Nutrition therapy

The Impact of Dietary Habits on Sleep Deprivation and Glucose Control in School-Aged Children with Type 1 Diabetes: A Cross-Sectional Study

Diet plays a crucial role in managing type 1 diabetes (T1DM). Background/Objectives:This study aimed to determine the impact of nutritional habits on sleep deprivation and glucose control in school-aged children with T1DM. Methods: In this cross-sectional study, nutritional habits and sleep deprivation were assessed in 100 school-aged children with T1DM, aged 7-13 years. The Dietary Habits Index and the Sleep Deprivation Scale for Children and Adolescents were used to evaluate nutritional habits and the level of sleep deprivation. Patients' sociodemographic and nutritional variables were collected through researcher-composed questionnaires. HbA1c levels over the past 6 months were obtained from the patient data system. Results: The study found a moderately strong positive correlation between the Dietary Habits Index score and HbA1c (p < 0.001), with 28% of the variation in HbA1c explained by changes in the Dietary Habits Index score. However, no correlation was found between the Dietary Habits Index score and the level of sleep deprivation. Conclusions: The nutritional habits of school-aged children with T1DM may affect glucose control and sleep deprivation. Therefore, it is important to educate children with T1DM on making healthy food choices to manage their condition effectively.

Menus prescribed for diabetes management by Malawian referral hospitals are loaded with calories from carbohydrates and may worsen diabetes condition

Background: Management of diabetes demands reduction of carbohydrates and moderation of total calories, fats and protein to promote weight loss while controlling postprandial blood glucose. Hospitals prescribe menus to diabetic patients to achieve these reasons. Whether these menus provide meals that help improve diabetes outcome remains unknown. Aim: Therefore, this study assessed six menus from six different referral hospitals in Malawi. Method: We formulated three separate diets (n = 3) encompassing breakfast, 10 am snack, lunch, 3 pm snack and super that a diabetic person would consume in a day as prescribed by each menu. We developed nutritionally adequate meals based on foods listed on the menu. We calculated, using the Malawi Food Composition Table (MFCT), total available carbohydrates, energy, protein, total fats, SAFA, MUFA and PUFA that each diet provides. We averaged the nutrient content from the three diets. Results: Menus from QECH and ST Joseph Mission Hospital provide significantly higher total carbohydrates (p = 0.001), total energy (p = 0.000) and fats (p = 0.01) but contain similar proteins (p = 0.761). The proportion of energy from carbohydrates for all the menus is very high and ranges from 68-81% while protein and fat proportions are lower and range from 7-16% and 7-20%, respectively. Conclusion: These menus have high propensity to increase postprandial blood glucose and promote weight gain that could be harmful to a diabetic person. All the menus deviate from a somehow recommended energy contribution of approximately 50:25:25 from carbohydrates, fat and protein, respectively.

Effectiveness of a dietician-led intervention in reducing glycated haemoglobin among people with type 2 diabetes in Nepal: a single centre, open-label, randomised controlled trial

Background

Nutrition education and counselling are considered a cornerstone for the management of type 2 diabetes (T2D). However, there is limited research related to the management of T2D through dietary approach, particularly in low-income and middle-income countries (LMICs) like Nepal. This study assessed the effectiveness of a dietician-led dietary intervention in reducing glycated haemoglobin (HbA1c) levels among people with T2D.

Methods

An open-label, two-armed, hospital-based, randomised controlled trial was conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Participants were randomly assigned to either dietician-led dietary intervention group (n = 78) or usual care control group (n = 78). People with type 2 diabetes with HbA1c >6.5% and aged 24-64 years were included in the study. The primary outcome was a change in HbA1c level over six months, and secondary outcomes included changes in biochemical and clinical parameters, Problem Areas in Diabetes (PAID) score, diabetic knowledge, dietary adherence, and macronutrient intake level. Data were analysed using an intention-to-treat approach. This trial is registered with ClinicalTrials.gov, NCT04267367.

Findings

Between August 15, 2021 and February 25, 2022, 156 people with type 2 diabetes were recruited for the study, of which 136 participants completed the trial. At six months of follow-up, compared to baseline values, the mean HbA1c (%) level decreased in the intervention group by 0.48 (95% CI: -0.80 to -0.16), while it increased in the control group by 0.22 (95% CI: -0.21 to 0.66). In an adjusted model, the reduction in HbA1c (%) levels for the intervention was 0.61 (95% CI: -1.04 to -0.17; p = 0.006). In addition, fasting blood glucose was decreased by 18.96 mg/dL (95% CI: -36.12 to -1.81; p = 0.031) after the intervention. The intervention resulted in the reduction of BMI, waist and hip circumference, PAID score, dietary adherence, and macronutrient intake in the intervention group compared to the control group.

Interpretation

The dietician-led intervention improved glycaemic control, improved macronutrient intake, and clinical outcomes among people with type 2 diabetes. The dietician-led intervention may be considered for diabetes management in LMICs.

Funding

The research was funded by the University Grants Commission (UGC), Nepal.

Canadian Registered Dietitians' Utilization of the 2018 Diabetes Canada Nutrition Therapy Clinical Practice Guidelines: A Cross-sectional Study

OBJECTIVES

Our aim in this work was to ascertain Canadian registered dietitians' (RDs) use of the 2018 Diabetes Canada nutrition therapy (NT) recommendations and to identify the degree of agreement with facilitator-to-use statements.

METHODS

A national 28-item anonymous cross-sectional survey of RDs who counsel people with diabetes was conducted.

RESULTS

Three hundred sixty RDs responded to the survey, but some questions had fewer responses. Mean age of respondents was 36.8±10.1 years and 51.3% were certified diabetes educators (CDEs). Energy/macronutrient recommendations used most were regular timing/spacing of meals (85%), 30 to 50 g/day dietary fibre intake (71%), and maintaining a low glycemic index (65%). Mediterranean and Dietary Approaches to Stop Hypertension (DASH) dietary patterns had similar utilization rates as macronutrient distribution ranges, at 50% to 60%. Specific food recommendations were used most often, with the emphasis on fruits/vegetables and whole grains at 92% and 86%, respectively. Of the special considerations for people on insulin, regular meals/meal spacing was the recommendation used most often (88%). The statements "I trust the content …" and "I understand the scientific basis …" of the NT chapter were the internal facilitators most agreed with, at 86% each. The least agreed upon external facilitators were "my workplace encourages me to use the NT chapter," at 54%, and "I learned about the NT chapter in my formal education," at 44%. CDEs had significantly higher agreement on 12 of the 21 facilitator statements compared with non-CDEs.

CONCLUSIONS

Canadian RDs are utilizing the NT guidelines, including the new dietary patterns. Simple, easy-to-implement recommendations, such as specific foods and timing/spacing of meals, were used most frequently. Opportunities for increased use could include encouraging dietetic training programs and worksites to promote utilization of CPGs in practice.

Update on Nutrition in Diabetes Management

Nutrition is a corner stone of diabetes management, and should be regarded as fundamental to achieving blood glucose control. The current advice for nutrition in diabetes management is discussed, with a focus on body weight, macro and micro nutrients, foods and food groups, dietary patterns, and the lifestyle context. More recent evidence on topics such as body weight and dietary patterns indicate flexibility in what can be recommended, which enables patient preference and may aid adherence. Importantly, a healthy diet for those with diabetes is also appropriate to recommend for their families and the general population.

Diet Therapy and Public Health

A major threat to the achievement of the Sustainable Development Goals and Universal Health Coverage continues to be malnutrition [...].

Trends in dietary macronutrient composition and diet quality among US adults with diagnosed and undiagnosed elevated glycemic status: a serial cross-sectional study

BACKGROUND

Knowledge of glycemic status may affect dietary intake for subjects with diabetes and prediabetes.

