Precision Diabetes Medicine and Nutrition Care – Ready for Prime Time?

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Precision Diabetes Medicine and Nutrition Care – Ready for Prime Time?

Hope Warshaw is a Registered Dietitian (RD) and Certified Diabetes Care and Education Specialist (CDCES) who has been involved in diabetes care, education and support for over forty years. She has and continues to apply her credentials as a consultant, book author, freelance writer and media spokesperson within her business, Hope Warshaw Associates, LLC, a consultancy based in Asheville North Carolina. 

Interest in how healthcare providers can apply precision medicine and—under this umbrella—precision nutrition in the future to optimize health and manage diseases is gaining momentum.

This is true in general and specific to Type 2 diabetes care.

This article defines key terms and summarizes conclusions from an interim consensus report from the Precision Medicine in Diabetes Initiative (PMDI).1

With this summary and acknowledgment that precision medicine for Type 2 diabetes care remains “aspirational,” this article encourages people with Type 2 diabetes to apply the body of knowledge we have today and work with a healthcare professional to personalize a healthy and sustainable eating plan.  

Definitions


What is precision medicine?
Precision Medicine means tailoring diagnostics or therapeutics (prevention or treatment) to subgroups of populations sharing similar characteristics, thereby minimizing error and risk while maximizing efficacy.1

More simply stated, providing the right therapy for the right person at the right time.1

What is precision diabetes medicine?
An approach to optimize the diagnosis, prediction, prevention, or treatment of diabetes by integrating data from various dimensions (e.g., diagnosis, treatments, monitoring techniques, etc.).1

The use of a complex array of data distinguishes precision medicine from standard medical care. 

What is precision nutrition?
The customization of food and nutrient intake for individuals based on diagnostic testing, a person’s unique characteristics (e.g., DNA, race, gender, health history, and lifestyle) with the goal to more accurately implement disease prevention and management.2


    Background, Status, and Conclusions from Precision Medicine in Diabetes Initiative

    The PMDI was launched in 2018 by the American Diabetes Association (ADA) in partnership with the European Association for the Study of Diabetes (EASD).1

    The initiative’s long-term promise is to reduce the multiple burdens of the growing epidemic and human toll of diabetes around the globe. 

    The report states that the concept of precision medicine (see definition above) is not new, but what has evolved is the ability of experts to obtain, characterize and interpret human biological variation through science and technology. 


    PMDI is a multi-year initiative with four phases.1 In the early years, 2018 through 2025, the PMDI is focusing on assessing current evidence, promoting research, providing education, and developing guidelines for the application of precision medicine in diabetes care.

    Phase four, the final phase, to take place starting in 2025, will communicate to and educate healthcare professionals and people with diabetes on the roadmap to implement an individualized, precise diabetes care regimen. 

    A phase one goal was to publish the consensus report.1 This lengthy and dense report provides a foundation for Precision Diabetes Medicine (PDM) (see definition above). Within it, the reader finds definitions of pertinent terms that focus on all aspects of this content from precision prevention to diagnosis (yes, we already know there are way more than two types of diabetes!), precision treatments (using data about a person’s unique biology and knowledge about treatments to provide a precise regimen), precision monitoring (including glucose monitoring and other biomarkers, like sleep, food choices, physical activity and more). 

    The report concludes by stating that for most types of diabetes, precision medicine at this point is, “aspirational, rather than standard of care.”

    Precision Medicine Nutrition

     

    More On Precision Nutrition

    The PMDI report contains minimal details about nutrition and lifestyle interventions to reduce risk factors, prevent disease and manage diabetes.

    It’s far from a deep dive on precision nutrition (see definition above). However, a recent debate at the ADA’s 2021 Scientific Sessions, Precision Nutrition – Are We There Yet?, did so with Paul Franks, Ph.D., Lund University Diabetes Center (Sweden), Harvard T.H. Chan School of Public Health, and co-chair of the PMDI, arguing yes. Kevin Hall, Ph.D., Section Chief, Integrative Physiology, National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health, arguing no.3

    Here are a few key takeaways:

    Precision Nutrition: Ready for Primetime

  • Now is the time for aggressive research into the use of precision nutrition, but at this point, precision nutrition should not replace the standard of care approaches. 
  • Biological characteristics (e.g., genotypes) influence a person’s response to lifestyle interventions and this data can be intelligently combined to help optimize food choices. 
  • Even if we know or learn what works best for someone, they may not adhere to the “optimal” eating plan, particularly over time. 

  • Precision Nutrition: Not Ready for Primetime
  • People have widely variable reactions to the same nutrition interventions. Research must show that these responses are reproducible regardless of social, economic, or environmental differences.  
  • Even “gold standard” methods for measuring glucose (e.g., continuous glucose monitors) and energy consumption have, at this point, substantial imprecision that introduce considerable variability.
  • We still cannot detect from studies how much variability of responses is due to biological variation (signal) vs. limits of methodological precision (noise).
  •  

    Precision Medicine 

    Today’s Healthy Eating Guidance for Prediabetes and Type 2 Diabetes
    For sure there’s excitement about the promise of precision medicine and nutrition, but what is the consensus about how individuals with prediabetes and type 2 diabetes should manage their food choices and eating habits today and tomorrow? That is before we can apply precision nutrition guidance.

