exercise habits

24. Research Design
 Randomized control trial
 Each met with RD for 1 hr initially
 Met weekly for 1 hr with assigned groups
throughout study
 Unannounced phone calls for dietary recall
 In addition, 3-day dietary records were
completed
 Physical activity was assessed over a 3-day
period (pedometer)

25. Lab Measurement Tools
 Laboratory measurements by blind
technicians
 Abbott Spectrum Analyzer
 plasma glucose, plasma cholesterol, triglycerides
 Friedewald equation
 LDL cholesterol
 Urinary albumin measured using anionic dye-
binding assay
 Bouchard 3-Day Physical Activity Record

26. Statistical Methods
 Abbott IMx analyzer
 T-tests
 Regression analyses
 Pearson correlations
 Interim analysis

27. Results
 Both groups reduced energy intake and
protein intake
 CHO intake increased in the vegan group
 Fat intake fell in both groups
 Pedometer readings had no significant
interest/difference between groups

28. Results: Dietary effects on
clinical measures
 43% of the vegan group and 26% of the ADA group participants
reduced diabetes medications.
 Including all participants, A1c decreased 0.96 percentage points
in the vegan group and 0.56 points in the ADA group.
 Excluding those who changed medications, A1c fell 1.23 points in
the vegan group compared with the 0.38 points in the ADA group.
 Body weight decreased 6.5 kg in the vegan group and 3.1 kg in
the ADA group.
 Among those who did not change lipid-lowering medications, LDL
cholesterol fell 21.2% in the vegan group and 10.7% in the ADA
group.
 Urinary albumin reductions were greater in the vegan group (15.9
mg/24 h) than in the ADA group (10.9 mg/24 h)

29. A1c at baseline, 11, & 22 wks

30. Conclusion
 Both a low-fat vegan diet and a diet based on
ADA guidelines improved glycemic and lipid
control in type 2 diabetic patients.
 These improvements were greater with a low-
fat vegan diet.

31. Pros and Cons
Pros:
 Clear and easy to read
 Keeping exercise at a
constant to isolate diet
 Applicability outside the
research setting
Cons:
 Diversity was limited among
subjects
 Many study participants were
taking antihypertensive
medications which may have
blunted the effect of diet on
blood pressure.
 All participants had access of
group support
 Dietary intake was based on
self-report, which is vulnerable
to distortion

32. Changes in Nutrient Intake and Dietary
Quality among Participants with Type
2 Diabetes Following a Low-Fat Vegan
Diet or a Conventional Diabetes Diet
for 22 Weeks
Article 2
Turner-McGrievy G, Barnard N, Cohen J,
Jenkins D, Gloede L, Green A

33. Objective
 Assess the changes in nutrient intake
and dietary quality among participants
following a low-fat vegan diet or the 2003
ADA dietary recommendations.

34. Subjects
 99 participants with type 2 diabetes in a free-
living setting
 49 followed low-fat vegan diet
 22 m, 27 f
 50 followed control diet
 17 m, 33 f

35. Intervention
 Vegan diet
 Grains, fruits, vegetables, and legumes
 Avoid animal products, limit high-fat foods, and favor foods
with low glycemic index value
 No restrictions on portion sizes or energy intake
 Control diet
 2003 ADA guidelines
 Exchange system used to provide recommended energy and
carbohydrate and saturated fat grams each participant
required
 Individualized based on body weight and lipid profile

36. Design
 Randomized, controlled clinical trial
 22-week trial examining changes in nutrient
intake and diet quality
 Before randomization, participants completed a
practice 3-day weighed dietary record
 Participants then completed a baseline food
record

37. Design cont.
 After randomization, participants met individually with an
RD experienced in the use of the assigned diet to
develop individualized meal plans
 Participants continued to meet with assigned diet
groups- 1/wk with RD and physicians
 Adherence to diet was assessed based on 22-wk dietary
records and 24-hr recalls with unexpected phone calls
 Quality control conducted by dietary records and recalls
by RD

38. Lab Measurement Tools
 AHEI Scores
 Alternate Healthy Eating Index
 Calculated for each participant based on food
categories: vegetables, fruit, nuts and soy
protein, cereal fiber, trans fat, and ratio of
polyunsaturated to saturated fatty acids
 Receives a score ranging from 0-10

39. Statistical Methods
 T tests
 Pearson's correlation

40. Results
 The vegan group improved in every AHEI
food category
 Increase in fruits, veg, nut, soy protein, and cereal
fiber; decrease in trans fat and increase in PUFA-
to-saturated fat ratio
 The ADA group showed changes in one food
 Increase PUFA-to-saturated fat

41. Clinical Data Results
 Both groups reported significant decreases in energy,
protein, fat, cholesterol, and vitamin D
 The vegan group significantly increased CHO, fiber,
vitamin A activity, beta carotene, vitamins A&K, folate,
magnesium, and potassium
 Note: Vegan group significantly reduced intakes of vitamin B-12
and calcium

42. Clinical Data Results cont.
 The vegan group significantly improved its
AHEI score, while the control diet group did
not.
 With both groups combined, AHEI score was
negatively correlated with both changes in A1c
value and weight