OBJECTIVES

We aimed to determine whether trends of macronutrient intake and dietary quality differed by diagnosis of glycemic status among US adults with diabetes and prediabetes.

METHODS

Data from NHANES 1999-2016 were analyzed. Diagnosed cases were established by self-report, and undiagnosed cases were defined by laboratory criteria (glycated hemoglobin ≥ 5.7%, fasting plasma glucose ≥ 100 mg/dL, or 2-h oral-glucose-tolerance test ≥ 140 mg/dL). A difference-in-differences model was used to compare the temporal trends between the 2 groups.

RESULTS

There were 7502 diagnosed and 12,974 undiagnosed cases with elevated glycemic status included in the study. During 1999-2016, the intake of low-quality carbohydrates was lower, whereas intakes of high-quality carbohydrates, animal protein, plant protein, and unsaturated fat and the Healthy Eating Index 2015 (HEI-2015) score were higher, among the diagnosed cases than among the undiagnosed cases (P < 0.001 for all). However, in the trend analyses from 1999 to 2016, the increase in intake of high-quality carbohydrates was smaller among the diagnosed cases than among the undiagnosed cases (difference: -1.16%; 95% CI: -1.82%, -0.50%; P = 0.001). Moreover, the decrease in low-quality carbohydrate intake was smaller (difference: 0.79%; 95% CI: 0.01%, 1.57%; P = 0.05) and the increase in saturated fat intake was larger (difference: 0.44%; 95% CI: 0.08%, 0.79%; P = 0.02) among the diagnosed cases than among the undiagnosed cases. A significant difference of temporal trends in the HEI-2015 score between the diagnosed and undiagnosed cases was also observed, in favor of the undiagnosed cases (difference: -2.56; 95% CI: -3.71, -1.41; P < 0.001).

CONCLUSIONS

Although dietary habits among adults with diagnosed diabetes and prediabetes were better than those among the undiagnosed cases, these advantages have been diminishing during the past 2 decades.

The effects of sesame, canola, and sesame-canola oils on cardiometabolic markers in patients with type 2 diabetes: a triple-blind three-way randomized crossover clinical trial

AIMS

To compare the effects of replacing regular dietary oils intake with sesame (SO), canola (CO), and sesame-canola (SCO) oils (a novel blend), on cardiometabolic markers in adults with type 2 diabetes mellitus (T2DM), in a triple-blind, three-way, randomized, crossover clinical trial.

METHODS

Participants were assigned to receive SO, CO, and SCO in three 9-week phases (4 weeks apart). Cardiometabolic makers (serum lipids, Apolipoprotein, cardiovascular risk scores, kidney markers, and blood pressure) were considered at the beginning and the end of intervention phases.

RESULTS

Ninety-two, ninety-five, and ninety-five participants completed the SO, SCO, and CO periods, respectively. After CO consumption, serum Apo A-1 concentrations were significantly higher compared with the SCO period in the whole population (p < 0.05). A considerable reduction in visceral adiposity index values was seen in the CO compared with the SO period in males (p < 0.05). Serum high-density lipoprotein concentration was also significantly higher after the SO intake compared with SCO in females (p < 0.05). The between-period analysis showed a substantial reduction in diastolic blood pressure in the SCO period compared with the CO and SO periods and lower systolic blood pressure after SCO versus CO intake in males (p < 0.05).

CONCLUSIONS

Canola oil might protect CVD through improving Apo A-1 levels in patients with T2DM (particularly in females) and visceral adiposity index in male patients. However, the blend oil might beneficially affect blood pressure in men. Future sex-specific studies might warrant the current findings.

REGISTRY OF CLINICAL TRIALS

This trial was registered in the Iranian Registry of Clinical Trials (IRCT, registration ID: IRCT2016091312571N6).

Dietary Counseling Aimed at Reducing Sugar Intake Yields the Greatest Improvement in Management of Weight and Metabolic Dysfunction in Children with Obesity

Pediatric obesity is a significant public health problem, the negative outcomes of which will challenge individual well-being and societal resources for decades to come. The objective of this study was to determine the effects of dietary counseling on weight management and metabolic abnormalities in children with obesity. One hundred and sixty-five patients aged 2−18 years old were studied over a two and a half year period. Data collected included demographic information, anthropometric assessment, laboratory measurements, and self-reported eating behaviors. Dietary counseling was provided at each visit. The data was analyzed from the first and last visits and the subjects were retrospectively divided into responders and non-responders based on a decrease in their BMI. After receiving dietary guidance, BMI decreased in 44% of the children, and these participants were classified as responders (BMI-R; n = 72). However, BMI did not improve in 56% of the participants, and these were classified as non-responders (BMI-NR; n = 93). At the initial visit, anthropometric measurements and dietary habits were similar between the groups. At the time of the last visit, mean change in BMI was −1.47 (SD 1.31) for BMI-R and +2.40 (SD 9.79) for BMI-NR. Analysis of food intake revealed that BMI-R significantly improved their dietary habits (p = 0.002) by reducing the intake of sugar-sweetened beverages (p = 0.019), processed foods (p = 0.002), sweets (p < 0.001), and unhealthy snacks (p = 0.009), as compared with BMI-NR. There was no change in the intake of second helpings, portion sizes, skipping meals, frequency of meals eaten at school, condiment use, intake of fruits and vegetables and consumption of whole grains between the groups. BMI-R also achieved an improvement in fasted glucose (p = 0.021), triglycerides (p < 0.001), and total cholesterol (p = 0.023), as compared to BMI-NR. In conclusion, children with obesity who were able to decrease their BMI implemented a significant reduction in consumption of foods with high sugar content. Focusing on reducing sugar intake may yield the biggest impact in terms of weight management and the improvement of metabolic abnormalities.

Adherence to the Dutch healthy diet index and change in glycemic control and cardiometabolic markers in people with type 2 diabetes

Purpose

To investigate whether adherence to the Dutch Healthy Diet index 2015 (DHD15-index) is associated with change in glycemic control and cardio-metabolic markers over two-year follow-up in people with type 2 diabetes (T2D).

Methods

This prospective cohort study included 1202 individuals with T2D (mean age 68.7 ± 9.0 years; 62.5% male; mean HbA1c 53.8 ± 11.7 mmol/mol) from the Diabetes Care System cohort. Baseline dietary intake was assessed using a validated food frequency questionnaire, and adherence to the DHD15-index was estimated (range 0–130). HbA1c, fasting glucose, blood lipids (HDL and LDL cholesterol, cholesterol ratio), blood pressure, estimated glomerular filtration rate (eGFR), and BMI were measured at baseline, and after one- and two-year follow-up. Linear mixed model analyses were conducted to examine the associations between adherence to the DHD15-index and glycemic control and the cardio-metabolic outcomes, adjusting for energy intake, sociodemographic and lifestyle characteristics, and medication.

Results

Highest adherence (T3) to the DHD15-index was not associated with change in HbA1c, compared to lowest adherence (T1) [β_T3vsT1: 0.62 mmol/mol (− 0.94; 2.19), P_trend = 0.44]. There was a non-linear association with fasting glucose, where moderate adherence (T2) was associated with a decrease in fasting glucose [β_T2vsT1: − 0.29 mmol/L (− 0.55; − 0.03), P_trend = 0.30]. Higher adherence to the DHD15-index was associated with a decrease in BMI [β_10point: − 0.41 kg/m² (− 0.60; − 0.21), P_trend < 0.001], but not with blood lipids, blood pressure or kidney function.

