Glycaemic responses to glucose and rice in people of Chinese and European ethnicity

Association of social determinants, lifestyle, and metabolic factors with mortality in Chinese adults: A nationwide 10-year prospective cohort study

Nationwide estimates of the impact of common modifiable risk factors on mortality remain crucial. We aim to assess the influence of social determinants, lifestyle, and metabolic factors on mortality in 174,004 adults aged ≥40 years from the China Cardiometabolic Disease and Cancer Cohort (4C) Study. We reveal that 17 modifiable factors are independently associated with mortality, accounting for 64.8% of all-cause mortality, 77.4% of cardiovascular mortality, and 44.8% of cancer mortality. Low education emerges as the leading factor for both all-cause and cancer mortality, while hypertension is predominant for cardiovascular mortality. Moreover, low gross domestic product per capita and high ambient particulate matter with a diameter of <2.5 μm (PM2.5) air pollution account for 7.8% and 4.3% for all-cause mortality, respectively, using a different method. Gender-specific analyses reveal distinct patterns, with women's mortality primarily associated with social determinants and men exhibiting stronger associations with lifestyle factors. Targeted health interventions are essential to mitigate mortality risks effectively in China.

Glycaemic Response to a Nut-Enriched Diet in Asian Chinese Adults with Normal or High Glycaemia: The Tū Ora RCT

Nut-based products are a good source of high-quality plant protein in addition to mono- and polyunsaturated fatty acids, and may aid low-glycaemic dietary strategies important for the prevention of type 2 diabetes (T2D). In particular, they may be advantageous in populations susceptible to dysglycaemia, such as Asian Chinese. The present study aimed to compare effects of a higher-protein nut bar (HP-NB, also higher in total fibre and unsaturated fats, comprising mixed almonds and peanuts) vs. an isoenergetic higher-carbohydrate cereal bar (HC-CB) within the diet of 101 Chinese adults with overweight and normo- or hyperglycaemia. Ectopic pancreas and liver fat were characterised using magnetic resonance imaging and spectroscopy (MRI/S) as a secondary outcome. Participants were randomized to receive HP-NB or HC-CB daily as a 1 MJ light meal or snack replacement, in addition to healthy eating advice. Anthropometry and clinical indicators of T2D risk were assessed fasted and during an oral glucose tolerance test (OGTT), pre- and post-intervention. No significant difference was observed between diet groups for body weight, body mass index, waist or hip circumference, blood pressure, glucoregulatory markers, lipid profile or inflammatory markers over 12 weeks (all, p > 0.05). No difference was observed between glycaemic subgroups or those with normal versus high ectopic organ fat. Although HP-NB can attenuate postprandial glycaemia following a meal, no effects were observed for either fasting or glucose-mediated outcomes following longer-term inclusion in the habitual diet of Chinese adults with overweight, including at-risk subgroups.

Glycemic load, but not glycemic index, is associated with an increased risk of ovarian cancer: A systematic review and meta-analysis

The association between glycemic index (GI),glycemic load (GL) and ovarian cancer risk remains unclear. Carbohydrate intake promotes insulin secretion, leading to cell proliferation and invasion. We hypothesized that high GI and GL intake may increase ovarian cancer risk. Therefore, we conducted a meta-analysis after systematically searching PubMed, Embase, Web of Science, and Cochrane Library from inception to December 2022. Fixed- or random-effect models calculated the pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs). Subgroup, sensitivity, publication bias analysis, and dose-response analysis were performed. Nine original studies were included, involving 4716 cases and 119,960 controls. No significant association was observed between GI or GL and ovarian cancer risk (GI: RR = 1.02 [95% CI, 0.83-1.26]; GL: RR = 1.11 [95% CI, 0.84-1.47]). Subgroup analysis suggested the results were not significantly modified by any group. Sensitivity analysis identified the sources of heterogeneity. No publication bias was observed. A linear positive dose-response relationship was observed between dietary GL and ovarian cancer risk after removing heterogeneous sources (RR = 1.11 [95% CI, 1.05-1.17], I2 = 32.9%, P = .23 at 50 U/d; RR = 1.04 [95% CI, 1.02-1.07], I2 = 19.1%, P = .29 at 20 U/d). These outcomes suggest that high dietary GL, but not GI, is associated with significantly increased ovarian cancer risk. Thus, sufficient intake of a low dietary GL is important for reducing ovarian cancer risk.

