1. DIET AND RISK OF TYPE 2 DIABETES Arja Erkkilä, UEF

2. CONTENT Risk factors and development of diabetes Evidence on dietary factors  Energy balance  Fat (quality and quantity)  Carbohydrates (fiber, sugar, glycemic index)  Vitamins and minerals  Dietary patterns Lifestyle interventions to reduce risk of type 2 diabetes Prevention of T2DM in primary health care

3. DIABETES BURDEN 382 million adults worldwide 2013 Projected to rise to 592 million by 2035 (www.idf.org)

4. Figure 2 Role of genes and the environment in development of obesity and type 2 diabetes Interaction of genes that affect body adiposity with environmental factors results in development of obesity and associated insulin resistance. However, only when genes for abnormal β -cell function are present along with those for body adiposity does interaction with the environment result in development of type 2 diabetes. Steven E Kahn, Mark E Cooper, Stefano Del Prato. Pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future. The Lancet, Volume 383, Issue 9922, 2014, 1068 - 1083

5. RISK FACTORS FOR TYPE 2 DIABETES Obesity, especially central obesity Low physical activity High fat, high saturated fat diet Low intake of dietary fiber High glycemic index diet Fetal malnutrition Some drugs Others:  genetic factors,  previous glucose metabolism disturbance (eg. gestational diabetes)  features of metabolic syndrome (high blood pressure, high serum triglyserides, insulin resistance)  aging

6. WEIGHT CHANGE, ENERGY BALANCE Obesity, especially abdominal obesity increase the risk of T2DM Even modest wight loss can significantly reduce the incidence of T2DM in subjects who have multiple risk factors for diabetes (see next slide)

7. Incidence of type 2 diabetes during the 1-year follow-up according to weight loss. Saaristo T et al. Dia Care 2010;33:2146-2151 Copyright © 2014 American Diabetes Association, Inc.

8. FAT QUALITY AND QUANTITY High total fat intake can increase risk of T2DM (intake should be less than 35% of energy) Saturated fat (hard fat) intake increases risk of T2DM  Might not be independent of BMI  Strong evidence  Saturated fat should be less than 10% of energy Mono- and polyunsaturated fat are soft fats. Increase in polyunsaturated fat intake can reduce risk of T2DM.  Linoleic acid (n-6 PUFA, eg. from sunflower oil) reduces risk  Moderate evidence  PUFA intake should be less than 10% of energy. Long-chain n-3 fatty acids (from fish or fish oils) do not significantly affect the risk (in some studies fish oils have increased the risk)  However, n-3 fatty acids can have beneficial effects on cardiovascular risk factors Monounsaturated fat (from eg. olive and rapeseed oil) are possibly protective. Diabetes and Nutrition Study Group/European Association for the the Study of Diabetes Recommendation 2004.

9. CARBOHYDRATES Total amount of carbohydrates does not have a clear association with diabetes risk. High fiber diet, especially cereal fiber, can reduce the risk of T2DM.  Strong evidence  Recommendation: 40 g/d or 20 g/1000 kcal/day Sugar sweetened beverages increase the risk. Simple sugars in diet possibly increase the risk.  Recommendation less than 10% of energy. High glycemic index diet is suggested to increase the risk Diabetes and Nutrition Study Group/European Association for the the Study of Diabetes Recommendation 2004.

10. MICRONUTRIENTS Dietary intake of magnesium inversely and iron directly associated with T2DM risk in observational studies. Vitamin D inversely associated in observational studies.  Level of evidence moderate. However, there are no clinical studies yet, so the importance of these associations is still unclear and more studies are needed

11. SOME FOODS Coffee and tea have been associated with reduced risk at dose of 4 cups per day Alcohol consumption in U-shaped association with the risk.  Moderate consumption possibly protective. (Moderate consumption up to 10g/day alcohol for women and up to 20 g/d alcohol for men, for those who choose to drimk).  Excessive consumption possibly promotive.  Alcohol consumption should be limited by those who are overweight, hypertensive or hypertriglyceridemic. Nut consumption has been associated with reduced risk.

12. DIETARY PATTERNS Dietary patterns characterized by high consumption of  Whole grains  Fruit and vegetables  Fish  Low-fat dairy have been associated with lower risk of T2DM (see next slide for details)

13. Salas-Salvado et al. Nutr Metab Cardiovasc Dis 2011;21:B32-B48

14. DIABETES PREVENTION TRIALS

16. THE FINNISH DIABETES PREVENTION STUDY The goals of the intervention were:  weight reduction at least 5% from baseline weight;  total fat intake <30% energy intake;  saturated fat intake <10% energy intake,  Fibre intake at least 15 g/4.2 MJ (1000 kcal);  moderate-to-vigorous exercise of at least 0.5 h/d. Intervention lasted for 4 years. Follow-up of new T2DM cases has lasted for 13 years.

17. Figure 2 Diabetes by treatment group Follow-up time is truncated at 8 years, since number of participants at risk beyond this point was low, but they are included in the calculation of hazard ratios. Lindström, et al. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. The Lancet, Volume 368, Issue 9548, 2006, 1673 - 1679

18. SUSTAINED BENEFIT FROM 4-Y LIFESTYLE INTERVENTION SEEN IN BODY WEIGHT IN A FOLLOW UP OF 13 YEARS Lindström et al. Improved lifestyle and decreased diabetes risk over 13 years: long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia. 2013 Feb;56(2):284-93. doi: 10.1007/s00125-012-2752-5.

19. SUSTAINED BENEFIT FROM 4-Y LIFESTYLE INTERVENTION SEEN IN PLASMA GLUCOSE IN A FOLLOW UP OF 13 YEARS Lindström et al. Improved lifestyle and decreased diabetes risk over 13 years: long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia. 2013 Feb;56(2):284-93. doi: 10.1007/s00125-012-2752-5.

20. COMMUNITY PREVENTION OF T2DM

21. FROM RESEARCH TO PREVENTION ON COMMUNITY LEVEL http://www.diabetes.fi/en/finnish_diabetes_association/dehko

23. Diabetes prevention in a primary health care setting Figure 1. Changes in estimated 10-year risk for cardiovascular disease (CVD) events estimated by the Framingham Risk Score (FRS) during the one-year follow-up according to changes in physical activity (PA) and dietary pattern in a healthier direction in individuals at high risk for type 2 diabetes (T2D). Rautio N et al. Eur J Cardiovasc Nurs 2014;1474515114521713 Copyright © by European Society of Cardiology

24. EXTRA INFORMATION ON COMMUNITY DIABETES PREVENTION FROM THE USA National Diabetes Prevention Program by NIH and CDC in the USA http://www.cdc.gov/diabetes/prevention/ http://www.youtube.com/watch?v=976SFoINOU0

25. SOURCES Hey SH, Hamdy O, Mohan V, Hu FB. Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet 2014;383:1999-2007. Lindström J, Peltonen M, Tuomilehto J, for the Finnish Diabetes Prevention Study Group. Lifestyle strategies for weight control: experience from the Finnish Diabetes Prevention Study. Proceedings of the Nutrition Society 2005;64:81-88, DOI:10.1079/PNS2004394412 Salas-Salvado J, Martinez-Gonzalez MA, Bullo M, Ros E. The role of diet in the prevention of type 2 diabetes. Nutrition, Metabolism & Cardiovascular Diseases 2011;21,B32-B48. Thomas T and Pfeiffer AFH. Foods for the prevention of diabetes: how do they work?. Diabetes Metab. Res. Rev., 2012; 28: 25–49. doi: 10.1002/dmrr.1229.