Conclusion

In this well-controlled population of people with T2D, adherence to the DHD15-index was associated with a decrease in BMI, but not with change in glycemic control or other cardio-metabolic parameters.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-022-02847-6.

Antipsychotic-Related Risks of Type 2 Diabetes Mellitus in Enrollees With Schizophrenia in the National Basic Public Health Service Program in Hunan Province, China

BACKGROUND

Antipsychotics contribute to the development of type 2 diabetes mellitus (T2DM) in individuals with schizophrenia. However, the extent of the relationship between antipsychotic use and T2DM varies in different settings, and the magnitude of the drug-specific effects fluctuates widely. This study aimed to explore the association of T2DM with antipsychotic use among enrollees with schizophrenia in China's National Basic Public Health Service Program (NBPHSP) and the drug-specific relationship with T2DM among patients receiving antipsychotic monotherapy.

METHODS

We recruited diabetes-free patients with schizophrenia who were enrolled in the NBPHSP of Hunan Province from October 2009 to December 2018. The participants were classified into the following three groups: regular antipsychotic use, intermittent antipsychotic use, and antipsychotic-free groups. The patients were followed up until they received a T2DM diagnosis or until April 2019. Cox regression models were constructed to calculate the overall and drug-specific hazard ratios (HRs) to determine the antipsychotic-T2DM relationship. Interactive and subgroup analyses were performed to assess the heterogeneity of the effects across subgroups.

RESULTS

A total of 122,064 NBPHSP enrollees with schizophrenia were followed up for 1,507,829 cumulative person-years, and 2,313 (1.89%) patients developed T2DM. Patients who regularly and intermittently used antipsychotics had 117% (HR: 2.17, 95% CI: 1.83-2.57) and 53% (HR: 1.53, 95% CI: 1.23-1.90) higher risks of developing T2DM than antipsychotic-free patients, respectively. Regarding monotherapy, the T2DM risk increased by 66, 80, 62, and 64% after the regular use of clozapine, risperidone, chlorpromazine, and perphenazine, respectively. In addition, the antipsychotic-related risk of T2DM decreased as the patient's baseline body mass index, and baseline fasting plasma glucose level, as well as the dietary proportion of animal products, increased.

CONCLUSION

Antipsychotics, especially clozapine, risperidone, chlorpromazine, and perphenazine, increased the T2DM risk among NBPHSP enrollees with schizophrenia. Mental health officers should accurately identify enrollees at a high risk of T2DM and take appropriate preventive measures to reduce the incidence of T2DM among patients with schizophrenia.

Meal Replacements for Weight-Related Complications in Type 2 Diabetes: What Is the State of the Evidence?

Comprehensive lifestyle management is a fundamental aspect of diabetes care. Clinical practice guidelines for the nutritional management of diabetes have evolved considerably over the last 25 years shifting from a focus on single nutrients to food- and dietary pattern-based recommendations. Use of meal replacements as a temporary short-term strategy to induce weight loss and then transitioning to a healthier dietary pattern (e.g., Mediterranean or Portfolio) for weight loss maintenance fits well with this new shift in focus of clinical practice guidelines. As adherence is the most important determinant for attaining the benefits of any diet, health professionals should recommend evidence-based dietary patterns (including meal replacements) that align best with the patient's values, preferences, and treatment goals.

Determinants of blood glucose control among people with Type 2 diabetes in a regional hospital in Ghana

Aims

To assess the determinants of glycaemic control among patients with Type 2 diabetes mellitus (T2DM) presenting at the Greater Accra Regional Hospital, Ghana.

Methods

The study employed semi-structured questionnaires and review of clinical records of patients 16 years and above with Type 2 Diabetes.

Results

The mean age of participants was 56.6 ± 13.8 years, with majority (71.6%) being females. A total of 161 (59.4%) of patients had poor glycaemic control (HbA1c ≥8.1%; 95% CI: 53.6 to 65.3%). Poor glycaemic control was significantly associated with high body mass index of the patient (AOR 13.22; 95% CI: 1.95 to 89.80), having only elementary education (AOR 5.22, 95% CI 2.12–12.86, p<0.0001) and being on insulin therapy (AOR 2.88; 95% CI: 1.05 to 7.88). On the other hand, seldom coffee intake (AOR: 0.27; 95% CI: 0.11 to 0.64), high physical activity (AOR 1.57, 95% CI 1.06–2.35, p = 0.025) and having a cardiovascular disease (AOR: 0.15; 95% CI: 0.05 to 0.46) appeared to positively influence glycaemic control. Self-monitoring of blood glucose and diet interventions did not appear to influence glycaemic control.

Conclusions

The study results showing that a high proportion of patients attending the Diabetes Clinic with uncontrolled diabetes has serious implications for the management of T2DM diabetes as it suggests that current hospital-based treatment measures are less effective. Comprehensive management of T2DM targeting all the key factors identified in this study and incorporating a multispectral collaborative effort based on holistic approach, combined with non-pharmacological components are strongly warranted.

'Old Is Gold': How Traditional Indian Dietary Practices Can Support Pediatric Diabetes Management

Nutrition is crucial for maintaining normal growth, development, and glycemic control in young people with diabetes (PwD). Undue restrictions cause nutrient deficiencies as well as poor adherence to meal plans. Widespread availability of low-cost, ultra-processed, and hyperpalatable food is further damaging. Most families struggle to find ways to provide nutritious, yet attractive, food with a low glycemic index (GI). India is one of the oldest continuous civilizations with a rich and diverse cultural and culinary heritage. Traditional dietary practices, including the centuries-old 'Thali' (meaning plate) concept, emphasize combinations (grains, lentils, vegetables, dairy, spices, prebiotics and probiotics, and fats) of local, seasonal, and predominantly plant-based ingredients. These practices ensure that all of the necessary food groups are provided and fit well with current evidence-based recommendations, including the International Society for Pediatric and Adolescent Diabetes (ISPAD) 2018 Guidelines. Techniques for the preparation, cooking, and preservation of food further impact the GI and nutrient availability. These practices benefit nutrient density, diet diversity, and palatability and thus improve adherence to meal plans and glycemic control. This narrative review describes the ancient wisdom, food composition, and culinary practices from across India which are still valuable today. These may be of benefit worldwide to improve glycemic control as well as quality of life, especially in PwD.

Dietary Glycaemic Index Labelling: A Global Perspective

The glycaemic index (GI) is a food metric that ranks the acute impact of available (digestible) carbohydrates on blood glucose. At present, few countries regulate the inclusion of GI on food labels even though the information may assist consumers to manage blood glucose levels. Australia and New Zealand regulate GI claims as nutrition content claims and also recognize the GI Foundation’s certified Low GI trademark as an endorsement. The GI Foundation of South Africa endorses foods with low, medium and high GI symbols. In Asia, Singapore’s Healthier Choice Symbol has specific provisions for low GI claims. Low GI claims are also permitted on food labels in India. In China, there are no national regulations specific to GI; however, voluntary claims are permitted. In the USA, GI claims are not specifically regulated but are permitted, as they are deemed to fall under general food-labelling provisions. In Canada and the European Union, GI claims are not legal under current food law. Inconsistences in food regulation around the world undermine consumer and health professional confidence and call for harmonization. Global provisions for GI claims/endorsements in food standard codes would be in the best interests of people with diabetes and those at risk.

