XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

This paper reviews studies performed to date that have employed cluster or factor analysis to empirically derive eating patterns. Since 1980, at least 93 studies were published that used cluster or factor analysis to define dietary exposures, of which 65 were used to test hypotheses or examine associations between patterns and disease outcomes or biomarkers. Studies were conducted in diverse populations across many countries and continents and suggest that patterns are associated with many different biomarkers and disease outcomes, whether measured by cluster or factor analysis. Despite clear differences in approaches and interpretations, there is some evidence that underlying eating patterns are revealed by either method. Although the research considered herein has created a meaningful body of literature, refining both the factor and cluster analysis methods will help to further establish eating patterns as a sound dietary assessment method.

Empirically Derived Eating Patterns Using Factor or Cluster Analysis: A Review

A systematic review of the literature on dietary patterns (multiple dietary components operationalized as a single exposure) in relation to nutrient adequacy, lifestyle and demographic variables, and health outcome was conducted. Most of the published reports on the subject have used one of two methods to determine dietary patterns: (a) diet indexes or scores that assess compliance with prevailing dietary guidance as dietary patterns, and (b) data-driven methods that use factor or cluster analysis to derive dietary patterns. Irrespective of the approach used, patterns characterized by fruit/vegetable/whole grain/fish/poultry consumption generally have been reported to relate to micronutrient intake, and to selected biomarkers of dietary exposure and disease risk in the expected direction. Age, income, and education have been reported to be among positive predictors of the so-called more healthful dietary patterns. An inverse association of healthful dietary patterns with all-cause mortality and cardiovascular disease risk was reported in most studies. However, the magnitude of risk reduction was modest and was attenuated after control for confounders. Few published studies showed an association between risk of most incident cancers and dietary patterns. Both of the currently used approaches for extracting dietary patterns have limitations, are subject to dietary measurement errors, and have not generated new diet and disease hypotheses.

Dietary patterns and health outcomes

Conjugated linoleic acid (CLA) is a mixture of positional and geometric isomers of octadecadienoic acid [linoleic acid (LA), 18:2n-6] commonly found in beef, lamb and dairy products. The most abundant isomer of CLA in nature is the cis-9, trans-11 (c9t11) isomer. Commercially available CLA is usually a 1:1 mixture of c9t11 and trans-10, cis-12 (t10c12) isomers with other isomers as minor components. Conjugated LA isomer mixture and c9t11 and t10c12 isomers alone have been attributed to provide several health benefits that are largely based on animal and in vitro studies. Conjugated LA has been attributed many beneficial effects in prevention of atherosclerosis, different types of cancer, hypertension and also known to improve immune function. More recent literature with availability of purified c9t11 and t10c12 isomers suggests that t10c12 is the sole isomer involved in antiadipogenic role of CLA. Other studies in animals and cell lines suggest that the two isomers may act similarly or antagonistically to alter cellular function and metabolism, and may also act through different signaling pathways. The effect of CLA and individual isomers shows considerable variation between different strains (BALB/C mice vs. C57BL/6 mice) and species (e.g., rats vs. mice). The dramatic effects seen in animal studies have not been reflected in some clinical studies. This review comprehensively discusses the recent studies on the effects of CLA and individual isomers on body composition, cardiovascular disease, bone health, insulin resistance, mediators of inflammatory response and different types of cancer, obtained from both in vitro and animal studies. This review also discusses the latest available information from clinical studies in these areas of research.

Biological effects of conjugated linoleic acids in health and disease.

Obesity is defined as an accumulation of excessive amounts of adipose tissue in the body, and is the most common nutritional disorder in companion animals. Obesity is usually the result of either excessive dietary intake or inadequate energy utilization, which causes a state of positive energy balance. Numerous factors may predispose an individual to obesity including genetics, the amount of physical activity, and the energy content of the diet. The main medical concern of obesity relates to the many disease associations that accompany the adiposity. Numerous studies demonstrated that obesity can have detrimental effects on the health and longevity of dogs and cats. The problems to which obese companion animals may be predisposed include orthopedic disease, diabetes mellitus, abnormalities in circulating lipid profiles, cardiorespiratory disease, urinary disorders, reproductive disorders, neoplasia (mammary tumors, transitional cell carcinoma), dermatological diseases, and anesthetic complications. The main therapeutic options for obesity in companion animals include dietary management and increasing physical activity. Although no pharmaceutical compounds are yet licensed for weight loss in dogs and cats, it is envisaged that such agents will be available in the future. Dietary therapy forms the cornerstone of weight management in dogs and cats, but increasing exercise and behavioral management form useful adjuncts. There is a need to increase the awareness of companion animal obesity as a serious medical concern within the veterinary profession.

