Discuss the epidemiological burden of diabetes and rising food intakes, recognize insulin-glucose pathway effects by intramyocellular lipids, familiarize with clinical evidence and utilize guidelines by ACE/AACE, implement rapid assessment and practical application of plant-based nutrition and apply CPT billing codes for this intervention

1. Plant-Based Food as
Medicine for Diabetes
Ashwani Garg, MD
Family Medicine
Lifestyle Medicine
January 31, 2020

2. Disclosures
No financial disclosures
No commercial funding
No pharmaceuticals
Views are my own

3. Learning
Objectives
3
1. Discuss the epidemiological burden of diabetes
and rising food intakes in the USA
2. Recognize Insulin-Glucose pathway effects by
intramyocellular lipids
3. Familiarize with clinical evidence for plant-based
diabetes intervention, disease outcomes
4. Utilize guidelines for plant-based nutrition by
ACE/AACE
5. Implement rapid assessment and practical
application of plant-based nutrition
6. Apply CPT billing codes for nutrition intervention

4. EEpidemiology
of Diabetes
4Credit: Physicians Committee (with permission)

5. USA Food
Intake
5

6. Cheese is the largest share of dairy in
USA

7. Potatoes and tomatoes are the most
commonly consumed vegetables.
Potatoes: 42% frozen (fries); Tomatoes 56% canned

8. Dietary Fiber intake
8
• Average intake in the USA is 15g/d for
women and 18g/d for men
• Most don’t meet adequate fiber intake
• Found in plant foods only, fiber improves
blood glucose control
• Fiber is linked to increased satiety and
reduced incidence of diabetes
Fiber Intake of the US population, What We Eat in
America, NHANES 2009-2010
M. Katherine Hoy Ed. D, RD and Joseph D. Goldman, MA
Image: Ardmore Institute

9. IIntramyocellular
Lipid (IMCL)
9
1. IMCL serves as an intracellular source
of energy during exercise.
2. IMCL content decreases during
prolonged submaximal exercise,
increased in the trained state, to
optimally match fat oxidative capacity
serving as readily available fuel.
3. skeletal muscle also stores fat simply
if the availability of fatty acids is high.
4. Under these conditions, the uptake
into skeletal muscle may have
negative consequences on insulin
sensitivity
Obesity, Volume: 14, Issue: 3, Pages: 357-367
First published: 06 September 2012
DOI: (10.1038/oby.2006.47)
Credit: Physicians Committee for Responsible
Medicine (with permission)

10. Intramyocellular Lipid Content in Skeletal Muscle
Obesity, Volume: 14, Issue: 3, Pages: 357-367, First published: 06 September 2012
DOI: (10.1038/oby.2006.47)

11. VOLUME 28, ISSUE 5, P354-364, MAY 1, 2017

12. P
B
Plant-Based
Intervention
for type 2
diabetes
12
Evidence of “low fat” and “high carb” approach:
• Walter Kempner MD (Rice Diet Program started
1939) Effect of rice diet on diabetes mellitus associated with
vascular disease (Postgrad Med. 1958 Oct;24(4):359-71)
• Anderson and Ward: High-carbohydrate, high-
fiber diets for insulin-treated men with diabetes
mellitus insulin reduced more than ½. (Am J Clin
Nutr. 1979 Nov;32(11):2312-21)
• Nathan Pritikin (1st book 1974) Long-term use of
a high-complex-carbohydrate, high-fiber, low-fat
diet and exercise in the treatment of NIDDM
patients. (Diabetes Care. 1983 May-Jun;6(3):268-73.)
• Neil Barnard MD: A low-fat vegan diet improves
glycemic control and cardiovascular risk factors
in a randomized clinical trial in individuals with
type 2 diabetes (Diabetes Care. 2006 Aug;29(8):1777-83.)
• Rotterdam Study, Netherlands, prospective
population based cohort (Plant versus
animal based diets and insulin resistance,
prediabetes and type 2 diabetes: the Rotterdam
Study. Eur J Epidemiol. 2018 Sep;33(9):883-893. doi:
10.1007/s10654-018-0414-8. Epub 2018 Jun 8.)
• Dr. Hana Kahleova: A Plant-Based Meal
Stimulates Incretin and Insulin Secretion More
Than an Energy- and Macronutrient-Matched
Standard Meal in Type 2 Diabetes: A
Randomized Crossover Study. (Nutrients. 2019 Feb
26;11(3). pii: E486. doi: 10.3390/nu11030486.)