Comparing Associations of Dietary Energy Density and Energy Intake, Macronutrients with Obesity in Patients with Type 2 Diabetes (JDDM 63)

To investigate the association between dietary energy density (DED) and obesity in people with type 2 diabetes mellitus. Moreover, we compared the strength of the associations of DED with intake of energy and macronutrients in terms of obesity as well as nutritional factors that have long been used for medical nutritional therapy. Cross-sectionally investigated were 1615 outpatients with type 2 diabetes who attended 26 clinics nationwide with diabetes specialists. Odds ratios (ORs) were calculated for the association between obesity and DED, energy, and macronutrients by quintile categories and a 1 SD increment with adjustment for potential confounders. β coefficients were calculated for the association between body mass index (BMI) and each nutritional factor by 1 SD increments in nutritional values. Multi-adjusted OR for obesity between extreme quintiles of DED was 2.99 (95% confidence interval (95% CI): 2.01-3.12). Conversely, the ORs did not differ significantly according to the quintiles of other nutrient factors. Multi-adjusted β coefficient of BMI per 1 SD according to DED was far higher than those of other nutrient factors (β coefficient 0.65, 95% CI: 0.41-0.88). These findings indicated that DED in persons with type 2 diabetes was positively associated with BMI and the prevalence of obesity. DED was also much more potently associated with obesity and BMI than nutritional indicators such as intake of energy or macronutrients.

Eating behavior among persons with type 2 diabetes mellitus in North Ethiopia: a cross-sectional study

BACKGROUND

Diet is central to the management of type 2 diabetes mellitus (T2DM). Depending on the stage of the disease at which the recommended diet is initiated, optimal adherence can reduce HbA1c by about 1 to 2%. However, evidence on eating behavior is generally scarce including in Ethiopia. The present study aimed to assess the eating behavior of adults with T2DM in North Ethiopia.

METHODS

This cross-sectional study was conducted among 421 adults with T2DM from September to November 2019. Socio-demographic variables were collected using structured questionnaires; an asset-based wealth index was used to determine socioeconomic status. Three dimensions of eating behavior were assessed using Likert-type items: food selection, meal planning and calorie recognition. Raw Likert scores in each dimension were transformed to percent scales to maximum (%SM). Participants' behavior in each dimension was categorized into healthy and unhealthy taking 66.7% SM score as a cutoff. Overall eating behavior was determined by aggregating ranks scored in the three dimensions. Correlates of overall eating behavior were identified using Chi-square test and multinomial logistic regression with statistical significance set at P-value < 0.05.

RESULT

Only 1% of the participants had overall healthy eating behavior. Yet, overall unhealthy eating was apparent in 54.4%. By dimensions, healthy eating behaviors in food selection, meal planning and calorie recognition were seen in 43.5, 7.4 and 2.9% participants, respectively. Factors that were positively associated with having healthy eating behavior in one dimension relative to unhealthy in all were: receiving nutrition education [AOR 1.73; CI 1.09, 2.74], female gender [AOR 1.78; CI 1.03, 3.08] & being in 26-44 age category [AOR 3.7; CI 1.56, 8.85]. But, being in the poor [AOR 0.42; CI 0.16, 1.32] or average [AOR 0.54; CI 0.19, 1.55] socioeconomic strata were negatively associated. However, only receiving nutrition education [AOR 3.65; CI 1.31, 10.18] was significantly associated with having healthy behavior in two eating dimensions over unhealthy in all.

CONCLUSION

In North Ethiopia, the overall eating behavior of adults with T2DM is extremely poor. Diverse and integrated approaches including nutrition education during consultation should be implemented to address the gap.

Dietary Management of Type 2 Diabetes in the MENA Region: A Review of the Evidence

The alarmingly rising trend of type 2 diabetes constitutes a major global public health challenge particularly in the Middle Eastern and North African (MENA) region where the prevalence is among the highest in the world with a projection to increase by 96% by 2045. The economic boom in the MENA region over the past decades has brought exceptionally rapid shifts in eating habits characterized by divergence from the traditional Mediterranean diet towards a more westernized unhealthy dietary pattern, thought to be leading to the dramatic rises in obesity and non-communicable diseases. Research efforts have brought a greater understanding of the different pathways through which diet and obesity may affect diabetes clinical outcomes, emphasizing the crucial role of dietary interventions and weight loss in the prevention and management of diabetes. The purpose of this review is to explore the mechanistic pathways linking obesity with diabetes and to summarize the most recent evidence on the association of the intake of different macronutrients and food groups with the risk of type 2 diabetes. We also summarize the most recent evidence on the effectiveness of different macronutrient manipulations in the prevention and management of diabetes while highlighting the possible underlying mechanisms of action and latest evidence-based recommendations. We finally discuss the need to adequately integrate dietetic services in diabetes care specific to the MENA region and conclude with recommendations to improve dietetic care for diabetes in the region.

Evaluation of Various Starchy Foods: A Systematic Review and Meta-Analysis on Chemical Properties Affecting the Glycemic Index Values Based on In Vitro and In Vivo Experiments

The chemical properties that serve as major determinants for the glycemic index (GI) of starchy food and recommended low-GI, carbohydrate-based foods have remained enigmatic. This present work performed a systematic assessment of linkages between chemical properties of foods and GI, and selected low-GI starchy foods. The data were sourced from literature published in various scientific journals. In total, 57 relevant studies and 936 data points were integrated into a database. Both in vitro and in vivo studies on GI values were included. The database was subsequently subjected to a meta-analysis. Meta-analysis from in vitro studies revealed that the two significant factors responsible for the GI of starchy foods were resistant starch and phenolic content (respectively, standardized mean difference (SMD): -2.52, 95% confidence interval (95%CI): -3.29 to -1.75, p (p-value) < 0.001; SMD: -0.72, 95%CI: -1.26 to -0.17, p = 0.005), while the lowest-GI crop type was legumes. Subgroup analysis restricted to the crop species with significant low GI found two crops, i.e., sorghum (SMD: -0.69, 95%CI: -2.33 to 0.96, p < 0.001) and red kidney bean (SMD: -0.39, 95%CI: -2.37 to 1.59, p = 0.001). Meta-analysis from in vivo studies revealed that the two significant factors responsible for the GI of starchy foods were flavonoid and phenolic content (respectively, SMD: -0.67, 95%CI: -0.87 to -0.47, p < 0.001; SMD: -0.63, 95%CI: -1.15 to -0.11, p = 0.009), while the lowest-GI crop type was fruit (banana). In conclusion, resistant starch and phenolic content may have a desirable impact on the GI of starchy food, while sorghum and red kidney bean are found to have low GI.

Chrono-nutrition for the prevention and treatment of obesity and type 2 diabetes: from mice to men

The proliferation in the rate of diagnosis of obesity and type 2 diabetes mellitus continues unabated, with current recommendations for primary lifestyle changes (i.e. modification to dietary patterns) having a limited impact in reducing the incidence of these metabolic diseases. Part of the reason for the failure to alter nutritional practices is that current dietary recommendations may be unrealistic for the majority of adults. Indeed, round-the-clock access to energy-dense, nutrient-poor food makes long-term changes to dietary habits challenging. Hence, there is urgent need for innovations in the delivery of evidence-based diet interventions to rescue some of the deleterious effects on circadian biology induced by our modern-day lifestyle. With the growing appreciation that the duration over which food is consumed during a day has profound effects on numerous physiological and metabolic processes, we discuss dietary protocols that modify the timing of food intake to deliberately alter the feeding-fasting cycle. Such chrono-nutrition functions to optimise metabolism by timing nutrient intake to the acrophases of metabolic rhythms to improve whole-body insulin sensitivity and glycaemic control, and thereby positively impact metabolic health. Graphical abstract.

