Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

75 g Glucose
Metabolically Ìrreversible process
healthy Reversible process
System Approaches to Prevention, β-cell
gluc
Pathology
Risk factor

Management and Cure for Type 2 Diabetes

reversible
Visceral Muscle metabolic
dyslipidemia
adiposity inflexibility
adipose ectopic
inflammation Adipose IR
lipid overload

The nutritional
Ben vansystems
Ommen biology systemic
inflammation
Fatty liver Hepatic IR

solution in Type 2 Diabetes and Hepatic

inflammation High cholesterol
High glucose systemic

Cardiovascular Desease prevention gut

inflammation
fibrosis
LDL elevated
Insulin resistance

endothelial
and therapy". IBD
inflammation

Microvascular Atherosclerosis
Glucose toxicity β-cell failure

The flexible phenotype: the system is a shock damageabsorber

Hypertension

irreversible
(“phenotypic flexibility”)
Retinopathy
Stroke
Ben van Ommen Nephropathy

Brain
disorders
Cardiac Heart Myocardial
dysfunction failure infactions Nakatsuji, Metabolism 2009

Wopereis et al, Genes and Nutrition, Sept 2017

Wopereis et al, Genes and Nutrition, Sept 2017

Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

Personalized?

Brain Type 2 diabetes subgroups react differently on different diets

Low-fat diet
Adipose improves T2D subgroup glucose respose to Oral Glucose Tolerance Test
Mediterranean liver IS

[Glucose]
Adipose insulin diet improves T2D
Pancreas Gut (diagnosed)
resistance index muscle IS Mediterranean
diet improves T2D
Disposition index (non-diagnosed)
systemic IS

IGT & IFG

Vasculature IGT (muscle)
Liver
Hepatic insulin IFG (liver)
healthy
resistance index
0 30 60 90 120
time(min)
Muscle insulin Kidney
Muscle resistance index
Blanco-Rojo, Diabetologia, Oct 2015

Reversal of type 2 diabetes: normalisation of beta cell function in

association with decrease pancreas and liver triacylglycerol
Lim and Taylor, Diabetologia 2011 Nestlé Optifast
(46% carb, 33% protein and
20% fat, micronutrients)

3 portions of non starchy

vegetables
8 weeks 600 Kcal diet
Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet

Shai, NEJM 359 (2008) Decision tree used to determine type 2 diabetes subgroups

Intensive lifestyle coaching with advanced type 2 diabetes

patients 2 stages in cure:
Average Insulin trend
11 type 2 diabetic patients in 1 – reversal : Proper glucose control (easy if I hardly consume glucose)
advanced disease state entered into
an intensive program of lifestyle 2 – cure: Organ flexibility (= insulin sensitivity restored)
coaching:
- Motivational coaching
- Physical activity But what if I do not produce insulin anymore (beta-cell failure)?
- Healthy diet

Insulin dosing was reduced with 80%

in 3 weeks.

After three months, 10 out of 11

patients did not use insulin anymore.
Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

mitophagy
Muoio, Cell 159, 2014 Popa and Mot, doi 10.5772/56467

Fasting Mimicking Diet and beta-cell regeneration

… and NONE of them aims

at CURING the disease …!
Cheng, Longo, Cell 168, 2017
Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

The role of medication: it will not cure type 2 diabetes The role of medication

Now: suppress glucose:

Sometimes: retreat if lifestyle works

Future: precision medicine and precision nutrition

Quercetin,
Se, Zn, …
carotenoids

Stannols,fibre

Carnitine, Choline, … Low glycemic index

Omega 3/6 FA
polyphenols
Antho cyanins

epicathechins
procyanidins
Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

Four Behavioural changes phases Each person deserves the right method for the right phase

Behavior Change Technique Initial Continued Maintenance Habit

(93 different techniues) response response
Prompt practice
Stress management
General communication skills training
Initial Continued Environmental restructuring
maintenance habit Model/demonstrate the behavior
response response Goal setting (outcome)
Relapse prevention/coping planning
Facilitate social comparison
Initial effort to Continue effort to Sustained effort to Self pertetuating Goal setting (behavior)

change behavior establish behavior continue newly pattern of behavior Action planning
Provide feedback on performance
established behavior Barrier identification/problem solving
Provide instruction
Teach to use prompts/cues
Provide normative information about others’ behavior

Plan social support/social change

Rothman (2009) Disentangling Provide rewards for behavior
behavioural initiation and behavioural maintenance
Prompt review of behavioral goals
Shaping