Influence of instant rice characteristics and processing conditions on starch digestibility-A review

Instant rice is increasingly popular around the world due to its convenience, but it commonly has a high glycemic index, and a frequent consumption might contribute to the occurrence of many chronic diseases. In this review, the main factors determining starch digestibility of instant rice were comprehensively evaluated, aiming to help the rice industry develop instant rice with slow starch digestibility. Starch digestibility in instant rice can be reduced by manipulating its intrinsic and extrinsic nutrients. Processing conditions, including pre-gelatinization, storage, and reheating are also important for the starch digestibility of instant rice. Individual differences in terms of glycemic response to the same carbohydrate-based diet should be considered when knowledge is transformed from in vitro method to human conditions. This review contains important information that has the potential to reduce the starch digestibility of instant rice and improve public health.

A Cost-effectiveness Analysis of iGlarLixi Versus IDegAsp and Appropriate Price Exploration of iGlarLixi for Type 2 Diabetes Mellitus Patients in China

BACKGROUND AND OBJECTIVE

The efficacy and safety of iGlarLixi, a fixed-ratio combination (FRC) of basal insulin glargine plus lixisenatide, have been demonstrated in type 2 diabetes mellitus (T2DM) patients. However, no relevant economic analysis of iGlarLixi has been done in China. Thus, the primary objective of this study is to evaluate the cost effectiveness of iGlarLixi versus IDegAsp in Chinese T2DM patients, and then back-calculate the appropriate drug price of iGlarLixi to support its pricing after listing in China.

METHODS

The United Kingdom Prospective Diabetes Study Outcome Model 2 (UKPDS OM2) was applied to estimate lifetime health and economic outcomes from the Chinese health-care system perspective. As no head-to-head comparison data are currently available, the baseline cohort characteristics and the initial clinical data for iGlarLixi were derived from the randomized LixiLan-L-China trial. The relative treatment effects for IDegAsp were based on an indirect treatment comparison. Due to the unavailability of iGlarLixi pricing data, the annual medication cost of iGlarLixi was assumed to be equal to that of IDegAsp at the beginning of the study. Afterwards, a break-even analysis using comparator drug price and the willingness-to-pay (WTP) threshold was performed to back-calculate the appropriate drug price of iGlarLixi. One-way sensitivity analysis, scenario analysis and probabilistic sensitivity analysis (PSA) were conducted to assess the robustness of the model.

RESULTS

Based on the initial assumption of equal annual medication cost of iGlarLixi and IDegAsp, iGlarLixi was cost effective compared to IDegAsp with an incremental cost-effectiveness ratio (ICER) far below the WTP threshold in Chinese T2DM patients. From the back calculation for the price of iGlarLixi, the annual medication cost of iGlarLixi was $656.96 and $1075.96 to obtain an ICER of iGlarLixi versus IDegAsp close to 1 × GDP and 3 × GDP, respectively. When the discount rate was changed from the base value to 8% (the most sensitive parameter to the model results in one-way sensitivity analysis), the ICER was nearly equal to 1 × GDP and 3 × GDP with the annual medication cost of iGlarLixi decreasing to $590.41 and $865.03, respectively. Thus, iGlarLixi was dominant over IDegAsp with an annual medication cost of $590.41 to $865.03. The findings were robust to one-way sensitivity analysis, PSA and scenario analysis.

CONCLUSION

This long-term cost-effectiveness analysis in Chinese T2DM patients indicates that iGlarLixi, assuming equal price to IDegAsp, is cost-effective versus IDegAsp with an ICER far below the WTP threshold. With 1 × GDP and 3 × GDP threshold set we back-calculate the appropriate annual medication cost of iGlarLixi to be $590.41 to $865.03, respectively.

Glycemic Responses of Milk and Plant-Based Drinks: Food Matrix Effects

The consumption of food items containing digestible carbohydrates in food products leads to postprandial increases in blood glucose levels and glycemic responses. The extent to which these occur depends on many factors, including concentration and type of carbohydrate, but also other physicochemical properties of the food matrix, which determine the rate of uptake of monosaccharides into the bloodstream, including product structure and factors affecting gastric emptying. For milk, control of postprandial glycemic responses appears to be multifaceted, including a controlled rate of gastric emptying, a rate of glucose and galactose uptake into the bloodstream controlled by enzymatic hydrolysis, as well as stimulated insulin secretion to enhance uptake of blood glucose from the bloodstream. Altogether, this allows milk to deliver comparatively high levels of carbohydrate with limited glycemic responses. For plant-based drinks positioned as milk alternatives, however, compositional differences (including carbohydrate type and concentration) as well as matrix factors limiting control over gastric emptying and insulin secretion can, in some cases, lead to much stronger glycemic responses, which are undesirable in relation to non-communicable diseases, such as type-2 diabetes. This review discusses glycemic responses to milk and plant-based drinks from this perspective, focusing on mechanistic insights and food matrix effects.