Glenn A, M. S. Wolever T, G. Josse R, L. O’Connor D, Thompson A, D. Noseworthy R, Seider M, Sobie M, Bhatti G, Cavanagh J, Jones E, B. Darling P. Evaluation of Glycemic Index Education in People Living with Type 2 Diabetes: Participant Satisfaction, Knowledge Uptake, and Application

The glycemic index (GI) has been included in the Canadian clinical practice guidelines for type 2 diabetes (T2D) management since 2003, and even longer in other parts of the world (e.g., Australia). Despite this, dietitians have reported that GI is "too difficult for patients to understand and apply." They have called for diverse GI-utility data and evidence-informed education materials. To address these concerns, we developed and evaluated a GI education workshop and supporting materials, using the Kirkpatrick Model, for a T2D population. Participants (n = 29) with T2D attended a dietitian-facilitated workshop and received education materials. A mixed-form questionnaire (GIQ) and 3-day-diet-record were used to capture patient demographics, satisfaction, knowledge, and application, prior to and immediately after the workshop, 1-week, and 4-weeks post-education. Dietary GI was significantly lower at 1 and 4 weeks post-education (mean ± SEM; both 54 ± 1), compared to pre-education (58 ± 1; p ≤ 0.001). Participants (28/29) were satisfied with the intervention. The GI knowledge score was significantly higher post-education at baseline (83.5 ± 3.4%; p ≤ 0.001), week one (87.5 ± 2.6%; p = 0.035), and week four (87.6 ± 3.8%; p = 0.011) when compared to pre-education (53.6 ± 5.1%). A significant reduction in dietary GI was achieved by participants living with T2D, after completing the workshop, and they were able to acquire and apply GI knowledge in a relatively short period.

Effect of high-carbohydrate or high-monounsaturated fatty acid diets on blood pressure: a systematic review and meta-analysis of randomized controlled trials

Context

Current dietary guidelines for cardiovascular disease risk management recommend restricting intake of saturated fatty acids (SFAs). However, the optimal macronutrient profile, in the context of a low-SFA diet, remains controversial. The blood-pressure effect of replacing SFAs in diets with monounsaturated fatty acids (MUFAs) compared with carbohydrate has not been quantified to date.

Objective

To synthesize the evidence for the effect of substituting a high-carbohydrate (high-CHO) diet for a high-monounsaturated fatty acid (high-MUFA) diet on blood pressure, a systematic review and meta-analysis of randomized clinical trials in a population without health restrictions was conducted.

Data Sources

MEDLINE, EMBASE, and Cochrane Central Register of Controlled Clinical Trials were searched through June 7, 2017. Randomized controlled trials of > 3 weeks duration that assessed the effect of high-MUFA diets in isocaloric substitution for high-CHO diets on systolic blood pressure (SBP) and diastolic blood pressure (DBP) were included.

Data Extraction

Data were pooled using the generic-inverse variance method with random effects models and expressed as mean differences (MDs) with 95% confidence intervals (CIs). Heterogeneity was assessed by Cochran Q statistic and quantified by the I2 statistic. The quality of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Results

Fourteen trials (n = 980 participants) were included in the analysis. Comparatively, the high-MUFA diets in isocaloric substitution for high-CHO diets did not demonstrate a greater reduction in blood pressure (SBP: MD, -0.08 mmHg [95%CI, -1.01 to 0.84], P = 0.86; DBP: MD = 0.01 mmHg [95%CI, -0.73 to 0.75], P = 0.98). The overall quality of the evidence was assessed as moderate.

Conclusions

In the context of low SFAs, high-MUFA diets in isocaloric substitution for high-CHO diets did not affect blood pressure in individuals with and without hypertension. Large-scale trials achieving higher MUFA targets are required to support these findings.

ClinicalTrials.gov ID

NCT02626325.

The Effects of Different Quantities and Qualities of Protein Intake in People with Diabetes Mellitus

The recommended amount and quality of protein in diets of diabetic patients are highly controversial. In order to provide evidence-based information, the Diabetes Nutrition Study Group (DNSG) used a grading procedure used for quality of evidence and strength of recommendations (GRADE). A protein intake of 10% to 20% of energy intake (E%) or about 0.8 to 1.3 g/kg body weight in people below 65 years of age, and 15% to 20% of E% in people above 65 years of age appeared safe in weight-stable conditions. There were no intervention studies addressing metabolic effects, mortality, or cardiovascular events over prolonged periods. Body weight is closely linked to metabolic control and high protein diets are often recommended. Weight-loss diets that include 23% to 32% of E% as protein for up to one year reduced blood pressure and body weight slightly but significantly more than lower protein diets, whereas blood lipids, fasting blood glucose, and HbA1c improved similarly with higher or lower protein intakes in participants with a glomerular filtration rate (GFR) >60 mL/min/1.73 m². Patients with a GFR <60 mL/min/1.73 m² did not show a faster decline of GFR or kidney function with protein intakes around 0.8 g/kg body weight as compared with lower intakes, thereby arguing against a restriction. The effects of protein intake on diabetic eye or nerve disease have not been reported. There are a number of studies that have compared different types of animal proteins (milk, chicken, beef, pork, and fish) or compared animal with plant protein in diabetic patients and have reported a greater reduction of serum cholesterol with plant protein. In summary, the suggested range of protein intake appears to be safe and can be adapted according to personal dietary preferences.

Emerging practices supporting diabetes self-management among food insecure adults and families: A scoping review

BACKGROUND

Food insecurity undermines a patient's ability to follow diabetes self-management recommendations. Care providers need strategies to direct their support of diabetes management among food insecure patients and families.

OBJECTIVE

To identify what emerging practices health care providers can relay to patients or operationalize to best support diabetes self-management among food insecure adults and families.

ELIGIBILITY CRITERIA

Food insecure populations with diabetes (type 1, type 2, prediabetes, gestational diabetes) and provided diabetes management practices specifically for food insecure populations. Only studies in English were considered. In total, 21 articles were reviewed.

SOURCES OF EVIDENCE

Seven databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Medline, ProQuest Nursing & Allied Health Database, PsychInfo, Scopus, and Web of Science.

RESULTS

Emerging practices identified through this review include screening for food insecurity as a first step, followed by tailoring nutrition counseling, preventing hypoglycemia through managing medications, referring patients to professional and community resources, building supportive care provider-patient relationships, developing constructive coping strategies, and decreasing tobacco smoking.

CONCLUSION

Emerging practices identified in our review include screening for food insecurity, nutrition counselling, tailoring management plans through medication adjustments, referring to local resources, improving care provider-patient relationship, promoting healthy coping strategies, and decreasing tobacco use. These strategies can help care providers better support food insecure populations with diabetes. However, some strategies require further evaluation to enhance understanding of their benefits, particularly in food insecure individuals with gestational and prediabetes, as no studies were identified in these populations. A major limitation of this review is the lack of global representation considering no studies outside of North America satisfied our inclusion criteria, due in part to the English language restriction.

Minimal effect of walking before dinner on glycemic responses in type 2 diabetes: outcomes from the multi-site E-PAraDiGM study

AIM

To examine the effect of walking before dinner on 24-h glycemic control in individuals with type 2 diabetes using the standardized multi-site Exercise-Physical Activity and Diabetes Glucose Monitoring (E-PAraDiGM) Protocol.

METHODS

Eighty participants were studied under two conditions (exercise vs. non-exercise control) separated by 72 h in a randomized crossover design. Each condition lasted 2 days during which standardized meals were provided. Exercise consisted of 50 min of treadmill walking at 5.0 km/h before the evening meal, while control involved 50 min of sitting. The primary outcome measure was mean glucose during the 24-h period following exercise (or sitting) measured by continuous glucose monitoring.

