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Fad Diets & Diabetes Management: What’s the Evidence?

MaureenChomko,RD,CDE

2019WADEAnnualConferenceApril25,2019

DisclosurestoParticipantsNoticeofRequirementsforSuccessfulCompletion:Forsuccessfulcompletion,participantsarerequiredtobeinattendanceinthefullactivityandcompletetheprogramevaluationattheconclusionoftheeducationalevent.PresenterConflictsofInterest/FinancialRelationshipsDisclosures:Noconflictsexist.DisclosureofRelevantFinancialRelationshipsandMechanismtoIdentifyandResolveConflictsofInterest:Noconflictsofinterest.Non-EndorsementofProducts:AccreditedstatusdoesnotimplyendorsementbyAADE,ANCC,ACPEorCDRofanycommercialproductsdisplayedinconjunctionwiththiseducationalactivity.Off-labelUse:ParticipantswillbenotifiedbyspeakerstoanyproductusedforapurposeotherthanthatforwhichitwasapprovedbytheFoodandDrugAdministration.

#1 Question to ADA consumer call center:

What Can I Eat?

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ADA:FoodandFitness->Food->WhatCanIEat

AADE:LivingwithDiabetes->AADE7Self-CareBehaviors->HealthyEating

EatingforDiabetes:Basics

• Effectiveplansbothreducecalorieintakeandincreasephysicalactivity

• Noclearpreferenceforanyspecificeatingplanormacronutrientdistribution

• Varietyofeatingplanswork•  Totalenergyintakeappearsmoreimportantthansourceofenergy

FranzM,etal.JAcadofNutrandDietetics.2015Sep;115(9):1447-63.MacLeodJ,etal.JAcadofNutrandDietetics.2017Oct;117(10):1637-1658.

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Eating for Diabetes Isn’t Easy… “Isn’t there another way?”

EatingforDiabetes:FadDiets

• Whatistheindividualwillingtofollow?• Patient-centeredcounselingleadstodevelopingplansforfaddietswithindividuals

• Donoharm•  Eatingplancannotputpersonwithdiabetesatgreaterhealthrisk

• Comparefaddietoutcomeswiththeindividual’sdesiredoutcomes

Joseph

•  68yoM;DM2x10years;mostrecentA1c8.4%aftermanagingA1c’s<7%

• Metformin1000mgBID;65unitsglargineand15-20unitsTIDaspart

• BMI36.Weightgainsinceretired2yearsago.

• HighlymotivatedtogetA1cbackdown•  Social:retiredengineer,liveswithwife,whoisstillworkingasRN.

• Wifecooksallmeals,hehashaddifficultygettinghertochangethewayshecooks.

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WhicheatingplanwouldbethebestoptionforJoseph?

Joe’soldcoworkerhaslostweightthroughintermittentfasting,soJoehasbeenthinkingaboutthis.SonDavethinksheshouldtryaPaleoplanthatDavefollowsthroughhisCrossfitgym.HiswifehasreadabouttheDASHeatingplanforhermother’sbloodpressure,wantsJoetofollowitaswell.

WhicheatingplanwouldbethebestoptionforJoseph?

IntermittentFastingPaleo

DASH

Limited data to recommend Paleo for DM. Very small studies lasting only a few

weeks or months have been conducted to date.

More research is needed.

“Dietary Approaches to Stop Hypertension” Reduces BP & Framingham risk score for

CVD Published data conflicting for weight loss and

A1c Pitt CE. Aust Fam Physician. 2016 Jan-Feb;45(1):35-8.

IntermittentFasting:Definitions

• Eatingplancyclingbetweenperiodsofeatingandfasting.•  Fastingperiodslongerthananormalovernightfastof8–12hours

• Severaltypesofintermittentfastingmethods:allofwhichsplitthedayorweekintoperiodsofeatingandperiodsoffasting

• DailyTime-RestrictedFeedingWindows• WeeklyEnergyRestrictionviaIntermittentFasting

• Noguidanceonwhatfoodstoeat,onlywhentoeat

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Time-RestrictedFeedingWindows

Limitingeatingperiodtoacertainnumberofhoursaday:Example:<10houreatingwindowduringdaytimewith>14hourfast

SuttonE,etal.CellMetabolism(27),2018:1212-1221.

