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Pharmacist-led therapeutic carbohydrate restriction as a treatment strategy for type 2 diabetes: the Pharm-TCR randomized controlled trial protocol.
Durrer, C, McKelvey, S, Singer, J, Batterham, AM, Johnson, JD, Wortman, J, Little, JP
Trials. 2019;(1):781
Abstract
BACKGROUND The current treatment paradigm for type 2 diabetes mellitus (T2D) typically involves use of multiple medications to lower glucose levels in hope of reducing long-term complications. However, such treatment does not necessarily address the underlying pathophysiology of the disease and very few patients achieve partial, complete, or prolonged remission of T2D after diagnosis. The therapeutic potential of nutrition has been highlighted recently based on results of clinical trials reporting remission of T2D with targeted dietary approaches. During the initial phase of such interventions that restrict carbohydrates and/or induce rapid weight loss, hypoglycemia presents a notable risk to patients. We therefore hypothesized that delivering very low-carbohydrate, low-calorie therapeutic nutrition through community pharmacies would be an innovative strategy to facilitate lowering of glycated hemoglobin (A1C) while safely reducing the use of glucose-lowering medications in T2D. METHODS A community-based randomized controlled trial that is pragmatic in nature, following a parallel-group design will be conducted (N = 200). Participants will have an equal chance of being randomized to either a pharmacist-led, therapeutic carbohydrate restricted (Pharm-TCR) diet or guideline-based treatment as usual (TAU). Pharm-TCR involves a 12-week very low carbohydrate, calorie-restricted commercial diet plan led by pharmacists and lifestyle coaches with pharmacists responsible for managing medications in collaboration with the participants' family physicians. Main inclusion criteria are diagnosis of T2D, currently treated with glucose-lowering medications, age 30-75 years, and body mass index ≥ 30. The primary outcome is a binary measure of use of glucose-lowering medication. Secondary outcomes include A1C, anthropometrics and clinical blood markers. DISCUSSION There are inherent risks involved if patients with T2D who take glucose-lowering medications follow very low carbohydrate diets. This randomized controlled trial aims to determine whether engaging community pharmacists is a safe and effective way to deliver therapeutic carbohydrate restriction and reduce/eliminate the need for glucose-lowering medications in people with T2D. TRIAL REGISTRATION ClinicalTrials.gov, NCT03181165. Registered on 8 June 2017.
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Carbohydrate restriction: Friend or foe of resistance-based exercise performance?
Cholewa, JM, Newmire, DE, Zanchi, NE
Nutrition (Burbank, Los Angeles County, Calif.). 2019;:136-146
Abstract
It is commonly accepted that adequate carbohydrate availability is necessary for optimal endurance performance. However, for strength- and physique-based athletes, sports nutrition research and recommendations have focused on protein ingestion, with far less attention given to carbohydrates. Varying resistance exercise protocols, such as differences in intensity, volume, and intraset rest prescriptions between strength-training and physique-training goals elicit different metabolic responses, which may necessitate different carbohydrate needs. The results of several acute and chronic training studies suggest that although severe carbohydrate restriction may not impair strength adaptations during a resistance training program, consuming an adequate amount of carbohydrate in the days leading up to testing may enhance maximal strength and strength-endurance performance. Although several molecular studies demonstrate no additive increases in postexercise mammalian target of rapamycin 1 phosphorylation with carbohydrate and protein compared with protein ingestion alone, the effects of chronic resistance training with carbohydrate restriction on muscle hypertrophy are conflicting and require further research to determine a minimal carbohydrate threshold necessary to optimize muscle hypertrophy. This review summarizes the current knowledge regarding carbohydrate availability and resistance training outcomes and poses new research questions that will better help guide carbohydrate recommendations for strength and physique athletes. In addition, given that success in physique sports is based on subjective appearance, and not objective physical performance, we also review the effects of subchronic carbohydrate ingestion during contest preparation on aesthetic appearance.
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A Low FODMAP Diet May Reduce Symptoms in Patients With Fecal Incontinence.