43. Changes in AHEI Score

44. Conclusions
 Vegan diets increase intakes of carbohydrate,
fiber, and several micronutrients, in contrast
with the ADA diet.
 The vegan group improved its AHEI score
whereas the ADA diet group's AHEI scored
remained unchanged

45. Pros and Cons
Pros:
 Clear and easy to read
 Prospective design and
an intention-to-treat
analysis
Cons:
 Not diverse group of
subjects
 All participants had
access of group support
 Dietary intake was based
on self-report, which is
vulnerable to distortion

46. A Low-Fat Vegan Diet Elicits Greater
Macronutrient Changes, but Is
Comparable in Adherence and
Acceptability, Compared with a More
Conventional Diabetes Diet among
Individuals with Type 2 Diabetes
Article 3
Barnard N, Gloede L, Cohen J, Jenkins D,
Turner-McGrievy G, Green A, Ferdowsian H

47. Objective
 To quantify adherence and acceptability
for two types of diets for diabetes.
 Main outcomes: Attrition, adherence, dietary
behavior, diet acceptability, cravings

48. Subjects
 99 individuals with type 2 diabetes
 49 followed low-fat vegan diet
 22 m, 27 f
 50 followed control diet
 17 m, 33 f

49. Interventions
 Vegan diet
 10% fat, 15% protein, 75% carbohydrate
 Grains, fruits, vegetables, and legumes
 Avoid animal products, fatty foods (avocadoes, fried foods,
nuts/seeds), and favor foods with low glycemic index value
 No restrictions on portion sizes or energy intake
 Control diet
 2003 ADA guidelines
 15-20% protein, <7% saturated fat, 60-70% CHO,
cholesterol and saturated fat <200 mg/day
 Individualized based on body weight and lipid profile
 All participants not to alter exercise habits.

50. Research Design
 Controlled trial
 Each participant met with RD for 1 hr prior to
discuss the assigned diet
 Thereafter, attended weekly 1 hr meeting with
their diet groups for 22 weeks
 Optional bi-weekly 1 hr meeting with their diet
groups for 52 weeks

51. Research Design cont.
 3-day dietary records complete at weeks 0, 11, 22,
and 74
 Diet records reviewed by RD
 In addition, at several weeks throughout the study,
an RD made unannounced telephone calls to each
participant to administer a 24-hr diet recall using a
multi-pass approach
 At weeks 0, 22, and 74 participants completed:
Eating Inventory, Food Acceptability Questionnaire,
Food-Craving Inventory Instruments

52. Lab Measurement Tools
 Food scales used for dietary records
 Nutrition Data System- used for diet analysis
 At weeks 0, 22, and 74 participants
completed:
 Eating Inventory
 Food Acceptability Questionnaire
 Food-Craving Inventory Instruments

53. Stastical Methods
 T tests
 Wilcoxon sum rank test
 Mann-Whitney U test

54. Results
 All participants completed the initial 22 weeks
 90% of control group and 86% of the vegan diet
group participants completed 74 weeks.
 Fat and cholesterol intake fell more and CHO and
fiber intake increased more in the vegan group.
 At 22 weeks, group specific diet adherence criteria
were met by 44% of members of the control and
67% of the vegan group participants

55. Results cont.
 Control group reported a greater increase in dietary
restraint; this difference was not significant at 74
weeks
 Both groups reported reduced hunger and reduced
disinhibition.
 Questionnaire responses rated both diets as
satisfactory, with no significant difference except
ease of preparation
 Cravings for fatty foods diminished more in the
vegan group at 22 weeks with no significant
difference at 74 weeks.

56. FA Questionnaire

57. Symptoms and Benefits

58. Conclusions
 Despite its greater influence on macronutrient
intake, a low-fat, vegan diet has an
acceptability similar to that of a more
conventional diabetes diet.
 Acceptability appears to be no barrier to its
use in medical nutrition therapy.

59. Pros and Cons
Pros
 Clear and easy to read
 Sample size that was
adequate to compare
differences
 Appropriate follow-up
period
.
Cons
 All self-selected research
volunteers: well educated
 All participants had
access of group support
 Dietary intake was based
on self-report, which is
vulnerable to distortion

60. Summary and Conclusion
 Both a low-fat vegan diet and the ADA diet
improved glycemic and lipid control in type 2
diabetic patients. These improvements were
greater with a low-fat vegan diet.
 Vegan diets increase intakes of carbohydrate,
fiber, and several micronutrients, in contrast
with the ADA diet.

61. Summary and Conclusion
cont.
 The vegan group improved its AHEI score
whereas the ADA diet group’s AHEI scored
remained unchanged.
 Despite its greater influence on macronutrient
intake, a low-fat vegan diet has an
acceptability similar to that of a more
conventional diabetes diet.
 Acceptability appears to be no barrier to its use
in medical nutrition therapy.

62. Suggestions for Future
Research
 Research on body’s
response if transitioning
back to a healthy diet (but
including healthy fats, lean
meats, lean dairy)
 Diagnosis at earlier age
 Extend research on
satiation/acceptability over
longer period of time
 More diverse subjects
 Research on vegan diets
and other chronic conditions

63. Questions

64. References
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