Efficacy and safety of basal-first titration order in individuals with type 2 diabetes receiving short-term intensive insulin therapy: An exploratory analysis of BEYOND V

AIMS

To present the results of an exploratory analysis of the BEYOND V study in which Chinese individuals with uncontrolled type 2 diabetes (T2D) received short-term intensive insulin therapy (SIIT) during study run-in (prior to randomization) using a basal-first insulin titration method.

MATERIALS AND METHODS

This was exclusively an exploratory analysis of the 7- to 10-day run-in period of BEYOND V. Participants were hospitalized and had oral therapies withdrawn (except metformin). They received SIIT with once-daily insulin glargine and three-times-daily premeal insulin glulisine, titrated daily from a total starting dose of 0.4 to 0.5 units/kg/d, first adjusting insulin glargine to achieve fasting blood glucose (FBG) of 4.4 to 6.1 mmol/L (79 to 119 mg/dL), then insulin glulisine to achieve pre-meal blood glucose of 4.4 to 6.1 mmol/L. Key outcomes were the proportions of participants achieving FBG and 2-hour postprandial blood glucose (PBG) targets.

RESULTS

Overall, 397 entered the run-in (mean 54.2 years, 235 males [59.2%]). At the end of SIIT, 374/396 participants (94.4%) had both FBG <7.0 mmol/L (<126 mg/dL) and 2-hour PBG <10 mmol/L (<180 mg/dL) and 282/396 (71.2%) had both FBG <6.1 mmol/L (<100 mg/dL) and 2-hour PBG <10 mmol/L. The mean first time taken to achieve FBG <7 mmol/L, 2-hour PBG <10 mmol/L, and both, was 4.35, 3.88, and 5.04 days, respectively. Hypoglycaemia occurred in 99 participants (24.9%). There was no severe hypoglycaemia.

CONCLUSIONS

Titrating basal insulin first is an effective and safe method of SIIT in individuals with T2D, rapidly achieving target glucose levels with a relatively low rate of hypoglycaemia.

Ethnic Variability in Glucose and Insulin Response to Rice Among Healthy Overweight Adults: A Randomized Cross-Over Study

BACKGROUND

The influence of ethnicity on postprandial glucose and insulin responses has been reported earlier and rice is a major contributor to the overall glycaemic load of Asian and Arab diets. This study aims to compare postprandial glycaemic and insulinaemic responses to rice among healthy overweight Asian, Arab and European participants.

METHODS

In a randomized crossover design, 47 healthy overweight participants (23 Asian, 16 Arab, and 8 European) consumed 75 grams of glucose beverage or ate 270 grams of cooked basmati rice (75 g of available carbohydrate) on two separate occasions, separated by a one 1-week washout period. Blood glucose and insulin levels were determined at fasting 0 (fasting), 30, 60, and 120 minutes and used to determine the incremental area under the curve (iAUC).

RESULTS

The three groups were matched on body mass index and gender. Although no differences were noted statistically in most clinical features, a wide range of variation was noted in age, systolic, diastolic blood pressure. The fasting blood glucose and insulin levels were highest among Asians, followed by Arabs and Europeans (p < 0.01). According to the HOMA-IR test and the Matsuda index, Asians have a higher insulin resistance than Arabs or Europeans when consuming a glucose beverage (p < 0.001) and rice (p < 0.01). Postprandial glucose and insulin responses to glucose beverage did not differ between ethnic groups (p = 0.28; p = 0.10). Based on an unadjusted regression model, European participants had significantly lower iAUC-glucose (p = 0.02) and iAUC-insulin (p = 0.01) after rice consumption than Asian participants. In the adjusted model, the difference between the two groups remained for iAUC-insulin (p = 0.04) but not for iAUC-glucose (p = 0.07).

CONCLUSION

Our study found that ethnic differences exist among healthy overweight adults in terms of insulin resistance, glycaemic response and insulinaemic response to rice. As a result of their high insulin resistance, Asian participants had a higher postprandial insulin spike than Europeans after eating rice. These findings could have substantial implications for nutrition recommendations based on ethnicity, particularly for Asians.