EarlyTimeRestrictedFeedingBenefits:•  Decreasedfastinginsulinandinsulinlevelsat60&90minutespostprandial•  Improvedinsulinsensitivity&responsiveness•  Lowereddesiretoeatintheevening

Noweightlossinthisfive-weekstudyof15prediabeticmen.SuttonE,etal.CellMetabolism(27),2018:1212-1221.

“Manyofmypatientshavetimerestrictedfeedingwindows….theydon’teatbreakfastuntil2pm,andtheystopeatingat2am.”

• Feedingperiodsbeginningafter4PMledto:• Noresults,or• WorsepostprandialBGlevels,betacellresponsiveness,BPandlipidlevels

CarlsonO,etal.Metabolism.2007;56(12):1729-34.StoteKSetal.AmJClinNutr.2007;85(4):981-8.

TinsleyG&LaBountyP.NutritionReviews,.2015;73(10)661–674.

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WeeklyEnergyRestriction

1.“Fasting-mimicking”diets:significantlyreducedcaloriesfor5daysofthemonth

2.Restrictingenergyintakeon1–3daysperweek,andeatingfreelyonthenon-restrictiondays

•  Example:5:2diet

3.Alternatedayfasting(ADF)•  “fastday”(75%energyrestriction)alternatingwitha“feedday”

WeeklyEnergyRestrictionOutcomes•  54obeseadultswithDM2randomizedinto3groups:

(1)VLCDx5daysfollowedbyonly1day/wkofVLCDx15weeks(2)VLCDx5daysfollowedby5daysofVLCDevery5weeks.Consuming1500-1800caloriesonnon-fastingdays(3)Controlgroup:1500-1800calories/dayforlengthofstudy

• BothVLCDgroupslostsignificantlymoreweight•  GroupTwomoresuccessfulthanGroup1(92%vs50%lost>5kg)•  GroupTwomorelikelytoachievenormalA1c,independentofweightloss

•  Shortstudy/nofollowup;Studydonein1998

Williams K, et al. Diabetes Care Jan 1998, 21 (1) 2-8.

WeeklyEnergyRestrictionOutcomes

• 63overweight/obeseadultswithDM:• GroupOne:2days/wkeating400-600kcal/day,thenhabitualeating5days/wk

• GroupTwo:dailyenergyrestrictionto1200-1550kcal/day

• After12weeks,bothgroupshadsimilarreductionsinA1c,bodyweight,meddoses,bodycomposition,andappetitereports

CarterSetal.DiabetesResClinPract.2016Dec;122:106-112.

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IntermittentFastingConcerns

• Variationsofdefinitionsmakeconsistentresearchfindingsdifficult

•  Numberoffastingdaysvaryineachstudy•  Amountofcaloriesvaryineachstudy

• Managinghungeronfastingdaysandappetiteonfeedingdays•  Potentialfor“rebound”overeatingon“feeding”days

• Sociallife

DiabetesMedicationAdjustmentsforIntermittentFasting

• Riskofhypoglycemiain41%ofindividualsstudied• Hypoglycemiarisk2xgreateronfastingdays(despitemedadjustment&hypoeducation)

• Reducemedicationsonfastingdays:•  Ifindividualseating<400calories,take1/2or1/3ofinsulindoses•  Ifpossible,eliminateuseofhypoglycemicmedicationsonfastingdays

CorleyBT,etal.DiabeticMedicine.Vol35(5):2018.

Real World Strategies: Intermittent Fasting

Eatingdinnerearlier

EatingalighterdinnerTryeatingmorecaloriesforbreakfastandlunch

Avoidinglate-nightsnacking

MostAmericanseatbetweena12-15hourwindow.

Reduceby1-2hoursStopeatingafter6or8PM

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Marilyn

•  72yoF,BMI33;HTN,HLD,CADwithh/o3-VesselCABG

•  Sinceretirement,hasgained30lbs.NewdxDM2;A1c6.8%.PCPwouldlikehertotrytoworkonherdietandbecomemoreactivebeforeinitiatingmetformin.

•  Social:Retiredphysician,livesalone.• Usedtocookmuchmore;raised3childrenandisenjoyingretirement.Atetortillachips,avocadoandsalsafordinnerlastnight.

• Noregularexercisebut“doddersaround”inhergarden.

WhichwouldbethebesteatingplanforMarilyn?

