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Alpana Shukla Part 1, Food Order Studies

In part 1 of this Exclusive Interview, Alpana Shukla talks with Diabetes in Control Medical Editor Joy Pape about the purpose and findings in the Food Order Studies.

Alpana Shukla, MD, MRCP (UK) is Assistant Professor of Research in the Division of Endocrinology, Diabetes & Metabolism at Weill Cornell Medical College in New York.

Transcript of this video segment:

Pape: Hi. I’m Joy Pape, Medical Editor with Diabetes in Control. We’re here today at the ADA 2018 Meeting and I have the privilege of interviewing my colleague, friend, Dr. Alpana Shukla, and we work together. She is the Assistant Professor of Research in Medicine, Director of Clinical Research at the Comprehensive Weight Control Center, Division of Endocrinology, and Diabetes & Metabolism at Weill Cornell Medicine in New York. Whenever I have to sign my name, I have to put that in. It’s quite a bit, but you’re the one doing such great work. So, why don’t you tell us a little bit about you and then I’ll ask you about the study.  

Shukla: Thank you, Joy. It’s such a pleasure. I’m delighted to be here today and share some of the research that we’ve been doing at our center. And as you know, one of the key areas of our research has been at looking at novel interventions for management of obesity and type 2 diabetes. And in this vein, we have been doing a series of studies which we have called the Food Order studies. We started this about three years ago and I want to share my thoughts and what we found so far about these studies.

Pape: So, this is the Food Order study. Okay. So, what do you mean by Food Order and what is its relevance to glycemic control?

Shukla: So, the term Food Order refers to the the nutrient sequence during a meal. And in particular, it refers to the order in which the carbohydrate component of the meal is actually consumed. So, we all know that the amount and the type of carbohydrate is a major determinant of the postprandial glucose response. In addition to that, the macro-nutrient composition of the meal, the amount of protein, fat, and fiber, all of these also favorably modify the post meal glucose. And accordingly, the current nutrition counseling that we offer patients with diabetes incorporates these principles and is personalized to achieve a low glycemic effect. Now, this is great and it does work provided patients can actually follow this advice. But we all know that in the real world patients have difficulty complying with reduced carbohydrate intake. And therefore, Food Order is an alternative strategy to mitigate the metabolic effects of carbohydrate. And in this vein, Dr. Louis Aronne, and I, and our entire team at the Comprehensive Weight Control Center, which includes you, Joy, we’ve been researching this field for the past three years. And we started by doing a first pilot study in 2015 where we had patients with type 2 diabetes who were well-controlled on Metformin come into our CTSC and eat the exact same meal. And the meal was like the kind of meal that people normally consumed in the real world. It had ciabatta roll and orange juice. It had vegetables as a salad and it had grilled chicken. And what we did was ask patients to consume the carbohydrate portion of the meal first, and then wait for 15 minutes, and then eat the chicken and vegetables. They came back a week later and they ate the exact same meal. And the only thing they did differently was to reverse the order in which they ate it. So, they ate the protein and vegetables first, they waited for 15 minutes, and then they had the bread and the orange juice. And I have to tell you that we had our students who were part of the research team strictly monitor all the patients, so that we insured that every patient ate everything each time. So, the whole experiment, as it were, was controlled for caloric as well as macronutrient composition, and this is what we found. So, if you look at this graph, you will see that the results are fairly remarkable.  We actually use this as part of the nutrition counseling that we offer every patient–

Pape: Yes, we do.

Shukla: — who’s seen at our center.

Pape: Yes, we do.

View study slides and graphs:

Shukla: Yes, Joy. You know this. And I can tell you that this picture speaks more than a thousand words. So, when we saw these results we were actually — we were surprised, very pleasantly surprised. We expected the results to be good, but this was more dramatic than what we thought. And so, we felt like that as being responsible researchers we should validate these results. We should try and understand the mechanisms. And we did the second study, when we actually had a bigger sample size and we had patients actually consumed the exact same meal again but over 180 minutes this time. And in addition to the two interventions that I previously described which was having the carbohydrate first or the carbohydrate last, we also had a third intervention which was having patients eat all meal components together as a sandwich which is the most common way in which people eat in the real world. And what did we find? So, if you look at this graph, you will see that once again we found that the glucose response when patients had the carbohydrate last, when they ate the bread last, was much lower, almost half of what it was when they had the bread portion first. When they had all the meal components together as a sandwich, the glucose levels were better than having the carbohydrate first. But somewhat closer, not as good as what we thought it would be. So, I think all in all these results actually confirmed what was our initial finding that the best way to actually attenuate, if you like, or reduce the effect of the carbohydrate consumed in a meal is to have it at the end of the meal.

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