The characteristics of postprandial glycemic response patterns to white rice and glucose in healthy adults: Identifying subgroups by clustering analysis

OBJECTIVES

Large interpersonal variability in postprandial glycemic response (PGR) to white rice has been reported, and differences in the PGR patterns during the oral glucose tolerance test (OGTT) have been documented. However, there is scant study on the PGR patterns of white rice. We examined the typical PGR patterns of white rice and glucose and the association between them.

MATERIALS AND METHODS

We analyzed the data of 3-h PGRs to white rice (WR) and glucose (G) of 114 normoglycemic female subjects of similar age, weight status, and same ethnic group. Diverse glycemic parameters, based on the discrete blood glucose values, were calculated over 120 and 180 min. K-means clustering based on glycemic parameters calculated over 180 min was applied to identify subgroups and representative PGR patterns. Principal factor analysis based on the parameters used in the cluster analysis was applied to characterize PGR patterns. Simple correspondence analysis was performed on the clustering categories of WR and G.

RESULTS

More distinct differences were found in glycemic parameters calculated over 180 min compared with that calculated over 120 min, especially in the negative area under the curve and Nadir. We identified four distinct PGR patterns to WR (WR1, WR2, WR3, and WR4) and G (G1, G2, G3, and G4), respectively. There were significant differences among the patterns regard to postprandial hyperglycemia, hypoglycemic, and glycemic variability. The WR1 clusters had significantly lower glycemic index (59 ± 19), while no difference was found among the glycemic index based on the other three clusters. Each given G subgroup presented multiple patterns of PGR to WR, especially in the largest G subgroup (G1), and in subgroup with the greatest glycemic variability (G3).

CONCLUSION

Multiple subgroups could be classified based on the PGR patterns to white rice and glucose even in seemingly homogeneous subjects. Extending the monitoring time to 180 min was conducive to more effective discrimination of PGR patterns. It may not be reliable to extrapolate the patterns of PGR to rice from that to glucose, suggesting a need of combining OGTT and meal tolerance test for individualized glycemic management.

Differences in cardiometabolic risk profiles between Chinese and Finnish older adults with glucose impairment and central obesity

BACKGROUND

Obesity and ethnicity play important roles in cardiovascular complications in patients with type 2 diabetes mellitus (T2DM). This study aimed to compare cardiometabolic risk profiles between Chinese and Finnish older adults of central obesity with prediabetes or T2DM.

METHODS

Study subjects were 60-74 years old and originated from two population samples. The Finnish subjects came from the Kuopio Ischemic Heart Disease (KIHD) study (n = 1089), and the Chinese subjects came from the Shanghai High-risk Diabetic Screen (SHiDS) study (n = 818). The KIHD and SHiDS studies used similar questionnaires to determine participants' baseline characteristics regarding the history of medication use and diseases and lifestyle factors. All study subjects participated in glucose tolerance tests and anthropometry assessments, including waist circumference measurements.

RESULTS

Among study subjects of central obesity with prediabetes (n = 298), fasting and 2-h glucose, and fasting insulin and insulin resistance were significantly higher in Chinese than in Finnish (p < 0.0001-0.016). In addition, triglyceride (TG) level was higher and the low-density lipoprotein cholesterol (LDL) and LDL to high-density lipoprotein cholesterol (HDL) ratio were lower in Chinese than in Finnish (p < 0.0001-0.003). Among subjects of central obesity with T2DM (n = 251), Chinese subjects had significantly less proportions of antihypertensive, glycaemic control medication, and statin users as well as lower level of physical activity (p < 0.0001 for all), while higher blood pressure (p = 0.002 for systolic blood pressure and p < 0.0001 for diastolic blood pressure), TG levels (p < 0.05) and HDL (p = 0.002) than the Finnish counterparts. There were no differences in β-cell function (HOMA-β) between Chinese and Finnish both in prediabetes and T2DM.

CONCLUSIONS

Our results indicated that Chinese and Finnish older adults of central obesity with prediabetes and T2DM had similar β-cell function. However, Chinese individuals with prediabetes are prone to insulin resistance. Meanwhile, lipid metabolism dysfunction is also different between Chinese and Finnish. Chinese older adults of central obesity with prediabetes showed higher TG, but Finnish showed higher LDL and LDL/HDL. Strategic for T2DM prevention and treatment should be ethnically specific.

