Download Can Pulses Play a Role in Reducing the Incidences of Obesity and

Can Pulses Play a Role in Reducing the
Incidences of Obesity and Chronic
Diseases?
John L Sievenpiper, MD, PhD, FRCPC1,2,3,4
1Associate
2Staff
Professor, Department of Nutritional Sciences, University of Toronto
Physican, Division of Endocrinology & Metabolism, St. Michael’s Hospital
3Scientist,
4Lead,
Li Ka Shing Knowledge Institute, St. Michael’s Hospital
Toronto 3D Knowledge Synthesis & Clinical Trials Unit
Little Beans, Big Opportunities: Realizing the Potential of Pulses to Meet
Today's Global Health Challenges
The New York Academy of Sciences
New York, New York
Nov 19, 2015
Disclosures (over past 24 mos)
Board Member/Advisory Panel
Ad Hoc Consulting Arrangements
–Tate & Lyle
–Canadian Diabetes Association (CDA) 2013 and 2018 Clinical
Practice Guidelines Expert Committee for Nutrition therapy
–Winston Strawn LLP
–European Association for the Study of Diabetes (EASD) 2015
Clinical Practice Guidelines Expert Committee for Nutrition therapy
–American Society for Nutrition (ASN) writing panel for a scientific
statement on sugars
–Perkins Coie LLP
Honouria or Speaker fees
–National Institutes of health (NIH)
–International Life Science Institute (ILSI) North America
–American Heart Association (AHA)
–Transcultural Diabetes Algorithm (tDNA) Group
–Canadian Nutrition Society (CNS)
–Diabetes Nutrition Study Group (DNSG) of the European Association
for the Study of Diabetes (EASD) Board
–Canadian Diabetes Association (CDA)
–Canadian Cardiovascular Society (CCS) 2015 Dyslipidemia
Guidelines Update
–University of South Carolina
–University of Alabama at Birmingham
–Pulse Canada
Research Support
–Canadian Diabetes Association (CDA)
–Abbott Laboratories
–PSI Foundation
–The Coca Cola Company
–American Society of Nutrition (ASN)
–Canadian Sugar Institute
–Canadian Institutes of Health Research (CIHR)
–Dr. Pepper Snapple Group
–Calorie Control Council
–C3 for Health
–The Coca Cola Company (unrestricted, investigator initiated)
–White Wave Foods
–Dr. Pepper Snapple Group (unrestricted, investigator initiated)
–Dairy Farmers of Canada
–Pulse Canada
–mdBriefcase
–International Tree Nut Council Nutrition Research & Education
Foundation
–INC International Nut and Dried Fruit Council
Other
–Spouse is an employee of Unilever Canada
–Editorial Board, American Journal of Clinical Nutrition
–Associate Editor, Frontiers in Nutrition, Nutrition Methodology
–Special Issue ("Sugar and Obesity“) Editor, Nutrients
Background
The problem
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Diabetes: A Global Epidemic
Number of people with diabetes by IDF region, 2014
International Diabetes Federation. Diabetes Atlas. Sixth Edition. Update 2014
International Diabetes Federation. Diabetes Atlas. Sixth Edition. Update 2013
Cardiovascular disease:
A growing problem fueled by diabetes in the developing world
Global atlas on cardiovascular disease prevention and control 2011
The opportunity
Failure of cardiovascular benefit with intensive
diabetes control by rosiglitazone or polypharmacy
(ACCORD, ADVANCE, VADT)
STOP-NIDDM Trial:
CV events in IGT (follow-up=3.3y, n=1429)
CV Events
Acarbose
↓ 49% RR
Chiasson J-L, Josse RG, Hanefeld M, et al. JAMA 2003;346:393.
Beans and peas
Lentils
Dietary pulses slow digestion and decrease
postprandial blood sugar responses
Jenkins et al. BMJ 1980;281:578-80
Jenkins et al. BMJ 1980;281:14-17.
Jenkins et al. Diabetologia 1982;22:450-55
Dietary pulses:
A nutritional model of acarbose
 Starch
digestion/absorption
 Amlyose starch
 Resistant starch
 Viscous fibre
 Vegetable protein
 Antinutrients
(phytates, phenolics, etc.)
 Postprandial
glycemia
 Glycemic index
?
 Longterm
metabolic control
Dietary guidelines
Dietary pulses in diabetes guidelines
“…A variety of eating patterns (combinations of different foods or
food groups) are acceptable for the management of diabetes.