13. • The key components of lifestyle therapy include medical nutrition therapy, regular
physical activity, sufficient amounts of sleep, behavioral support, and smoking cessation
with avoidance of all tobacco products
• Lifestyle therapy begins with nutrition counseling and education. All patients should
strive to attain and maintain an optimal weight through a primarily plant-based meal
plan high in polyunsaturated and monounsaturated fatty acids, with limited intake of
saturated fatty acids and avoidance of trans fats.
[in other words, avoid dairy/meat and processed foods]
AACE/ACE Guideline for Diabetes 2019Alan J. Garber, Martin J. Abrahamson, Joshua I. Barzilay, Lawrence Blonde, Zachary T. Bloomgarden, Michael A. Bush, Samuel Dagogo-Jack, Ralph A. DeFronzo, Daniel
Einhorn, Vivian A. Fonseca, Jeffrey R. Garber, W. Timothy Garvey, George Grunberger, Yehuda Handelsman, Irl B. Hirsch, Paul S. Jellinger, Janet B. McGill, Jeffrey I. Mechanick, Paul
D. Rosenblit, and Guillermo E. Umpierrez (2019) CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE
OF ENDOCRINOLOGY ON THE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM – 2019 EXECUTIVE SUMMARY. Endocrine Practice: January 2019, Vol. 25,
No. 1, pp. 69-100.
13

14. Assessment of Nutrition Status
14
• Starting point for motivational interviewing
• Brings greater self-awareness and self-
efficacy
• Establishes rapport
• Changes may be incremental small steps
or a wholesale change when discussing
what is possible
• 4-leaf survey was created in 2012 and
available in 8 languages, a rapid tool for
identification of plant food intake available
free at 4leafsurvey.com; more information
at 4leafprogram.com
• Exercise: pause, go to 4leafsurvey.com
on your device and email yourself the
results from the survey

15. • Code 99401 “Preventive Medicine,
Individual Counseling, 15 minutes”
• Payment can be only for non government
payors, in addition to E&M (not
preventive) code, wRVU 0.48
• Check with your compliance and billing
• Threshold for billing is 8 minutes (1/2 of
the visit time)
• Must document additional time spent,
assessment/counseling of nutrition
• Use ICD-10 code Z71.3 (diet counseling)
and Z71.82 if talking about exercise
Billing Codes for nutrition analysis
15

16. Putting meals together
16
(1) Eat a plant-based diet: fruits,
vegetables, whole grains, legumes
(2) Limit added fats (oil and animal
products)
(3) Eat lower glycemic (beans, whole
grains such as oats, sweet potatoes,
squash, berries and lentils)
(4) Aim for 40 gm of fiber/daily
Whole Foods Market
Full Plate Living
(FullPlateLiving.Org or
full plate diet book)
PCRM.ORG/Diabetes
Resources for English, Indians, Spanish
speakers, and Chinese language

17. Nutrient Composition
Plant and Animal-Based Foods (Per 500 Calories of Energy)
1. USDA Nutrient Database for
Standard Reference.
http://ndb.nal.usda.gov/ndb/.
2. Holden JM, Eldridge AL,
Beecher GR, et al. “Carotenoid
content of U.S. foods: an update
of the database.” J. Food Comp.
Anal. 12 (1999): 169–196.
3. The exact food listings in the
database were: Ground Beef,
80% lean meat/20% fat, raw;
Pork,fresh, ground, raw;
Chicken, broilers or fryers, meat
and skin, raw; Milk, dry, whole;
Spinach,raw; Tomatoes, red,
ripe, raw, year-round average;
Lima Beans, large, mature
seeds, raw; Peas,green, raw;
Potatoes, russet
*B12 is from soil bacteria and is variable; can be
obtained from supplements or supplemented
foods