Effects of high-amylose maize starch on the glycemic index of Chinese steamed buns (CSB)

The incorporation of resistant starch (RS) in food has gained importance to be a good replacement for digestible carbohydrate. This study examined the effect of compositing RS (high-amylose maize starch (HM)) as wheat flour substitute (30%) in Chinese steamed bun (CSB) formulation on postprandial glycemic response in healthy human subject. In this single-blind and cross-over experimental trial, a total of 15 female participants (mean age = 31.5 ± 3.9) were randomly assigned to receive CSB containing 30% HM (HM30) or control CSB (without HM) with their blood glucose were recorded throughout the test. The blood glucose concentrations recorded for HM30 were significantly lower than control CSB at 15 min (6.03 vs. 7.04 mmol/L, p = 0.041), 30 min (6.93 vs. 7.76 mmol/L, p = 0.021), 45 min (6.21 vs. 7.55 mmol/L, p = 0.032), 60 min (5.68 vs. 6.26 mmol/L, p = 0.038), and 90 min (5.08 vs. 5.73 mmol/L, p = 0.022). The 2-h postprandial glucose was significantly lower in HM30 (iAUC = 105.2 mmol x min/L) than the control (186.1 mmol x min/L). The low GI property of HM30 (GI = 39.11 ± 5.6) did not cause sudden rapid increase in blood glucose concentration as observed in medium-GI control CSB (GI = 69.18 ± 9.8). This study suggests that adding 30g of HM decreased the glycemic index of CSB in healthy female adult.

Ethnicity impact on oral processing behaviour and glycemic response to noodles: Chinese (Asian) vs. New Zealander (Caucasian)

There is an increasing awareness of the link between food breakdown during chewing and its nutrient release and absorption in the gastrointestinal tract. However, how oral processing behaviour varies among different ethnic groups, and how such difference further impacts on bolus characteristics and consequently glycemic response (GR) are not well understood. In this study, we recruited a group of Asian (Chinese) subjects in China (n = 32) and a group of Caucasian subjects in New Zealand (n = 30), both aged between 18 and 30 years, and compared their blood glucose level (BGL) over 120 min following consumption of a glucose drink and cooked white noodles. We also assessed their chewing behaviour, unstimulated saliva flow rate, and ready-to-swallow bolus characteristics to determine whether these measures explain the ethnic differences in postprandial glycaemia. Compared to New Zealand subjects, the Chinese subjects showed 35% slower saliva flow rate but around 2 times higher salivary α-amylase activity in the unstimulated state. During consumption of noodles, Chinese subjects on average took a larger mouthful size, chewed each mouthful for longer and swallowed a larger number of particles with a smaller particle size area. Total GR measured by area under the curve (IAUC) was higher among the Chinese subjects. They also experienced higher BGL at 15 min, as well as higher peak BGL. There were strong correlations observed between oral processing and GR parameters. Results of this study confirmed the significance of oral processing in determining food digestion, and will provide new insights on the role of ethnicity in influencing people's physiological response to food.

Use of a Continuous Glucose Monitor to Determine the Glycaemic Index of Rice-Based Mixed Meals, Their Effect on a 24 h Glucose Profile and Its Influence on Overweight and Obese Young Adults' Meal Preferences

Postprandial hyperglycaemia is associated with an increased risk of type-2 diabetes. This study aims to determine the glycaemic index (GI) of three varieties of rice-based mixed meals and their effects on glycaemic variability (GV), 24 h mean glucose levels and target ranges, and rice variety preferences among overweight and obese young adults using real-time continuous glucose monitoring (rtCGM). In a randomised controlled crossover design, 14 participants (22.8 ± 4.6 years, 32.9 ± 5.8 kg/m2) were randomly assigned to receive 3 rice-based mixed meals containing 50 g of available carbohydrates (white rice meal = WRM; brown rice meal = BRM; and parboiled basmati rice meal = PBRM) and 50 g of a glucose reference drink on alternate days. GI, GV, 24 h mean glucose levels and target ranges were measured. Rice variety preferences were compared with those of baseline data and determined at the end of the study period. Results: The analysis found that PBRM was low in GI (45.35 ± 2.06), BRM medium in GI (56.44 ± 2.34), and WRM high in GI (83.03 ± 2.19). PBRM had a significantly (p < 0.05) lower 24 h mean glucose level, higher in-target 24 h glucose level percentage and non-significantly (p > 0.05) lower GV compared to WRM. Prior to observing their postprandial glucose levels generated by rtCGM, the participants preferred WRM (64.3%) over other meals, whereas this preference changed significantly (p < 0.05) at the endpoint (PBRM, 71.4%). PBRM reduced 24 h glucose level and GV of overweight and obese young adults. The rtCGM is proven to be reliable in measuring GI, while providing robust continuous glycaemic information. This may serve as an educational tool that motivates eating behaviour changes among overweight and obese young adults.