Menees, SB, Chandhrasekhar, D, Liew, EL, Chey, WD
Clinical and translational gastroenterology. 2019;(7):e00060
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Abstract
INTRODUCTION Fecal incontinence (FI) is a common complaint and is often associated with diarrhea and urgency. Foods high in fermentable oligo-, di-, and mono-saccharides and polyols (FODMAP) cause symptoms of diarrhea and urgency. Therefore, this study assesses the impact of a low FODMAP diet on the occurrence of FI due to loose stool. METHODS This study is a retrospective chart review of patients with FI seen in the Michigan Bowel Control Program clinic between August 2012 and December 2017. Patients who had FI with loose stool without red flag signs and who were recommended a low FODMAP diet and underwent formal dietary instruction with a Michigan Medicine dietician were included. RESULTS Sixty-five patients with FI who underwent formal dietary teaching were included in this study. Eighty-eight percent of the patients were white, and 87% were women with a mean age of 62 years (±14 years). Additionally, the chart review showed that 35% of the patients had FI daily, 21.5% had FI weekly, and 5% had FI monthly. About 64.6% of the patients (42) had reported a reduction in their FI symptoms with the low FODMAP diet. There was no demographic or clinical characteristic that predicted the response to a low FODMAP diet. DISCUSSION In this case series, dietary manipulation with a low FODMAP diet was a useful tool to treat patients who suffer from FI due to loose stool. Further confirmatory, prospective randomized controlled trials are required to see the true efficacy of a low FODMAP diet in patients who suffer with FI.
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All that a physician should know about FODMAPs.
Mehtab, W, Agarwal, A, Singh, N, Malhotra, A, Makharia, GK
Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology. 2019;(5):378-390
Abstract
A diet low in poorly absorbed, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is now considered as an effective strategy for symptoms control in patients with irritable bowel syndrome (IBS). The low FODMAP diet is administered in three phases, namely restriction of all dietary FODMAPs followed by rechallenge and then reintroduction of specific FODMAPs according to the tolerance of patients. A dietician should be involved in patients in whom a low FODMAP diet is planned. While restricting high FODMAPs, it is pertinent that patients are advised a well-balanced diet and suitable alternatives with low FODMAP contents in each food groups are prescribed. Strict adherence to a low FODMAP diet has been shown to improve symptoms, stool output, quality of life, and the overall well-being of patients with IBS. For those who do not respond to this dietary approach, a normal diet may be initiated and other treatment strategies (dietary or nondietary) should be considered. Interestingly, the low FODMAP diet has also been tried in other functional disorders, nonceliac gluten sensitivity, and even inflammatory bowel disease. Since the concept of FODMAP is relatively new, there is only limited data on the content of FODMAP in the Indian food items and there is a need to address this question. There is also a need for well-designed and adequately powered studies to explore the efficacy of low FODMAP diet in patients with IBS. In the present review article, we have compiled all the relevant information about FODMAPs with an objective to provide comprehensive information on FODMAPs to a physician.
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Low-carbohydrate diet by staple change attenuates postprandial GIP and CPR levels in type 2 diabetes patients.
Kondo-Ando, M, Seino, Y, Morikawa, R, Negi, K, Todoroki, H, Kawakami, T, Asada, Y, Yoshimoto, R, Tanaka, C, Okamoto, K, et al
Journal of diabetes and its complications. 2019;(11):107415
Abstract
AIMS: The aim of this study is to investigate the effects of a low-carbohydrate staple food (i.e., low-carbohydrate bread) on glucose and lipid metabolism and pancreatic and enteroendocrine hormone secretion in comparison with meals containing normal-carbohydrate bread, without consideration of the carbohydrate content of the side dishes. METHODS T2DM patients (n = 41) were provided meals containing low-carbohydrate bread (LB) together with side dishes or normal-carbohydrate bread (NB) together with side dishes every other day as a breakfast. Blood glucose levels were evaluated by using a continuous glucose monitoring system; blood samples were collected before and 1 and 2 h after the breakfast. RESULTS Postprandial blood glucose levels, plasma insulin, plasma glucose-dependent insulinotropic polypeptide (GIP) and plasma triglyceride were significantly lower and plasma glucagon levels were significantly higher in LB compared with those in NB. Plasma glucagon-like peptide-1 (GLP-1) levels did not differ in the LB and NB groups. CONCLUSIONS These results indicate that changing only the carbohydrate content of the staple food has benefits on glucose and lipid metabolism in T2DM patients concomitant with the decrease of insulin and GIP secretion, which ameliorate body weight gain and insulin resistance.
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The effect of single-nucleotide polymorphisms at the ADIPOQ gene locus rs1501299 on metabolic parameters after 9 mo of a high-protein/low-carbohydrate versus a standard hypocaloric diet.