Marilynrememberslearningaboutlowfatdietsforweightlosswhenshewasinresidency,hasbeenconsideringthis.ShehasreadarticlesaboutMediterranean-styleeating,shehasalwaysenjoyedMiddleEasternfood.HerdaughterisontheketogenicdietandinsiststhiswillworkforMarilyn’snewdiagnosisdiabetes.

WhichwouldbethebesteatingplanforMarilyn?

LowFatMediterraneanKetogenic

Concern due to high CVD

risk

LOOK AHEAD trial: lowering total fat intake did not consistently improve

glycemic control in patients with DM2.

LookAHEADResearchGroup.NEnglJMed2013;369:145-154

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WhatisMediterraneanStyleEating?

“Fillyourplatewithfreshfruitsandvegetables,healthyfats,wholegrains,legumesandfishandenjoymoderate

amountsofredwine”

MEDEatingPlan:DMStudyOutcomes

• Whencomparedtohighcarbohydrate-lowfat,small&shortstudiesfind:

• NodifferenceinA1corweight•  SignificantloweringofVLDL&TG• MixedresultswithHDLchange

Rodriguez-VillarC.DiabetMed.2004Feb;21(2):142-9.GargA.etal.DiabetesCare.1992Nov;15(11):1572-80.GargA.etal.JAMA.1994May11;271(18):1421-8.MonlezunDJ,etal.DiabetesResClinPract.2015Aug;109(2):420-6.

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Mixed Results in Larger DM Mediterranean Studies

• A1c&BMIloweredwhenMEDcombinedwith:PA+stressmgmt+smokingcessation

• Whencomparedtolowerfat-highercarb,MEDresultedinlowerweight,improvedglycemiccontrol,insulinsensitivity,HDL,TGandBP,lessDMmedicationuseandlongertimetoDMmedicationsinMEDgroup.àAt4years,weightandbloodpressuresimilarbetweengroups•  LessinsulinresistanceinMEDgroupvslowfatgroup.WhenMED

comparedtolowercarbgroup,A1clowestinlowcarbgroup

ToobertDJ,etal.DiabetesCare.2003Aug;26(8):2288-93.EspositoK,etal.DiabetesCareJul2014,37(7)1824-183.

ShaiI,etal.NEnglJMed2008;359:229-241

• Priority:reducingCVDrisk• IncidenceofmajorCVDeventslowerforthoseconsumingMediterraneandietvscontrolgroup(advisedtoreducefatintake)

• GlycemiccontrolvsMortalityReduction• Cardiovasculardiseaseremainsthemostprevalentcauseofmorbidityandmortalityindiabeticpatients

MediterraneanEatingPlan:Barriers• HigheradherencetoMEDeatingassociatedwithgreaterspendingonfood

•  CostmuchmorelikelytodecreaseadherencetoMEDeatingplaninthoseoflowersocioeconomicstatus

• MEDeatingassociatedwithlowerCVDriskinthosewithgreaterincomeorgreatereducationlevel

• NorelationshipfoundforlowerCVDriskinthosewithlowereducation/incomelevel,despitesimilarMEDadherencescores

G.AlbuquerqueG,etal.PortoBiomedicalJournal.(2017)2,115-119BonaccioM,etal.IntrJEpi,Vol46,(5),2017,1478–1487.

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MediterraneanEatingPlan:Barriers

• Time/MealPreparation•  Few“convenience”MEDfoods• Requireshigher-levelcookingskills

• Starkdifferencefromotherculturaleatingpatterns•  ~93%oftheworldisnotMediterranean

MooreSE,etal.JHumNutrDiet.(2018);31:451-462.Tong,etal.BritishJournalofNutrition(2018),119,685–694

MediterraneanEatingPlan:Solutions• Notallnutrient-densefoodscostmore,itcouldbepossibletoconstructaMED-styleplanusinglowercostoptionsineachfoodcategory

•  Lessspendingonredmeat&sweetscouldbeusedforvegetables,fruitsandfish

• Providingshoppinglists,mealplanners,andrecipescanhelpassistindividualsfollowingMED-styleeatingplan

G.AlbuquerqueG,etal.PortoBiomedicalJournal.(2017)2,115-119.