Impact of Masticatory Behaviors Measured With Wearable Device on Metabolic Syndrome: Cross-sectional Study

Background

It has been widely recognized that mastication behaviors are related to the health of the whole body and to lifestyle-related diseases. However, many studies were based on subjective questionnaires or were limited to small-scale research in the laboratory due to the lack of a device for measuring mastication behaviors during the daily meal objectively. Recently, a small wearable masticatory counter device, called bitescan (Sharp Co), for measuring masticatory behavior was developed. This wearable device is designed to assess objective masticatory behavior by being worn on the ear in daily life.

Objective

This study aimed to investigate the relation between mastication behaviors in the laboratory and in daily meals and to clarify the difference in mastication behaviors between those with metabolic syndrome (MetS) and those without (non-MetS) measured using a wearable device.

Methods

A total of 99 healthy volunteers (50 men and 49 women, mean age 36.4 [SD 11.7] years) participated in this study. The mastication behaviors (ie, number of chews and bites, number of chews per bite, and chewing rate) were measured using a wearable ear-hung device. Mastication behaviors while eating a rice ball (100 g) in the laboratory and during usual meals for an entire day were monitored, and the daily energy intake was calculated. Participants’ abdominal circumference, fasting glucose concentration, blood pressure, and serum lipids were also measured. Mastication behaviors in the laboratory and during meals for 1 entire day were compared. The participants were divided into 2 groups using the Japanese criteria for MetS (positive/negative for MetS or each MetS component), and mastication behaviors were compared.

Results

Mastication behaviors in the laboratory and during daily meals were significantly correlated (number of chews r=0.36; P<.001; number of bites r=0.49; P<.001; number of chews per bite r=0.33; P=.001; and chewing rate r=0.51; P<.001). Although a positive correlation was observed between the number of chews during the 1-day meals and energy intake (r=0.26, P=.009), the number of chews per calorie ingested was negatively correlated with energy intake (r=–0.32, P=.002). Of the 99 participants, 8 fit the criteria for MetS and 14 for pre-MetS. The number of chews and bites for a rice ball in the pre-MetS(+) group was significantly lower than the pre-MetS(–) group (P=.02 and P=.04, respectively). Additionally, scores for the positive abdominal circumference and hypertension subgroups were also less than the counterpart groups (P=.004 and P=.01 for chews, P=.006 and P=.02 for bites, respectively). The number of chews and bites for an entire day in the hypertension subgroup were significantly lower than in the other groups (P=.02 and P=.006). Furthermore, the positive abdominal circumference and hypertension subgroups showed lower numbers of chews per calorie ingested for 1-day meals (P=.03 and P=.02, respectively).

Conclusions

These results suggest a relationship between masticatory behaviors in the laboratory and those during daily meals and that masticatory behaviors are associated with MetS and MetS components.

Trial Registration

University Hospital Medical Information Network Clinical Trials Registry R000034453; https://tinyurl.com/mwzrhrua

Effect of Different Carbohydrate Intakes within 24 Hours after Glycogen Depletion on Muscle Glycogen Recovery in Japanese Endurance Athletes

Daily muscle glycogen recovery after training is important for athletes. Few studies have reported a continuous change in muscle glycogen for 24 h. We aimed to investigate the changes in carbohydrate intake amount on muscle glycogen recovery for 24 h after exercise using 13C-magnetic resonance spectroscopy (13C-MRS). In this randomized crossover study, eight male participants underwent prolonged high-intensity exercise, and then consumed one of the three carbohydrate meals (5 g/kg body mass (BM)/d, 7 g/kg BM/d, or 10 g/kg BM/d). Glycogen content of thigh muscle was measured using 13C-MRS before, immediately after, and 4 h, 12 h and 24 h after exercise. Muscle glycogen concentration decreased to 29.9 ± 15.9% by exercise. Muscle glycogen recovery 4−12 h after exercise for the 5 g/kg group was significantly lower compared to those for 7 g/kg and 10 g/kg groups (p < 0.05). Muscle glycogen concentration after 24 h recovered to the pre-exercise levels for 7 g/kg and 10 g/kg groups; however, there was a significant difference for the 5 g/kg group (p < 0.05). These results suggest that carbohydrate intake of 5 g/kg BM/d is insufficient for Japanese athletes to recover muscle glycogen stores 24 h after completing a long-term high-intensity exercise.