Personal preferences (e.g., tradition, culture, religion, health beliefs
and goals, economics) and metabolic goals should be considered
when recommending one eating pattern over another. (E)…
Mediterranean, vegetarian, low fat, low carbohydrate, and DASH”
American Diabetes Association. Diabetes Care 2013; DOI: 10.2337/dc13-2042
“Alternative dietary patterns may be used in people with type
diabetes to improve glycemic control, (including):
a. Mediterranean-style dietary pattern [Grade B, Level 2]
b. b. Vegan or vegetarian dietary pattern [Grade B, Level 2]
c. c. Incorporation of dietary pulses (e.g. beans, peas, chick
peas, lentils) [Grade B, Level 2]
d. Dietary Approaches to Stop Hypertension (DASH) dietary
pattern [Grade C, Level 2]”
Dworatzek et al. Can J Diabetes 2013;37:S45eS55
“Vegetables, legumes, fruits and wholegrain cereals
should be incorporated into the diet of people with T1DM and T2DM…
Grade A… Daily consumption of at least 5 servings of fibre-rich
vegetables or fruit and at least 4 servings of legumes per week can help
to provide minimum requirements for fibre intake. Grade C”
Mann et al. Nutr Metab Cardiovasc Dis 2004;14:373–394
AHA/ACC
Dietary pulses in lipid and CV guidelines
“Consume a dietary pattern that emphasizes intake of
vegetables, fruits, and whole grains; includes low-fat
dairy products, poultry, fish, legumes, nontropical
vegetable oils and nuts… Achieve this pattern by
following plans such as the DASH dietary pattern, the
USDA Food Pattern, or the AHA Diet”
CCS
Eckel et al. Circulation. 2014; 129: S76-S99
We recommend the Mediterranean, Portfolio, or Dietary
Approach to Stop Hypertension (DASH) diets to
improve lipid profiles or decrease CVD risk (Strong
Recommendation, High-quality Evidence), and for cholesterol
lowering consider increasing phytosterols, soluble fibre, soy,
and nut intake.
ESC
Anderson et al. Can J Cardiol 2013;29:151–167
“The DASH [Dietary Approach to Stop Hypertension ] trial
has shown that increasing fruit and vegetable intake
contributed to the observed decrease in BP in the intervention
arm… The recommendation is to eat at least 200 g of fruit (2–
3 servings) and 200 g of vegetables (2–3 servings) per day.
Eur J Cardiovac Prev Rehab; 2012;33:1635-1701
Obesity Canada
***No dietary pulses/legumes***
EASO
***No dietary pulses/legumes***
US PSTF
Dietary pulses in obesity guidelines
Lau et al. CMAJ. 2007;176:S1-S13
http://www.uspreventiveservicestaskforce.org/uspstf/uspsobes.htm
***No dietary pulses/legumes***
Tsigos et al. Obesity Facts 2008;1:106–116
What does the evidence say?
Meta-analyses of the effect of dietary pulses on acute
postprandial metabolic control:
A series of systematic reviews and meta-analyses to provide evidence-based
guidance for health claims development
(NCT01605422)
Acute postprandial glycemia
Dietary Pulses
Augustin et al. Diabetes Care, to be submitted
Acute food intake regulation
Li et al. Obesity. 2014 May 13 [Epub ahead of print].
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Glycemia
Sievenpiper et al. Diabetologia 2009;52:1479-95
Lipid (established CV targets)
Dietary Pulses
Ha, et al. CMAJ. 2014;186(8):E252-62.
Blood pressure
Jayalath et al. Am J Hypertens 2014;27:56-64.
Body weight
Kim et al. Ann Intern Med, submitted
Series 1.