    Actually, there’s lots to chew on! In 2019 the ADA published their latest Nutrition Therapy Consensus Report for adults with diabetes or prediabetes.4 A core principle reflects the goal of personalization and recommends that healthcare providers: “Address individual nutrition needs based on personal, cultural, literacy, numeracy, access to healthy foods, willingness and ability to make behavior changes understanding a person’s barriers.”4 This goal appreciates the reality that regardless of evidence-based guidance, a person’s eating habits and food choices, are wrapped up in so much more than simply choosing healthy foods in right-sized portions. The ADA Nutrition Therapy Consensus Report also dug into the existing data on a broad array of eating patterns that have been studied in people with diabetes, from Mediterranean to low carbohydrate, DASH and others.4 From this analysis they culled four commonalities among healthful eating patterns and recommended implementing these as a starter to make day-to-day food choices. They are: 

    1. Emphasize consumption of non-starchy vegetables
    2. Minimize consumption of added sugars and refined grains
    3. Choose whole foods over highly processed foods
    4. Replace sugar-sweetened beverages with water as often as possible

    A common thread among the top three recommendations (above) encourages consumption of foods that contain dietary fibers. These include: all non-starchy vegetables; whole foods, such as fruit, corn, and legumes/beans; and unrefined grains, such as whole grain cereals, breads, and pasta. Eating a wide variety of these foods in right-size portions day in and day out, offers an array of dietary fibers (note the plural on fibers, we eat thousands of different fibers), the body needs for optimal health, including a healthy gut microbiome. 

    Not only is eating this way consistent with ADA recommendations,4 as well as those in the 2020-2025 Dietary Guidelines for Americans,5 it can also help people with prediabetes and type 2 diabetes take one critical step towards correcting two potential imbalances in their gut microbiome.  A growing body of evidence demonstrates that people with metabolic syndrome and those on the path to prediabetes and those with prediabetes and type 2 diabetes, may have:6,7

    1. A deficiency in the body’s functional ability to produce short-chain fatty acids, particularly butyrate. (Learn more about butyrate here.)
    2. An impaired functional ability to maintain the mucin layer of the gut lining.

    For starters, it is essential to consume at a minimum 14 grams of fiber per 1000 calories a day.4,5 Dietary fibers help promote numerous reactions in the body that support health and minimize risks of some diseases. For one, some dietary fibers increase production of butyrate (an important short-chain fatty acid (SCFA) created in the gut microbiome through the breakdown of dietary fibers. Another step to consider is to use Pendulum Glucose Control, a synbiotic that contains five targeted bacterial strains (butyrate producers plus a mucin regulator) and the prebiotic inulin, to provide the initial food source for the probiotic strains. In a double-blind, randomized placebo-controlled study, in people with Type 2 diabetes on metformin, Pendulum Glucose Control, reduced A1c levels by 0.6% compared to placebo and generated a 33% reduction in postprandial glucose spikes (area under the curve).8,9   

    Curious to learn more about Pendulum? Click here to see Pendulum’s Story featured in ADA’s 2021 Scientific Sessions. 

    In summary, though it is interesting and enticing to glimpse into the future of precision medicine and precision nutrition, there are many evidence-based actions, as outlined here, to take today to prevent, delay and/or manage prediabetes and type 2 diabetes. If you have prediabetes or type 2 diabetes work with your diabetes care healthcare providers to personalize an eating plan that works for you over the long haul. Remember you are an individual, or as they say, an N of one. 




     


    References: 
    1. Chung WK, Erion K, Florez JC, et al. Precision medicine in diabetes: a consensus report from the ADA and EASD. Diabetes Care. 2020;43;1617-1635. 
    2. Harvard T.H. Chan School of Public Health. Precision Nutrition. https://www.hsph.harvard.edu/nutritionsource/precision-nutrition/. Accessed July 8, 2021.
    3. Franks P, Hall K. Precision Nutrition – Are We There Yet? ADA 2021 Scientific Sessions.  
    4. Evert AB, Dennsion M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: A consensus report. Diabetes Care. 2019;42(5):731-754. 
    5. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf. Accessed July 8, 2021.
    6. Mishra SP, Jain S, Taraphder S, Yadav H. New horizons in microbiota and metabolic health research. J Clin Endocrin Metab. 2021;106(2):e1052-e1059. doi:10.1210/clinem/dgaa769
    7. Herrema H, Niess JH. Intestinal microbial metabolites in human metabolism and type 2 diabetes. Diabetologia. 2020;63:2533-2547. 
    8. Perraudeau F, McMurdie P, Bullard J, et al. Improvements to postprandial glucose control in subjects with type 2 diabetes: a multicenter, double-blind, randomized placebo-controlled trial of a novel probiotic formulation. BMJ Open Diabetes Research and Care. 2020;8:e001319. 
    9. Warshaw H. Our published clinical study, explained. https://pendulumlife.com/blogs/news/our-published-clinical-study-explained. Accessed July 8, 2021.



    Disclaimer: Hope Warshaw was compensated for the development and promotion of this blog from Pendulum Therapeutics, the manufacturer of the medical probiotic, Pendulum Glucose Control.

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