Decreasing the RAG:SAG ratio of granola cereal predictably reduces postprandial glucose and insulin responses: a report of four randomised trials in healthy adults

Dietary starch contains rapidly (RAG) and slowly available glucose (SAG). To establish the relationships between the RAG:SAG ratio and postprandial glucose, insulin and hunger, we measured postprandial responses elicited by test meals varying in the RAG:SAG ratio in n 160 healthy adults, each of whom participated in one of four randomised cross-over studies (n 40 each): a pilot trial comparing six chews (RAG:SAG ratio 2·4–42·7) and three studies comparing a test granola (TG1-3, RAG:SAG ratio 4·5–5·2) with a control granola (CG1–3, RAG:SAG ratio 54·8–69·3). Within studies, test meals were matched for fat, protein and available carbohydrate. Blood glucose, serum insulin and subjective hunger were measured for 3 h. Data were subjected to repeated-measures analysis of variance (ANOVA). The relationships between the RAG:SAG ratio and postprandial end points were determined by regression analysis. In the pilot trial, 0–2 h glucose incremental areas under the curve (iAUC0–2; primary end point) varied across the six chews (P = 0·014) with each 50 % reduction in the RAG:SAG ratio reducing relative glucose response by 4·0 %. TGs1-3 elicited significantly lower glucose iAUC0–2 than CGs1–3 by 17, 18 and 17 %, respectively (similar to the 15 % reduction predicted by the pilot trial). The combined means ± sem (n 120) for TC and CG were glucose iAUC0–2, 98 ± 4 v. 118 ± 4 mmol × min/l (P < 0·001), and insulin iAUC0–2, 153 ± 9 v. 184 ± 11 nmol × h/l (P < 0·001), respectively. Neither postprandial hunger nor glucose or hunger increments 2 h after eating differed significantly between TG and CG. We concluded that TGs with RAG:SAG ratios <5·5 predictably reduced glycaemic and insulinaemic responses compared with CGs with RAG:SAG ratios >54. However, compared with CG, TG did not reduce postprandial hunger or delay the return of glucose or hunger to baseline.

Seaweeds as Ingredients to Lower Glycemic Potency of Cereal Foods Synergistically-A Perspective

Seaweeds are traditional food ingredients mainly in seaside regions. Modern food science and nutrition researchers have identified seaweed as a source of functional nutrients, such as dietary soluble and insoluble fibers, proteins, omega-3 fatty acids, prebiotic polysaccharides, polyphenols, and carotenoids. Owing to the rich nutrients, seaweeds and seaweed extract can be used as functional ingredients by modifying the nutrients composition to reduce the proportion of available carbohydrates, delaying the gastric emptying time and the absorption rate of glucose by increasing the digesta viscosity, and attenuating the digesting rate by blocking the activity of digestive enzymes. This review presents the concept of using seaweed as unconventional ingredients that can function synergistically to reduce the glycemic potency of cereal products.

Ethnic differences in response to lifestyle intervention for the prevention of type 2 diabetes in adults: A systematic review and meta-analysis

The risk of type 2 diabetes mellitus (T2DM) varies by ethnicity, but ethnic differences in response to diabetes prevention interventions remain unclear. This systematic review and meta-analysis assessed ethnic differences in the effects of lifestyle interventions on T2DM incidence, glycemic outcomes (fasting glucose, 2-h glucose, HbA_1c ), anthropometric measures (weight, BMI, waist circumference), and lifestyle behaviors (physical activity, energy intake, energy from fat, fiber intake). MEDLINE, EMBASE, and other databases were searched (to June 15, 2020) for randomized and non-randomized controlled trials on lifestyle interventions (diet and/or physical activity) in adults at risk of T2DM. Ethnicity was categorized into European, South Asian, East and Southeast Asian, Middle Eastern, Latin American, and African groups. Forty-four studies were included in meta-analyses. Overall, lifestyle interventions resulted in significant improvement in T2DM incidence, glycemic outcomes, anthropometric measures, physical activity, and energy intake (all P < 0.01). Significant subgroup differences by ethnicity were found for 2-h glucose, weight, BMI, and waist circumference (all P < 0.05) but not for T2DM incidence, fasting glucose, HbA_1c , and physical activity (all P > 0.05). Few studies in non-European groups reported dietary intake. Lifestyle interventions in different ethnic groups may have similar effects in reducing incidence of T2DM although this needs to be confirmed in further studies.