Meta-analyses of the effect of dietary pulses on acute
postprandial metabolic control:
Systematic reviews and meta-analyses to provide evidence-based guidance for
health claims development
(NCT01605422)
Acute postprandial glycemia
Dietary Pulses
Augustin et al. Diabetes Care, to be submitted
Acute food intake regulation
Li et al. Int J Obes, to be submitted
Meta-analyses of the effect of dietary pulses on acute
postprandial metabolic control:
Systematic reviews and meta-analyses to provide evidence-based guidance for
health claims development
(NCT01605422)
Acute postprandial glycemia
Dietary Pulses
Augustin et al. Diabetes Care, to be submitted
Consort Statement
Dr. Livia Augustin, PhD
Screened: 744
Postprandial glycemia:
38 trials in diabetes (n=308)
Effect of chickpeas on postprandial glycemia in diabetes:
5 trials (n=41), dose range=100g (dry)/250-336g (wet); median time: 3h (2-3h)
Effect of beans on postprandial glycemia in diabetes:
19 trials (n=150); dose range=79-112g (dry)/200-435g (wet); median time: 3h (2-5h)
Effect of lentils on postprandial glycemia in diabetes:
10 trials (n=81), dose range=50-107g (dry)/225-434g (wet); median time: 3h (3-5h)
Effect of split peas on postprandial glycemia in diabetes:
4 trials in diabetes (n=36), dose range=90-98g (dry); median time: 3h (3h)
Meta-analyses of the effect of dietary pulses on acute
postprandial metabolic control:
Systematic reviews and meta-analyses to provide evidence-based guidance for
health claims development
(NCT01605422)
Acute postprandial glycemia
Dietary Pulses
Augustin et al. Diabetes Care, to be submitted
Acute food intake regulation
Li et al. Obesity. 2014 May 13 [Epub ahead of print].
Meta-analyses of the effect of dietary pulses on acute
postprandial metabolic control:
Systematic reviews and meta-analyses to provide evidence-based guidance for
health claims development
(NCT01605422)
Dietary Pulses
Acute food intake regulation
Li et al. Obesity. 2014 May 13 [Epub ahead of print].
Li et al. Obesity (Silver Spring). 2014 May 13 [Epub ahead of print].
Consort Statement
Screened: 1753
Satiety index:
10 trials (n=158)
2nd meal intake:
6 trials (n=98)
Effect of pulses on satiety index:
10 trials (n=158), median dose=104g/d (7.7-311g/d) & time=148min (120-270min)
Effect of pulses on 2nd meal intake
6 trials (n=98), median dose=27.5g/d (7.7-292.5g/d); & time=148min (120-260min)
Series 2.
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Glycemia
Sievenpiper et al. Diabetologia 2009;52:1479-95
Lipid (established CV targets)
Dietary Pulses
Ha, et al. CMAJ. 2014;186(8):E252-62.
Blood pressure
Jayalath et al. Am J Hypertens 2014;27:56-64.
Body weight
Kim et al. Ann Intern Med, submitted
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Glycemia
Sievenpiper et al. Diabetologia2009;52:1479-95
Dietary Pulses
The cover picture shows the renaissance oil
on canvas painting, 'The Beaneater (Il
Mangiafagioli)' (c. 1580–1590) by Annibale
Carracci (1560–1609). Low-glycaemic index
foods, such as beans and other pulses, have
been extensively exploited for their ability to
improve metabolic control, related to blood
glucose and lipids. In a systematic review
and meta-analysis in the present issue of
Diabetologia (52: 1479–1495), Sievenpiper et
al. report that dietary pulses taken alone or
as a part of low-glycaemic index or highfibre diets may improve markers of longer
term glycaemic control in people with and
without diabetes. The data indicate that
more clinical research is needed to explore
these metabolic benefits as part of the
dietary strategy to prevent and treat
diabetes and cardiovascular disease
Sievenpiper, et al. Diabetologia, 2009;52:1479-95
Sievenpiper, et al. Diabetologia, 2009;52:1479-95
Consort statement
Screened: 1014
Pulses alone:
11 trials (n=253)
Pulses in low-GI:
19 trials (n=762)
Pulses in high-fibre:
11 trials (n=641)
Pulses Alone
Effect of pulses alone on FBG:
11 trials (n=253), median dose=120g/day (15.5-465g/day)
Sievenpiper, et al. Diabetologia, 2009;52:1479-95
Effect of pulses alone on FBI:
9 trials (n=213), median dose=120g/day (15.5-465g/day)
Sievenpiper, et al. Diabetologia, 2009;52:1479-95
Pulses as part of low-GI diets
Effect of pulses in low-GI diets on GP:
19 trials (n=762), mean GI (bread scale)=67 (54.3-79)
-0.48%
Sievenpiper, et al. Diabetologia, 2009;52:1479-95
Pulses as part of high-fibre diets
Effect of pulses in high-fibre diets on FBG:
11 trials (n=641), mean fibre=58g/day (27-97g/day)
Sievenpiper, et al. Diabetologia, 2009;52:1479-95
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Glycemia
Sievenpiper et al. Diabetologia 2009;52:1479-95
Lipid (established CV targets)
Dietary Pulses
Ha, et al. CMAJ. 2014;186(8):E252-62.