MooreSE,etal.JHumNutrDiet.(2018);31:451-462.Tong,etal.BritishJournalofNutrition(2018),119,685–694

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Real World Strategies: Mediterranean Eating Plan

Nutsasasnack(inmoderation)

Moreplant-basedfats:Avocado,nuts,seeds,olives

Cookingathomemore

Trymoremeatlessmeals,ordecreasingredmeatintake

Rosalba

• 39yoF,pre-DM.BMI36.• A1c6.3%,fastingBG117• Herhusbandhasdiabetes,shewouldliketopreventitifshecan

• Social:homewithkidsduringtheday,worksnightsatanactivejob

• Lost10lbslastyearwhensheatelesstortillas&rice;shethenstoppedlosing.Shebecamediscouragedandreturnedtohernormaleatinghabits.

WhicheatingplanwouldbethebestoptionforRosalba?

Rosalba’shusbandhasbeentellinghertoeatlikehedoesforyears.He’sbeenfollowingalow-fatplansincehisheartattack.Shecoulddothis,butdoesn’twanttoadmithe’sright.Shehasheardaboutlow-carb,butisworriedthateverythingsheeatsisacarbohydrate.Herbosstoldheraboutintermittentfastingandhowitcuredhisfather’sdiabetes.Shewantsmoreinformationonhowthisworks.

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WhicheatingplanwouldbethebestforRosalba?

Low-fatLow-carbohydrateIntermittentFasting

Meta-analysis of 11 cohort studies showed a low-carbohydrate pattern did not have a lower

risk of developing DM2 than a high-carbohydrate pattern.

Need more research on IF for DM prevention

NotoH,etal.JofGenandFamMed.Vol17(1);2016.

Whatislow-fateating?

Typically20-30%(orless)ofcaloriesfromfat

2000caloriediet=40-60gramsfat/day

Low-fatEatingforDiabetesPrevention

•  FinnishDiabetesPreventionStudy:<30%calsfromfatPLUS30minofdailymoderateactivityresultedin:

•  Moreparticipantsachieving>5%weightloss•  Riskfortype2diabeteswasreducedby58%

• USDiabetesPreventionProgram(DPP):~25%ofcalsfromfatPLUS150minPA/wkresultedin:

•  58%reducedincidenceofdevelopmentofDM2,DESPITEonly38%meetingthe7%weightlossgoal

Tuomilehto J. N Engl J Med 2001; 344:1343-1350.

Studiesbothcombinedwithphysicalactivity–difficulttoseparatetheindividual

effectsonDMprevention

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LowFatEatingPlan:Concerns

• Reductioninfatusuallyreplacedbyincreaseincarbohydrate

• Mediterraneandietshowsusthathigher(plant)fatcanbecardioprotective

• Low-fatmealsmayresultinlowersatiety

LowFatDiet:Solutions• Reducefatandincreasefiber(offerideas!)

• Provideeducationonhealthyfatchoices

• Managesatietyviaincreasedfiberorpost-mealhungermanagement

Real World Strategies: Low Fat

Decreasingintakeofhigh-fatdairy

Cookinghighfatmeatslessfrequently

Lessfastfoodordifferentchoicesatfastfood

Replacinghighfatsnackswithhighfibersnacks

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Kevin

• 29yoM,DMx4years.BMI37;A1c8.8%• Metformin1000unitsBID;glipizide2mgBID

• Social:Workssecurityforprosportsteam• HeandfiancéehavedoneWhole30&Paleodietsasmonthlychallengeswitheachotheroverthepastyear.Worksforamonth,thentheygobacktoregulareating.

• Wantstolose40lbsbeforeweddingin3months

WhatisthebesteatingplanforKevin?

HehastriedPaleobefore,andcouldseehimselfdoingthisdietagain,helikedtheamountofmeatinvolved.Hisfiancéehasbeenwantingtodoavegetarian/veganchallengewithhim,buthe’sbeenputtingitoffformonths.TheFacebookgroupheisamemberofhasbeentalkingabouttheketogenicdiet,andtheamountofweighttheyhavelosthasbeenappealingtohim.

Insufficient data that these eating plans result in

significant weight loss in those with DM

WhatisthebesteatingplanforKevin?

PaleoVegetarian/VeganLowcarb/Ketogenic

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Whatisalow-carbohydrateeatingplan?

Whatislow-carbohydrateoftendefinedas? <45%fromcarbohydrate

Whatishigh-carbohydrateoftendefinedas? >45%fromcarbohydrate

Firstproblemwithlow-carbohydrateresearch:

• Analysisof36RCT’s(lowCHOvslowFAT):lowCHOimprovesA1cmorethanlowfatinthosewithdiabetes

• NodifferencewhenfollowedouttotwoyearsVanZuuren,E,etal.AmerJourofClinNutr,Vol108(2),2018.