RESULTS

Of the 80 participants who were initially randomized, 73 completed both exercise and control. Sixty-three participants [29 males, 34 females; age = 64 ± 8 years, body mass index = 30.5 ± 6.5 kg/m² and HbA1c = 51 ± 8 mmol/mol (6.8 ± 0.7%), mean ± SD] complied with the standardized diets and had complete continuous glucose monitoring data. Exercise did not affect mean 24-h glucose compared to control (0.03 mmol/L; 95% CI - 0.17, 0.22, P = 0.778) but individual differences between conditions ranged from - 2.8 to +1.8 mmol/L. Exercise did not affect fasting glucose, postprandial glucose or glucose variability. Glucose concentrations measured by continuous glucose monitoring were reduced during the 50 min of walking in exercise compared to sitting in control (- 1.56 mmol/L; 95% CI - 2.18, - 0.95, p < 0.001).

CONCLUSION

Contrary to previous acute exercise studies, 50 min of walking before dinner in the E-PAraDiGM protocol did not affect 24-h glucose profiles. However, highly heterogeneous responses to exercise were observed.

TRIAL REGISTRATION

NCT02834689.

Restricting carbohydrates at breakfast is sufficient to reduce 24-hour exposure to postprandial hyperglycemia and improve glycemic variability

BACKGROUND

The breakfast meal often results in the largest postprandial hyperglycemic excursion in people with type 2 diabetes.

OBJECTIVE

Our purpose was to investigate whether restricting carbohydrates at breakfast would be a simple and feasible strategy to reduce daily exposure to postprandial hyperglycemia.

DESIGN

Adults with physician-diagnosed type 2 diabetes [n = 23; mean ± SD age: 59 ± 11 y; glycated hemoglobin: 6.7% ± 0.6%; body mass index (kg/m2): 31 ± 7] completed two 24-h isocaloric intervention periods in a random order. Participants consumed one of the following breakfasts: 1) a very-low-carbohydrate high-fat breakfast (LCBF; <10% of energy from carbohydrate, 85% of energy from fat, 15% of energy from protein) or 2) a breakfast with dietary guidelines-recommended nutrient profile (GLBF; 55% of energy from carbohydrate, 30% of energy from fat, 15% of energy from protein), with the same lunch and dinner provided. Continuous glucose monitoring was used to assess postprandial glucose responses over 24 h, and visual analog scales were used to assess ratings of hunger and fullness.

RESULTS

The LCBF significantly reduced postprandial hyperglycemia after breakfast (P < 0.01) and did not adversely affect glycemia after lunch or dinner. As such, overall postprandial hyperglycemia (24-h incremental area under the glucose curve) and glycemic variability (mean amplitude of glycemic excursions) were reduced with the LCBF (24-h incremental area under the glucose curve: -173 ± 361 mmol/L; P = 0.03; mean amplitude of glycemic excursions: -0.4 ± 0.8 mmol/L · 24 h; P = 0.03) compared with the GLBF. Premeal hunger was lower before dinner with the LCBF than with the GLBF (P-interaction = 0.03).

CONCLUSIONS

A very-low-carbohydrate high-fat breakfast lowers postbreakfast glucose excursions. The effects of this simple strategy appear to be sufficient to lower overall exposure to postprandial hyperglycemia and improve glycemic variability. Longer-term interventions are warranted. This trial was registered at clinicaltrials.gov as NCT02982330.

Healthy Eating and Active Living for Diabetes-Glycemic Index (HEALD-GI): Protocol for a Pragmatic Randomized Controlled Trial

BACKGROUND

Rigorous evidence is needed regarding the best approach for increasing the uptake of Diabetes Canada's evidence-based recommendations to include low-glycemic index (GI) foods in daily meal planning as an effective dietary self-care strategy for glycemic control among people with type 2 diabetes (T2D).

OBJECTIVE

This study aims to present the study design and baseline data from the Healthy Eating and Active Living for Diabetes-Glycemic Index (HEALD-GI) trial, which was designed to evaluate the effectiveness of an enhanced GI-targeted nutrition education on GI-related knowledge and mean daily GI among adults with T2D in Edmonton, Alberta.

METHODS

We used a pragmatic randomized controlled trial design and allocated 67 adults (aged ≥18 years) with T2D living in Edmonton, Alberta, Canada, to a control group that received standard printed copies of Canada's Food Guide and Diabetes Canada's GI resources or to an intervention group that received the same materials, plus a customized Web-based platform with 6 self-directed learning modules and print material. Each module included videos, links to reliable websites, chat rooms, and quizzes. Evidence-based GI concept information included GI values of foods and low-GI shopping, recipes, and cooking tips by a registered dietitian. In addition, support through email, text messaging (short message service), phone calls, or postal mail was provided to reinforce participants' learning. The primary outcome, average dietary GI, was assessed using 3-day food records. Additional measures including GI knowledge and self-efficacy, glycated hemoglobin (HbA_1c), lipids, systolic blood pressure, body mass index (BMI; weight, height), waist circumference, and computer proficiency were assessed at baseline and at 3-month postintervention.

RESULTS

Between November 2017 and February 2018, we contacted adults (aged ≥18 years) with T2D living in Edmonton, Alberta, screened and recruited eligible participants into the study. All data collection ended in June 2018. Overall, 64% (43/67) participants were males; mean age was 69.5 (SD 9.3) years, with a mean diabetes duration of 19.0 (SD 13.7) years. Mean BMI was 30.1 (SD 5.7) kg/m², and mean HbA_1c value was 7.1% (SD 1.2%). Data analysis was completed in December 2018.

CONCLUSIONS

The GI concept is often difficult to teach. The HEALD-GI study aims to provide evidence in support of an alternative approach to translating the GI concept to adults with T2D. Findings from this study may help registered dietitians to better disseminate low-GI dietary recommendations using efficient and cost-effective, patient-centered approaches. Furthermore, evidence generated will contribute to addressing some of the controversies regarding the clinical usefulness of the GI concept.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/11707.

Optimizing glycemic control in type 2 diabetic patients through the use of a low-carbohydrate, high-fat, ketogenic diet: a review of two patients in primary care

Established guidelines continue to promote carbohydrate-rich (>130 g/day) diets in the primary-care management of type 2 diabetic (DM2) patients. A growing body of evidence suggests that a low-carbohydrate, high-fat, ketogenic diet (KD) may be a more effective nutritional strategy for improving glycemic control. Two diabetic patients, a 65-year-old female and a 52-year-old male, were placed on KDs consisting of 70% fat, 20%-25% protein, and 5%-10% carbohydrates and monitored for 12 weeks. The 65-year-old female demonstrated a 2.4% reduction in HBA1C over 12 weeks while reducing her diabetic medication by 75%. The 52-year-old male demonstrated a 2.5% reduction in HBA1C while eliminating all diabetic medications. These cases demonstrate the efficacy of KDs in terms of improving glycemic control in DM2 patients and lend support to the increased use of KDs in this population cohort.

Positioning the Value of Dietary Carbohydrate, Carbohydrate Quality, Glycemic Index, and GI Labelling to the Canadian Consumer for Improving Dietary Patterns

The objectives of this qualitative study was to: (1) understand Canadian consumers’ knowledge and perception of dietary carbohydrates, carbohydrate quality, and the glycemic index (GI); and (2) determine Canadian’s receptiveness to GI labelling to assist with identifying and consuming foods of higher carbohydrate quality. Focus groups were recruited in Vancouver, Toronto, and Montreal and grouped according to body mass index (BMI) (NBW, normal body weight; PO, previously obese; and OW/OB, overweight/obese) and diagnosis with prediabetes and diabetes (PO (Vancouver) and OW/OB (Montreal and Toronto). Subjects in all groups linked excess consumption of carbohydrate with weight gain. PO and OW/OB groups were conflicted between perceived negative consequences and feelings of pleasure associated with carbohydrate consumption. Subjects were largely unfamiliar with the term ‘carbohydrate quality’, but were often associated with classifying carbohydrates as ‘good’ or ‘bad’. The concept of the GI resonated well across groups after exposure to corresponding educational materials. However, NBW groups largely felt that the GI was irrelevant to their dietary choices as they did not have a history of diabetes. PO and OW/OB groups associated the GI with diabetes management. The concept of a GI labelling program to help facilitate healthier carbohydrate choices was well received across all groups, especially when the low GI was interpreted as giving permission to consume foods they enjoyed eating. Results suggest that the GI could be used as a consumer-facing labelling program in Canada and assist with de-stigmatizing carbohydrate foods by helping to facilitate the consumption of carbohydrate foods that align with healthy dietary patterns.