Blood pressure
Jayalath et al. Am J Hypertens 2014;27:56-64.
Body weight
Kim et al. Ann Intern Med, submitted
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Lipid (established CV targets)
Dietary Pulses
Ha, et al. CMAJ. 2014;186(8):E252-62.
Ha, et al. CMAJ. 2014 May 13;186(8):E252-62.
Consort Statement
Screened: 3001
LDL-C:
25 trials (n=960)
Apo-B:
1 trials (n=114)
Non-HDL-C:
22 trials (n=816)
Effect of pulses on LDL-C:
25 trials (n=960), median dose=130g/d (50-377g/d) and FU=6wk (3-52wk)
Ha, et al. CMAJ. 2014 May 13;186(8):E252-62.
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Glycemia
Sievenpiper et al. Diabetologia 2009;52:1479-95
Lipid (established CV targets)
Dietary Pulses
Ha, et al. CMAJ. 2014;186(8):E252-62.
Blood pressure
Jayalath et al. Am J Hypertens 2014;27:56-64.
Body weight
Kim et al. Ann Intern Med, submitted
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Dietary Pulses
Blood pressure
Jayalath et al. Am J Hypertens 2014;27:56-64.
Jayalath et al. Am J Hypertens. 2014 Jan;27(1):56-64.
Consort Statement
Screened: 341
SBP:
8 trials (n=554)
DBP:
8 trials (n=554)
MAP:
8 trials (n=554)
Effect of pulses alone on SBP:
8 trials (n=554), median dose=162g/d (81-275g/d) and FU=10wk (4-52wk)
Jayalath et al. Am J Hypertens. 2013 Sep 7. [Epub ahead of print]
Effect of pulses alone on DBP:
8 trials (n=554), median dose=162g/d (81-275g/d) and FU=10wk (4-52wk)
Jayalath et al. Am J Hypertens. 2013 Sep 7. [Epub ahead of print]
Effect of pulses alone on MAP:
8 trials (n=554), median dose=162g/d (81-275g/d) and FU=10wk (4-52wk)
Jayalath et al. Am J Hypertens. 2013 Sep 7. [Epub ahead of print]
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Glycemia
Sievenpiper et al. Diabetologia 2009;52:1479-95
Lipid (established CV targets)
Dietary Pulses
Ha, et al. CMAJ. 2014;186(8):E252-62.
Blood pressure
Jayalath et al. Am J Hypertens 2014;27:56-64.
Body weight
Kim et al. Ann Intern Med, submitted
Effect of dietary pulses on cardiometabolic risk in humans:
A series of systematic reviews and meta-analyses to provide
evidence-based guidance for future nutrition guidelines
development (NCT01594567)
Dietary Pulses
Body weight
Kim et al. Ann Intern Med, submitted
Consort Statement
2207 Reports identified
600 MEDLINE (through June 2013)
1294 EMBASE (through June 2013)
122 Cochrane Library (through June 2013)
185 CINHAL (through June 2013)
6 Manual searches
2119 Reports excluded based on title or abstract
Shana Kim
Screened: 341
Body weight:
19 trials (n=791)
88 Reports reviewed in full
71 Reports excluded
17 Reports (19 trials) included in the meta-analysis (n= 791)
Effect of pulses alone on body weight:
19 trials (n=791), median dose=132g/d (80-278g/d) and FU=6wk (3-48wk)
Contr
ol
Do these improvements in
cardiometabolic risk factors result in
a cardiovascular benefit?
Legumes are associated with decreased IHD:
Meta-analysis 5 prospective cohorts, N=198,904 (6514 events), FU=10-26y
Ashkan et al. Am J Clin Nutr 2014;100:278-288
Conclusions
Conclusions
1. Dietary pulses result in a clinically meaningful improvement
in blood sugar control that is comparable to that seen with
medications which have shown benefits for cardiovascular
disease.
2. Dietary pulses benefit other important markers of
cardiovascular disease including body weight, blood lipid
levels , and blood pressure and are associated with a
decreased risk of CVD
3. Traditional dietary patterns rich in dietary pulses may
represent an important part of the solution for addressing the
epidemics of obesity, diabetes, and cardiovascular disease
4. To confirm these results more research is needed: larger,
Acknowledgements