Aller, R, Izaola, O, Primo, D, de Luis, DA
Nutrition (Burbank, Los Angeles County, Calif.). 2019;:44-49
Abstract
OBJECTIVE Some adiponectin gene (ADIPOQ) single-nucleotide polymorphisms (SNPs) have been related to basal and adiponectin levels and metabolic parameters. The aim of this study was to evaluate the effect of the genetic variant rs1501299 ADIPOQ gene on biochemical changes after weight loss secondary to a high-protein and low-carbohydrate diet versus a standard severe hypocaloric diet over 9 mo as the primary endpoint. METHODS A white population of 270 obese patients was enrolled in a randomized clinical trial with two hypocaloric diets (high-protein and low carbohydrate diet [HP] versus standard diet [S]) over 9 mo of intervention. The statistical analysis was performed for the combined GT and TT as a group (T-allele carriers) and GG as second group (non-T-allele carriers). Before and after 12 wk on each hypocaloric diet, an anthropometric evaluation, an assessment of nutritional intake, and a biochemical analysis were realized. RESULTS With both dietary interventions, body weight, body mass index (BMI), fat mass, waist circumference, systolic blood pressure, and leptin levels decreased. In non-T-allele carriers after both diets, the decrease in total cholesterol levels -12.3 ± 2.2 mg/dL (T-allele carriers -6.9 ± 2.1 mg/dL; P = 0.01 diet HP) and 12.2 ± 3.1 mg/dL (T-allele carriers -4.7 ± 1.2 mg/dL; P = 0.02 after diet S), low-density lipoprotein cholesterol -13.2 ± 2.7 mg/dL (T-allele carriers -6.1 ± 2.1 mg/dL; P = 0.02 after diet HP) and -9.3 ± 1.8 mg/dL (T-allele carriers -4.8 ± 2.9 mg/dL; P = 0.01 after diet S), triacylglycerol levels -12.7 ± 6.1 mg/dL (T-allele carriers -6 ± 2.9 mg/dL; P = 0.01 after diet HP) and -16.3 ± 7.2 mg/dL (T-allele carriers -5.3 ± 1.4 mg/dL; P = 0.03 after diet S), insulin levels -5 ± 1.1 mUI/L (in T-allele -1.7 ± 0.9 mUI/L; P = 0.02 after diet HP) and -3.2 1.1 mUI/L (T-allele carriers -0.7 ± 0.7 mUI/L; P = 0.02 after diet S), and homeostatic model assessment of insulin resistance levels -0.4 ± 0.2 units (T-allele group -0.1 ± 0.1; P = 0.04 after diet HP) and -0.7 ± 0.1 units (T-allele carriers -0.1 ± 0.5 mg/dL; P = 0.01 after diet S) was higher than T-allele carriers. Only no T-allele carriers showed an increase in adiponectin levels after both diets. CONCLUSION After two different hypocaloric diets during 9 mo of intervention, the GG genotype of an ADIPOQ gene variant (rs1501299) is related to better improvement in adiponectin levels, insulin resistance, and lipid profile than T-allele carriers.
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Review article: implementation of a diet low in FODMAPs for patients with irritable bowel syndrome-directions for future research.
Mitchell, H, Porter, J, Gibson, PR, Barrett, J, Garg, M
Alimentary pharmacology & therapeutics. 2019;(2):124-139
Abstract
BACKGROUND Despite the efficacy of a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) for patients with irritable bowel syndrome, many questions remain unanswered with respect to its clinical implementation. AIM: To review literature to identify, synthesise, and provide direction for future research in the implementation and evaluation of the low FODMAP diet. METHODS Bibliographical searches were performed in Ovid Medline, CINAHL, Scopus and PubMed from database commencement until September 2018, with search terms focused on the population (irritable bowel syndrome) and intervention of interest (FODMAP). RESULTS Predictors of response to a low FODMAP diet remain under investigation, with preliminary data supporting faecal microbiota or faecal volatile organic compound profiling. Training of clinicians, and standards for the education of patients about the phases of a low FODMAP diet, as well as the role of Apps, require formal evaluation. There are limited data on the longer term efficacy and safety of the low FODMAP diet with respect to sustained symptom control, effect on quality of life and healthcare utilisation, nutritional adequacy, precipitation of disordered eating behaviours, effects on faecal microbiota and metabolomic markers, and subsequent translation to clinical effects. CONCLUSIONS Many gaps in implementation of the low FODMAP diet in clinical practice, as well as long-term safety and efficacy, remain for further investigation.
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A randomized, 6-wk trial of a low FODMAP diet in patients with inflammatory bowel disease.