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LowCarbOutcomes• Analysisof25RCT’s(lowCHOvshighCHO):greaterA1creductionswhen<20%ofcaloriesarefromcarbohydrate

•  Lowerthecarbohydrate=greaterbloodglucoselowering

•  Significantreductionsat3and6months• Nosignificantdifferencebetweenlow-carbandmoderatecarbohydratewhenfollowedoutto12+months

SnorgaardO,etal.BMJOpenDiabetesResearchandCare2017.Sato,etal.PLOSOne,Dec4;12(12):2017.

Ex)2000caloriediet:100gCHOperdayorless

Ex)1200caloriediet:60gCHOperdayorless

Whatisaketogeniceatingplan?

• Highfat:65-80%oftotalcalories

• Moderateprotein:0.8-1.2g/kg[ideal]bodyweight

• Verylowcarb:<50-60g/day5-15%ofcalories

KetogenicEating:Outcomes

• 34adultsw/DM/pre-DM:16onketovs18onlow-fat

• KetoreducedA1c(6.6%to6.1%)morethanlow-fat(6.9%to6.7%)

• Ketoreducedweight(-7.9kg)morethanlow-fat(-1.7kg)

• Largerreductionsinuseofsulfonylureas&DPP4sinketogroup

Limitations:• Only12monthstudy• Participantsattended19classesover12months

Saslow,etal.NutritionandDiabetes.(2017)Vol7:304-309.

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KetogenicEating:Outcomes

• 349adultsw/DM2:262chosetofollowketogeniceatingplanplusbehaviorchangecoachingwhile87incontrolgroupchosetocontinueusualcare

•  Ketogenicgroup:at12months:A1c(7.6%à6.3%),weight(-13.8kg),TG,LDL,BPandmedicationrequirementslower

• Studynotrandomized• Notjustketogenic:Individualizedhealthcoaching,on-siteorweb-basedclasses,onlinecommunitysupport,andremotecareteamprovidingmonitoring,education,andcommunicationviaphoneapp

HallbergS,etal.DiabetesTher(2018)9:583-612.

KetogenicEating:Concerns• NutrientQuality

•  LowerinvitaminsD,A,K,C,folate,calcium,potassium&fiber• Constipation• Hydration

• Dividebodyweight(lbs)inhalfforfluidgoal240lbs/2=120ouncesor~15cups/day

• Keto“flu”• Cost

KetogenicEating:Concerns• Kidneydisease:Ketonotrecommended

• NostudiesdoneonketogeniceatinginindividualswithCKD+DM

• Cardiovascularoutcomes:•  Saturatedfatintaketypicallyincreasesandfiberintakedecreases• Nolong-termstudiesevaluatingriskforCVDeventswhenfollowingketoeatingplan

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CarbohydrateIntakeDistribution&Mortality

•  1999–2010NHANESdata;N=24,825•  Lowcarbintake:

•  32%morelikelytodieprematurelyfromanycause

•  51%morelikelytodiefromcoronaryheartdisease

•  50%morelikelytodiefromcerebrovasculardisease

•  35%morelikelytodieofcancer

SeidelmannSB,etal.TheLancetPublicHealth(2018).

MedicationAdjustmentsforKetogenicEating

• AvoidSGLT2-Imedications

• PossibleincreasedriskofeuglycemicDKA

• Reducedosesofinsulin&sulfonylureas

Real World Strategies: Lower-Carbohydrate Eating

Focusonliquidsourcesofcarbohydrate

Identifyingsourcesofaddedsugars/labelreading

Reducingportionsizesofhigh-carbohydratefoods

Increasingfiberandplant-basedfatintake

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Sidebar: SSB & ASB

SSB=SugarSweetenedBeveragesASB=ArtificiallySweetenedBeverages

SugarSweetenedBeverages&Juices

•  EatYourFood–Don’tDrinkIt!

•  “Don’tbeapassiveparticipantinthedigestiveprocess”MichaelPollan•  “Howmuchworkdoesittaketosucksomethingdownwithastraw?”AlisonEvert

Artificial Sweeteners

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Mossavar-Rahmani, et al. Stroke; 2019.