18. Example analysis (plant-based)
Cronometer.COM
(1) breakfast smoothie, soy milk, spinach, banana, pineapple, kiwi, hemp
(2) lunch chickpeas, broccoli, bulgur
(3) apple/PB snack
(4) dinner bean/veg/kale curry with swt potato, tahini + 4 brazil nuts
(5) 10 almonds for a snack w/soymilk

22. Plant Foods are the best fuel for the body
• Nutrient-dense
• Anti-inflammatory, anti-oxidative stress
• Increased energy
• Optimized athletic performance
• Reduction and treatment of cancer
• Prevention AND reversal of heart disease

23. Phytochemicals
• Phytochemicals are compounds only in plants that promote health
• There is no daily reference intake for phytochemicals
• New research shows they may very well be essential to life, and for prevention of
cardiovascular diseases and cancer
• ONLY about 1/5 of Americans meet the minimum intake

24. Flavonoids
• Pigments in foods found in pigmented foods such as leafy greens, citrus, tea, berries,
and chocolate
• Over 5000 natural occurring flavonoids have been isolated
• Antioxidant, anti-inflammatory, anticancer, antiplatelet, antibacterial

25. Carotenoids
• Alpha/beta carotene, lutein, lycopene, zeaxanthin
• Found in Carrots, fruits, vegetables, tomatoes
• Reduce muscle fatigue, neutralize free radicals, reduce risk of
prostate cancer
• Regulate cell growth, modulate gene expression
• Carotenoids also regulate body fat and modulate obesity

26. Nonstarchy polysaccharides
• fucoidan, beta glucan
• Mushrooms, barley, oats, brown seaweed, wheat bran
• Apoptosis of cancer cells, brain development,
antithrombotic, blood pressure, reduced risk of
breast/colon cancer, improved cholesterol and reduced
CVD

27. Lignans
• Outer coat of seeds, woody parts of plants, provide building blocks
• 100 times higher in flax than other foods
• Lowering of blood pressure
• Hormone regulation (phytoestrogen)
• Protective against heart disease and breast cancer

28. Glucosinolates
• Sulfur containing compounds found in brassica
(cruciferous vegetables)
• Indole-3-carbinol (I3C) formed from metabolism
• Denatured by high heat (boiling) and activated by
chewing
• Antibiotics will inactivate the absorption
• Anti-cancer, anti-CVD, immune regulation

29. Isoflavones (soy)
• Isoflavones (genistein and dadzein) act as agonist/antagonist for estrogen
receptor
• Isoflavones were thought to be harmful based on ANIMAL studies
• HUMAN research supports benefit of soy foods
• Lower type 2 diabetes risk
• Lower menopause symptoms
• Lower breast and gynecologic cancers
• Lower prostate cancer

30. Omega-3 fatty acids
• ALA is an essential fatty acid, converted to DHA/EPA
• Omega-6 found in oils will “compete” with the conversion and interfere
• DHA can be obtained in algae form (for example Vegetology)
• Turmeric can increase absorption of DHA
• Role in heart health, brain health, anti-inflammatory

31. 31

32. Summary
32
• Diabetes is rapidly rising, obesity rates are staggering. Food
intakes have risen rapidly with high intake of refined,
processed and fatty foods.
• Treatment is much more complicated than just macronutrient
modification, as excess fat will interfere with the glucose-
insulin signalling
• There is long standing clinical evidence for a generally plant-
based and lower fat approach
• Guidelines by ACE/AACE endorse a plant-based diet
• Nutrition interventions can be assessed, treated, and ALSO in
some cases, reimbursed.
• Lifestyle interventions can be life-changing and transform lives