DASH Dietary Pattern and Cardiometabolic Outcomes: An Umbrella Review of Systematic Reviews and Meta-Analyses

Background: The Dietary Approaches to Stop Hypertension (DASH) dietary pattern, which emphasizes fruit, vegetables, fat-free/low-fat dairy, whole grains, nuts and legumes, and limits saturated fat, cholesterol, red and processed meats, sweets, added sugars, salt and sugar-sweetened beverages, is widely recommended by international diabetes and heart association guidelines. Objective: To summarize the available evidence for the update of the European Association of the Study of Diabetes (EASD) guidelines, we conducted an umbrella review of existing systematic reviews and meta-analyses using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach of the relation of the DASH dietary pattern with cardiovascular disease and other cardiometabolic outcomes in prospective cohort studies and its effect on blood pressure and other cardiometabolic risk factors in controlled trials in individuals with and without diabetes. Methods: MEDLINE and EMBASE were searched through 3 January 2019. We included systematic reviews and meta-analyses assessing the relation of the DASH dietary pattern with cardiometabolic disease outcomes in prospective cohort studies and the effect on cardiometabolic risk factors in randomized and non-randomized controlled trials. Two independent reviewers extracted relevant data and assessed the risk of bias of individual studies. The primary outcome was incident cardiovascular disease (CVD) in the prospective cohort studies and systolic blood pressure in the controlled trials. Secondary outcomes included incident coronary heart disease, stroke, and diabetes in prospective cohort studies and other established cardiometabolic risk factors in controlled trials. If the search did not identify an existing systematic review and meta-analysis on a pre-specified outcome, then we conducted our own systematic review and meta-analysis. The evidence was summarized as risk ratios (RR) for disease incidence outcomes and mean differences (MDs) for risk factor outcomes with 95% confidence intervals (95% CIs). The certainty of the evidence was assessed using GRADE. Results: We identified three systematic reviews and meta-analyses of 15 unique prospective cohort studies (n = 942,140) and four systematic reviews and meta-analyses of 31 unique controlled trials (n = 4,414) across outcomes. We conducted our own systematic review and meta-analysis of 2 controlled trials (n = 65) for HbA1c. The DASH dietary pattern was associated with decreased incident cardiovascular disease (RR, 0.80 (0.76–0.85)), coronary heart disease (0.79 (0.71–0.88)), stroke (0.81 (0.72–0.92)), and diabetes (0.82 (0.74–0.92)) in prospective cohort studies and decreased systolic (MD, −5.2 mmHg (95% CI, −7.0 to −3.4)) and diastolic (−2.60 mmHg (−3.50 to −1.70)) blood pressure, Total-C (−0.20 mmol/L (−0.31 to −0.10)), LDL-C (−0.10 mmol/L (−0.20 to −0.01)), HbA1c (−0.53% (−0.62, −0.43)), fasting blood insulin (−0.15 μU/mL (−0.22 to −0.08)), and body weight (−1.42 kg (−2.03 to −0.82)) in controlled trials. There was no effect on HDL-C, triglycerides, fasting blood glucose, HOMA-IR, or CRP. The certainty of the evidence was moderate for SBP and low for CVD incidence and ranged from very low to moderate for the secondary outcomes. Conclusions: Current evidence allows for the conclusion that the DASH dietary pattern is associated with decreased incidence of cardiovascular disease and improves blood pressure with evidence of other cardiometabolic advantages in people with and without diabetes. More research is needed to improve the certainty of the estimates.

The effect of a short-term low-carbohydrate, high-fat diet with or without postmeal walks on glycemic control and inflammation in type 2 diabetes: a randomized trial

Lowering carbohydrate consumption effectively lowers glucose, but impacts on inflammation are unclear. The objectives of this study were to: 1) determine whether reducing hyperglycemia by following a low-carbohydrate, high-fat (LC) diet could lower markers of innate immune cell activation in type 2 diabetes (T2D) and 2) examine if the combination of an LC diet with strategically timed postmeal walking was superior to an LC diet alone. Participants with T2D ( n = 11) completed a randomized crossover study involving three 4-day diet interventions: 1) low-fat low-glycemic index (GL), 2) and 3) LC with 15-min postmeal walks (LC+Ex). Four-day mean glucose was significantly lower in the LC+Ex group as compared with LC (-5%, P < 0.05), whereas both LC+Ex (-16%, P < 0.001) and LC (-12%, P < 0.001) conditions were lower than GL. A significant main effect of time was observed for peripheral blood mononuclear cells phosphorylated c-Jun N-terminal kinase ( P < 0.001), with decreases in all three conditions (GL: -32%, LC: -45%, and LC+Ex: -44%). A significant condition by time interaction was observed for monocyte microparticles ( P = 0.040) with a significant decrease in GL (-76%, P = 0.035) and a tendency for a reduction in LC (-70%, P = 0.064), whereas there was no significant change in LC+Ex (0.5%, P = 0.990). Both LC (-27%, P = 0.001) and LC+Ex (-35%, P = 0.005) also led to significant reductions in circulating proinsulin. An LC diet improved 4-day glycemic control and fasting proinsulin levels when compared with GL, with added glucose-lowering benefits when LC was combined with postmeal walking.

Impacts of self-management education on glycaemic control in patients with type 2 diabetes mellitus

OBJECTIVES

Dietary and physical activity advice have been considered to be seminal ingredients in prevention and management of type 2 diabetes mellitus. In this regard, the impacts of a three-month self-management intervention on glycemic control in patients with type 2 diabetes were examined in the present study.

STUDY DESIGN

A Double-arm post-test intervention study.

METHODS

In the current post-test intervention study, three two-hour educational sessions on dietary habits and physical activity designed according to Health Belief Model were presented to 16 non-complicated type 2 diabetic patients and their dietary, physical activities, and biochemical outcomes were compared to a 23 patient-control arm in Iraq in 2017. The level of physical activity was measured through International Physical Activity Questionnaire (IPAQ), dietary habits through UK Diabetes and Diet Questionnaire (UKDDQ), and biochemical indicators including HbA1c were measured after three months of program completion.

RESULTS

The study showed that walking, taking vegetable, fruit, and bread were higher and taking full-fat cheese and full-fat spread was lower among experimental group significantly compared to control arm. In addition, the experimental group had a substantial higher albumin and lower urea, ALP-Phosphatase, and glucose levels in comparison with control patients. No substantial change was seen in HbA1C and no change in milk and fish products.

CONCLUSIONS

The substantial positive changes in physical activity, dietary habits, and some biochemical indicators were seen following intervention completion in the experimental arm.

Effects of meal replacement therapy on metabolic outcomes in Thai patients with type 2 diabetes: A randomized controlled trial

Background:

A meal replacement (MR) with a low glycemic index (GI) is possibly beneficial for glycemic control. However, the effects of MR on diabetes mellitus have not been studied among Thai patients with type 2 diabetes (T2DM).