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The Growing Problem of Obesity in Dogs and Cats

Lack of effect of dietary conjugated linoleic acids naturally incorporated into butter on the lipid profile and body composition of overweight and obese men

Background: Dietary conjugated linoleic acid (CLA) is known to reduce atherosclerosis, plasma total and LDL-cholesterol concentrations,andbodyfataccumulationinseveralanimalspecies.Ofthe few studies that investigated the effects of CLA supplementation in humans, all used commercially formulated oral supplements made from a mixture of CLA isomers. Objective: We compared the effects on plasma lipoproteins and body composition of the consumption of a modified butter naturally enriched with CLA (CLA-B: 4.22 g CLA/100 g butter fat) by the additionofsunfloweroiltothedietofdairycowswiththeconsumptionofacontrolbutter(CON-B)thatwaslowinCLA(0.38gCLA/100 g butter fat). Design: In a crossover design study including an 8-wk washout period, 16 men [x SD age: 36.6 12.4 y; body mass index (in kg/m 2 ):31.24.4]werefedeachofthe2experimentalisoenergetic

Lack of effect of dietary conjugated linoleic acids naturally incorporated into butter on the lipid profile and body composition of

The purpose of this study was to identify dietary patterns among adults in Quebec and to determine their relationship to nutritional adequacy of the diet. We used 24-hour food recall data on 2,104 adults from the Quebec nutrition survey (1990). Nutritional adequacy was assessed based on the 1990 Nutrition Recommendations for Canadians; dietary patterns were assessed via a factor analysis of the 30 food groups consumed. The three major patterns identified ('high-energy density', 'traditional' and 'health-conscious') explained 18% of the variation in food intake. Only the 'health-conscious' pattern correlated positively with the four chosen indicators of nutritional adequacy. Generally, men scored positively on the 'high-energy density' and the 'traditional' pattern whereas women scored positively on the 'health-conscious' pattern. Aside from sex, scoring was most related to age and education. The use of these patterns to define and target nutrition interventions should be tested in the aim of improving the effectiveness of health promotion.

/pdf/dietary-patterns-of-adults-in-quebec-and-their-nutritional-13lymefgx8.pdf

Dietary patterns of adults in Québec and their nutritional adequacy

Sequential release of amino acids and peptides during in vitro digestion of casein and rapeseed proteins

Four diets containing different mixtures of dietary fibre (DF) were tested in the rat to verify the effects of fibre source and fibre level on plasma glucose, insulin and lipids and on apparent intestinal absorption of minerals. Diets Puri5 and Puri 10 contained 5 and 10% of total DF from pectin and cellulose. Diets Bran 5 and Bran 10 supplied 5 and 10% DF from oat bran and wheat bran. A fifth diet with 5% cellulose was used as a control. Ten rats were fed each diet for 4 weeks. On days 3, 17 and 28, feces were collected and analyzed for Fe, Zn, Ca and Mg. On day 29, blood samples were collected in portal vein and abdominal aorta in fasted and fed rats from each group. All diets had similar effects on plasma insulin and triglycerides. Compared to Bran diets, Puri diets induced higher portal glucose (p 10%). This indicates that in fibre mixtures, the source rather than the amount of fibre generally affects absorptive and metabolic parameters.

Isabelle Galibois

Papers

Lack of effect of dietary conjugated linoleic acids naturally incorporated into butter on the lipid profile and body composition of overweight and obese men

Lack of effect of dietary conjugated linoleic acids naturally incorporated into butter on the lipid profile and body composition of

Dietary patterns of adults in Québec and their nutritional adequacy

Sequential release of amino acids and peptides during in vitro digestion of casein and rapeseed proteins

Effects of dietary fibre mixtures on glucose and lipid metabolism and on mineral absorption in the rat.