The real value of MY health data:

how can this data work for me?
Program Components that Support Diabetes-
related Behavior Change Health Data Cooperative as legal entity
• Patient Education Classes that valorizes my own health data.
• “Prescriptions” for Food and Exercise
• Food Shopping Tours
• Skills Training in Healthy Food Preparation/Cooking Holland Health Data Coöperatie
• Community Food Pantries
• Physical Activity Classes
• Provider Workshops
• Mobile Technology Program
Doctors ch
Research Retail Heal Service
Health
Behavior Change Theoretical Frameworks at all Infant Providers
levels formula Farmers
rmer
• Patients Developers Hospitals producers market
• Family, Friends and Small Groups food Government
Go
• Organizations, Communities, and Culture Schools & Education
daycare industry
• Government, Policies, Large Systems www.mdog.nl
Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

Social system Physiological system Healthcare system

Precision medicine
T2 Diabetes is a ‘systems disease’

Obesogenic environment Multiple interacting

Precision Limited engagement with
physiological processes
Conflicting stakeholder interests
No focus on prevention
health status T2 Diabetes initiates when
nutrition Social interactions are
one or more biological
processes lose flexibility
Short term financial vision

important for outcome

T2 Diabetes needs a ‘systems solution’

Optimal coaching, participation Diagnosis of all relevant processes Patient empowerment
Health (care) and communication and predispositions
Implement in regional setting
Integration of medical, social, Goal: regain flexibility in all relevant
Acceptance by accreditation
economical and mental processes, exploiting diet, lifestyle,
solutions medication and genetics where
Research relevant

The financial aspects … € 131k

Total costs of a patient
now, and when treated with Lifestyle as Medicine THE ‘LIFESTYLE AS MEDICINE’ TIMELINE
cost are 13x lower than € 121K saving!
Total potential of
current practice LaM (Euro’s) Intense (cure) phase Citizen (habit) phase
for a patient who is treated with
€ 35k start 2 wks 12 wks 1 year
success at the moment of € 30K saving
diagnosis. € 10k
€ 9k Aim: cure by lifestyle Aim: maintain changed lifestyle
€ 5k € 3k
Intense personalized lifestyle program All aspects of new lifestyle have settled into new
As-is
is LaM As-is
As-is LaM As-is
As-is LaM habits
- Start motivational coaching
5. Life style costs € 0.2 € 10 € 0.1 €5 €- €3
- Health literacy - All tools are personalized and connected to a
4. Employability costs € 76 €- €6 €- €- €-
3. Complications & comorbidities
sustainable support system
€ 19 €- €8 €- €2 €- - Optimal diet
2. Direct medical costs € 11 €- €5 €- €2 €- - Connected to one personal health data system
1. Medication € 25 €- € 16 €- €5 €-
- Physical activity (Health Data Cooperative)
- Introduction e-health - Social, economic and regulatory environment
cooperates in habituation
(Age 57) (Age 67)
Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

systems interventions need systems diagnosis systems interventions need systems diagnosis
Metabolically Metabolically
healthy healthy

Visceral Muscle metabolic government

adiposity
dyslipidemia
inflexibility diet obese
leadership

adipose ectopic Healthcare

inflammation Adipose IR system Food industry research
lipid overload

Fatty liver
Fat Hepatic IR Insurance comp.
Insura regulation
systemic Healthcare
inflammation
inf economy

Hepatic Healthcare
inflammation High cholesterol bankruptcy comorbidities
systemic Health data
High glucose patient
gut Insulin resistance Healthy ownership
inflammation LDL elevated
ted communities work
k health

endothelial Healthcare staff

inflammation education

We have the same challenge

So let`s face it together

Regional Symposium on Diabetes - Current Science and Multi-Stakeholder Approaches to Prevention & Management, October 4-5, 2017, Singapore

Hanno Pijl Suzan Wopereis

Maurice Bizino Iris de Hoogh
Hildo Lamb Koen Hogenelst
Gerault Eggermont Hanneke Molema
Niels Chavannes Femke Hoevenaars
Marise Kasteleijn Wilrike Pasman
Mattijs Numans Jildau Bouwman
Andrea Evers (UL) Tim van de Broek
John Verhoef (HL) Thanks to Marjan van Erk
Robert Kleemann
Eugene van Someren
André Boorsma
Wilma Otten
Pepijn van Empelen
Hilde van Keulen

Health Coach Un Cordoba Tufts University

Luuk Simons José Lopez-Miranda José Ordovas
Bas Gerritsen Pablo Pérez-Martinez Larry Parnell
Javier Delgado-Lista