Aim:

To compare metabolic outcomes between T2DM patients receiving the new MR formula (ONCE PRO) and normal controlled diets.

Methods:

A multicenter, open-labeled, randomized controlled trial was conducted. Eligible patients received either ONCE PRO for one meal daily with controlled diets or only controlled diets for 3 months. The differences in metabolic profile between the baseline and end point of each group and between groups were measured.

Results:

110 participants were enrolled; the mean difference and standard deviation in hemoglobin A1C (HbA1c) (%) from baseline were –0.21 ± 0.78 (p = 0.060) and –0.27 ± 0.60 (p = 0.001) in the MR and control groups, respectively; however, there was no significant difference between groups (p = 0.637). Patients consuming a MR instead of breakfast had a significant decrease in HbA1c (p = 0.040). Body weight (BW) and body mass index (BMI) were significantly reduced in both groups. There were no significant change in waist circumference, fasting plasma glucose, total cholesterol and triglycerides. Low-density lipoprotein cholesterol (LDL-C) was significantly decreased in the MR group compared with the control group (p = 0.049).

Conclusions:

Short-term conventional diet control and the low-GI MR product were associated with a decreased BW and BMI. Changes in the other metabolic outcomes, HbA1c, total cholesterol and triglycerides, were comparable despite ONCE PRO as the MR having a better effect on LDL-C lowering.

Effect of combined use of a low-carbohydrate, high-protein diet with omega-3 polyunsaturated fatty acid supplementation on glycemic control in newly diagnosed type 2 diabetes: a randomized, double-blind, parallel-controlled trial

Background

The combined effect of a low-carbohydrate, high-protein (LCHP) diet and omega-3 (n-3) polyunsaturated fatty acid (PUFA) supplementation on patients with type 2 diabetes (T2D) is not known.

Objective

The aim of this study was to evaluate the effect of an LCHP diet combined with ω-3 (LCHP+ω-3) on glycemic control in patients with T2D.

Design

In this randomized, double-blind, parallel-controlled trial, 122 newly diagnosed participants with T2D were randomly assigned to receive a high-carbohydrate, low-protein diet with low ω-3 PUFAs [control (CON)], an LCHP, ω-3, or LCHP+ω-3 diet for 12 wk. The ratio of carbohydrate to protein was 42:28 in the LCHP and LCHP+ω-3 diet and 54:17 in the CON and ω-3 diet. The participants were given 6 g fish oil/d (containing 3.65 g docosahexaenoic acid, eicosapentaenoic acid, and docosapentaenoic acid/d) in the ω-3 and LCHP+ω-3 diet groups or 6 g corn oil/d (placebo) in the CON and LCHP diet groups.

Results

Compared with the CON diet group, greater decreases in glycated hemoglobin (HbA1c) and fasting glucose were observed in all of the other 3 diet groups at 12 wk. Of note, HbA1c reduction in the LCHP+ω-3 diet group (-0.51%; 95% CI: -0.64%, -0.37%) was greater than that in the LCHP (P = 0.03) and ω-3 (P = 0.01) diet groups at 12 wk. In terms of fasting glucose, only the LCHP+ω-3 diet group showed a significant decrease at 4 wk (P = 0.03 compared with CON). Moreover, the reduction in fasting glucose in the LCHP+ω-3 diet group (-1.32 mmol/L; 95% CI: -1.72, -0.93 mmol/L) was greater than that in the LCHP (P = 0.04) and ω-3 (P = 0.03) diet groups at 12 wk.

Conclusions

The LCHP+ω-3 diet provided greater effects on HbA1c and fasting glucose and faster effects on fasting glucose than both the LCHP and ω-3 diets, indicating the potential necessity of combining an LCHP diet with ω-3 PUFAs in T2D control. This trial was registered at chictr.org.cn/ as ChiCTR-TRC-14004704.

Two-year trial of intermittent insulin therapy vs metformin for the preservation of β-cell function after initial short-term intensive insulin induction in early type 2 diabetes

AIMS

To test the hypothesis that "induction" intensive insulin therapy (IIT) needs to be followed by "maintenance therapy" to preserve β-cell function, and to evaluate the impact on β-cell function over 2 years of two approaches to maintenance therapy: intermittent short-term IIT every 3 months vs daily metformin.

MATERIALS AND METHODS

In this trial, 24 adults with a mean type 2 diabetes mellitus (T2DM) duration of 2.0 ± 1.7 years and glycated haemoglobin (HbA1c) levels 6.4 ± 0.1% (46 ± 1.1mmol/mol) were randomized to 3 weeks of induction IIT (glargine, lispro) followed by either repeat IIT for up to 2 weeks every 3 months or daily metformin. Participants underwent serial assessment of β-cell function using the Insulin Secretion-Sensitivity Index-2 (ISSI-2) on an oral glucose tolerance test every 3 months.

RESULTS

The primary outcome of baseline-adjusted ISSI-2 at 2 years was higher in the metformin arm compared with intermittent IIT (245.0 ± 31.7 vs 142.2 ± 18.4; P = .008). Baseline-adjusted HbA1c at 2 years (secondary outcome) was lower in the metformin arm (6.0 ± 0.2% vs 7.3 ± 0.2%; P = .0006) (42 ± 2.2 vs 56 ± 2.2mmol/mol). At study completion, 66.7% of participants randomized to metformin had an HbA1c concentration ≤ 6.0% (≤42mmol/mol), compared with 8.3% of those on intermittent IIT (P = .009). There were no differences in insulin sensitivity.

CONCLUSION

After induction IIT, metformin was superior to intermittent IIT for maintaining β-cell function and glycaemic control over 2 years. The strategy of induction and maintenance therapy to preserve β-cell function warrants exploration in early T2DM.

Carbohydrate Replacement of Rice or Potato with Lentils Reduces the Postprandial Glycemic Response in Healthy Adults in an Acute, Randomized, Crossover Trial

Background

The postprandial blood glucose response (PBGR) following carbohydrate replacement of high-glycemic index (GI) foods with pulses, in a mixed meal, has not been accurately defined.

Objective

We aimed to determine the extent to which PBGR and relative glycemic response (RGR) are lowered when half of the available carbohydrate (AC) from rice or potato is replaced with cooked lentils.

Methods

Using a crossover design, 2 groups of 24 healthy adults randomly consumed 50 g AC from control white rice alone [mean ± SD body mass index (BMI, in kg/m2): 24.3 ± 0.5; mean ± SD age: 27.7 ± 1.2 y], instant potato alone (BMI: 24.0 ± 0.5; age: 27.4 ± 1.2 y), or the same starch source in a 50:50 AC combination with each of 3 types of commercially available lentils (large green, small green, split red). Fasting and postprandial blood samples were analyzed for glucose and insulin, and used to derive incremental area under the curve (iAUC), RGR, and maximum concentration (Cmax). Treatment effects were assessed with the use of repeated-measures ANOVA within the rice and potato treatments.

Results

In comparison to rice alone, blood glucose iAUC and Cmax (P < 0.001) were lowered after consumption of rice with large green (P = 0.057), small green (P = 0.002), and split red (P = 0.006) lentils. Blood glucose iAUC and Cmax were also significantly lowered (P < 0.0001) after consumption of potato combined with each lentil, compared to potato alone. Plasma insulin iAUC and Cmax were significantly (P < 0.001) decreased when lentils were combined with potato, but not with rice. The RGRs of rice and potato were lowered by ∼20% and 35%, respectively, when half of their AC was replaced with lentils.

Conclusions

Replacing half of the AC from high-GI foods with lentils significantly attenuates PBGR in healthy adults; this can contribute to defining a health claim for pulses and blood glucose lowering. This trial was registered at clinicaltrials.gov as NCT02426606.