Bodini, G, Zanella, C, Crespi, M, Lo Pumo, S, Demarzo, MG, Savarino, E, Savarino, V, Giannini, EG
Nutrition (Burbank, Los Angeles County, Calif.). 2019;:110542
Abstract
OBJECTIVE The aim of this study was to assess the safety and efficacy of a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet (LFD) in patients with inflammatory bowel disease (IBD). METHODS An LFD is associated with symptom improvement in patients with functional intestinal disorders, although its safety and efficacy has not been characterized in patients with IBD. Fifty-five patients with IBD in remission or with mild disease activity were randomized to a 6-wk LFD or standard diet (SD). Disease activity (Harvey-Bradshaw index [HBi], partial Mayo score), fecal calprotectin, and disease-specific quality of life (IBD-Q) were assessed at baseline and at the end of dietary intervention. RESULTS After the 6-wk dietary intervention, median HBi decreased in the LFD (4; IQR, 3-5 versus 3; IQR, 2-3; P = 0.024) but not in the SD (3; IQR, 3-3 versus 3; IQR, 2-4), whereas Mayo scores were numerically decreased in the LFD group and unmodified in the SD group. Median calprotectin decreased in the LFD (76.6 mg/kg; IQR, 50-286.3 versus 50 mg/kg; IQR, 50.6-81; P = 0.004) but not in the SD group (91 mg/kg; IQR, 50.6-143.6 versus 87 mg/kg; IQR, 50-235.6). Lastly, we observed a barely significant increase in median IBD-Q in the LFD group (166; IQR, 139-182 versus 177; IQR, 155-188; P = 0.05) and no modification in the SD group (181; IQR, 153-197 versus 166; IQR, 153-200). CONCLUSIONS A short-term, LFD is safe for patients with IBD, and is associated with an amelioration of fecal inflammatory markers and quality of life even in patients with mainly quiescent disease.
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Effects of Low-FODMAPS Diet on Irritable Bowel Syndrome Symptoms and Gut Microbiome.
Su, H, Li, YT, Heitkemper, MM, Zia, J
Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates. 2019;(2):150-158
Abstract
Patients with irritable bowel syndrome (IBS) suffer from abdominal pain, bloating, and abnormal defecation. Reducing the dietary intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been shown to be beneficial in reducing IBS symptoms. However, diet modification plays an important role in the composition of colonic microbiota. Currently, the effects of a FODMAP diet on the composition of the gut microbiome are not known. We conducted a systematic review to determine (1) the effectiveness of low-FODMAPs diet to reduce symptoms of patients with IBS and (2) the association between a low-FOMAPs diet and the composition of gut microbiome. Four electronic databases were searched using key words "IBS" or "irritable bowel syndrome," and "FODMAP" or "FODMAPs" or "fermentable oligosaccharides, disaccharides, monosaccharides, and polyols," and "microbiome." Two reviewers (H.S. and Y.T.L.) selected and reviewed articles according to our inclusion criteria. A total of 87 articles were reviewed and 7 met inclusion criteria. Based on the systematic review, low FODMAPs appear to reduce gastrointestinal symptoms for a least a subset of patients with IBS. However, due to the heterogeneity of reviewed studies, the influence on patients' gut microbiome composition and/or microbiota metabolites requires additional studies.
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An evidence-based approach to developing low-carbohydrate diets for type 2 diabetes management: A systematic review of interventions and methods.
Turton, J, Brinkworth, GD, Field, R, Parker, H, Rooney, K
Diabetes, obesity & metabolism. 2019;(11):2513-2525
Abstract
AIM: To identify core diet and delivery components of low-carbohydrate (CHO) diets that have demonstrated efficacy for type 2 diabetes (T2D) management. MATERIALS AND METHODS MEDLINE, Pre-MEDLINE, EMBASE, CINAHL and the Cochrane Library of Controlled Trials databases were systematically searched from inception until August 18, 2018. Primary intervention studies of low-CHO diets (≤130 g/d or 26% total energy intake [TEI]) were included. Content analysis was performed on the low-CHO diet protocols classified as safe and effective for T2D management. RESULTS A total of 41 studies published between 1963 and 2018 were included, of which 40 were classified as safe and effective for inclusion in the primary analysis. Thirteen studies (13/40) were on very-low-CHO diets (<50 g/d), 14/40 included low-CHO diets (≤130 g/d or 26% TEI), and 13/40 were adapted according to participant progress. Thirty-one studies reported a total energy prescription, of which 18/31 encouraged ad libitum intakes. Twenty studies reported a prescribed dietary fat amount, of which 18/20 were unrestricted or high-fat (>35% TEI). Twenty-six studies reported a prescribed dietary protein amount, of which 22 were unrestricted or were high-protein (>25% TEI). The types of dietary CHO, fat and protein recommended were predominantly whole foods. Common delivery methods reported were dietician and/or physician involvement, moderate to high frequency of contact (≥1 session/month) and use of participant self-monitoring. CONCLUSIONS Multiple approaches for developing and delivering a low-CHO diet intervention for T2D management are safe and effective. A comprehensive set of core dietary components to consider in the formulation of low-CHO diet protocols were identified for use in clinical practice and to inform evidence-based guidelines for T2D management.