ASB and Stroke

•  IncreasedriskofischemicstrokeamongfrequentASBconsumersobservedamongblackwomenbutnotwhitewomen

•  FrequentASBconsumptionwasassociatedwithincreasedincidenceofstrokeonlyamongtheobese

•  Increasedriskofcoronaryheartdiseaseinwhitepostmenopausalwomen,butnotblackwomen.

•  AllcausemortalityincreasedamongnormalweightoroverweightfreqASBconsumers,butnotdefinitelyamongthosewhowereobese.

• CausalnatureoftheseASBandstrokeassociationisunclear•  Thosewhodrank>2ASBperdayweremorelikelytobeoverweightorobese,havelowerlevelsofexercise,higherenergyintakeandlowerdietquality,morehistoryofDM,MIorstroke

Artificial Sweeteners: Debate

• ASB=increasedsugarcravings/appetitestimulation?• ASBconsumption=caloriccompensation?• Weightgain?

•  Shorttermhumantrialsshowpromotionofweightloss•  Observationalstudies&rodentstudiesresultsyieldinconsistentresults

• Glucoseintolerance?•  Reversecausality–ASBconsumptionoftenoccursinlaterlife,possiblyduetoanalreadyincreasedriskofvasculardisease

• Gutmicrobiotachanges?

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Artificially Sweetened Beverages

Trevor

• 24yoM;DM1x9years.• BMI28.Interestedinweightloss.• A1c’sconsistently7-8%• Glargine38unitsandSSIaspartTID• Inactivesincegraduatingfromhighschool

• Worksasgeneralmanagerforrestaurant,typically60+hourweeks

WhatisthebesteatingplanforTrevor?

• LimitedornoresearchonDM1and:• Mediterranean• Vegetarian/Vegan• DASH• Paleo• Low-Fat• Low-carbohydrate(26-45%ofcaloriesfromcarbohydrates)

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LowCarbResearchinDM1Population• 10adultswithDM1;47gcarb/day;1weekstudy.

• VLChadlessglycemicvariability,moretimeineuglycemiaandrequiredlessinsulinwhencomparedtohighcarbdiet(>250gcarb/day).

• 48adultswithDM1;<75gcarb/day;f/uat3monthsand4years.

•  3months:weight,A1candTGreduced.HDLincreased.•  4years:weightandTGreturnedtobaseline;A1cremainedlower,HDLhigherthanbaseline

• Adherencerate48%• Nocomparisonorcontrolgroup

RanjanA,etal.DiabetesObesMetab.2017;19(10):1479-1484.

Nielsen J, et al. Diabetology & Metabolic Syndrome. 2012; 4(23).

EatingPlansforType1Diabetes:Summary

• Inadequateresearch• Verylow-carbohydrateeatingmayhavepotentialforimprovedglucosecontrol• Nolongterm(>2years)RCT’sconductedforanydietarypatternintype1diabetes

EatingPlansforType2Diabetes:Summary

•  Low-carbohydrateeating,especiallyverylow-carbohydrateeating,mayreduceA1candneedfordiabetesmedicationswhencomparedtohighercarbohydratediets

•  Difficultymaintainingpast12months

•  Limitedevidencetorecommendlow-fateatingtomanagetype2diabetes

• Mixedeffectsseenin:Mediterranean,vegetarian ,DASH,orintermittentfasting

•  Fewlongtermtrials(>2years)havebeenconductedinanydietarypattern

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EatingPlansforPrediabetes:Summary• Bestchoicesappeartobelow-fat,Mediterranean,orvery-low-carbohydrate

• Norandomizedcontrolledtrialhascomparedtheseagainsteachother• LowfatPLUSphysicalactivitystrongestevidence10-15yearsout

• EpidemiologicalstudiessuggestMediterranean,vegetarian,andDASHeatingpatternsresultinlowerriskofdevelopingtype2diabetes

• Mediterraneaneatingassociatedwith20%lowerriskofdevelopingtype2diabetes

•  IncreasedplantproteinanddecreasedmeatproteinreducedriskforDMby23-35%

EspositoK.Endocrine.2014Sep;47(1):107-16.VasantiSetal,AmerJourEpi,183(8)2016,715–728

LeeY,etal.Nutrients2017,9(6),603

Thankyou!MaureenChomko,RD,CDE

maureenc@neighborcare.org