Clinical Characteristics of Patients With HNF1-alpha MODY: A Literature Review and Retrospective Chart Review

The clinical manifestation of hepatocyte nuclear factor-1-alpha (HNF1-alpha) maturity-onset diabetes of the young (MODY) is highly variable. This study aims to investigate the clinical characteristics of patients with HNF1-alpha MODY in general, by geographical regions (Asian or non-Asian), HNF1-alpha mutations, and islet autoantibody status. A literature review and a chart review of patients with HNF1-alpha MODY were performed. The means and proportions from studies were pooled using the inverse variance method for pooling, and subgroup analyses were performed. A total of 109 studies involving 1,325 patients [41.5%, 95% confidence interval (CI): 35.2, 48.1; male] were identified. The mean age of diagnosis was 20.3 years (95% CI: 18.3-22.2), and the mean glycated hemoglobin was 7.3% (95% CI: 7.2-7.5). In comparison, Asian patients exhibited significantly higher HbA1c (p = 0.007) and 2-h post-load C-peptide (p = 0.012) levels and lower levels of triglyceride (TG) (p < 0.001), total cholesterol (TC) (p < 0.001), and high-density lipoprotein cholesterol (HDL-c) (p < 0.001) and less often had macrovascular complications (p = 0.014). The age of diagnosis was oldest in patients with mutations in the transactivation domain (p < 0.001). The levels of 2-h post-load C-peptide (p < 0.001), TG (p = 0.007), TC (p = 0.017), and HDL-c (p = 0.001) were highest and the prevalence of diabetic neuropathy was lowest (p = 0.024) in patients with DNA-binding domain mutations. The fasting (p = 0.004) and 2-h post-load glucose (p = 0.003) levels and the prevalence of diabetic neuropathy (p = 0.010) were higher among patients with positive islet autoantibodies. The study demonstrated that the clinical manifestations of HNF1-alpha MODY differed by geographical regions, HNF1-alpha mutations, and islet autoantibody status.

Postprandial Metabolism and Physical Activity in Asians: A Narrative Review

The widespread benefits of physical activity in enhancing health and lowering the risk of non-communicable chronic diseases are well established across populations globally. Nevertheless, the prevalence of several lifestyle-related chronic diseases, including cardiovascular disease, varies markedly across countries and ethnicities. Direct ethnic comparative studies on the health benefits of physical activity are sparse and evidence-based physical activity guidelines are not ethnicity-specific. Indeed, physical activity guidelines in some Asian countries were developed primarily based on data from Western populations even though the magnitude of potential benefit may not be the same among different ethnic groups. Unfavorable diurnal perturbations in postprandial triglycerides and glucose are risk factors for cardiovascular disease. This narrative review summarizes differences in these risk factors primarily between individuals of Asian and white European descent but also within different Asian groups. Moreover, the variable effects of physical activity on mitigating risk factors among these ethnic groups are highlighted along with the underlying metabolic and hormonal factors that potentially account for these differences. Future ethnic comparative studies should include investigations in understudied ethnic groups, such as those of East Asian origin, given that the effectiveness of physical activity for ameliorating cardiovascular disease varies even among Asian groups.

Race/ethnicity and challenges for optimal insulin therapy

AIMS

We aimed to review insulin dosing recommendations, insulin regulation and its determinants, glycaemic response to carbohydrates, and the efficacy and safety of insulin therapy in different races/ethnicities.

METHODS

We searched for articles in PubMed and Google Scholar databases up to 31 March 2021, with the following keywords: "ethnicity", "diabetes", "insulin", "history of insulin", "insulin therapy", "food/rice", "carbohydrate intake", "insulin resistance", "BMI", "insulin dosing", "insulin sensitivity", "insulin response", "glycaemic index", "glycaemic response", "efficacy and safety", with interposition of the Boolean operator "AND".In addition, we reviewed the reference lists of the articles found.

RESULTS

The differential effect of race/ethnicity has not yet been considered in current insulin therapy guidelines. Nevertheless, body size and composition, body mass index, fat distribution, diet, storage, and energy expenditure vary significantly across populations. Further, insulin sensitivity, insulin response, and glycaemicresponse to carbohydrates differ by ethnicity. These disparities may lead to different insulin requirements, adversely impacting the efficacy and safety of insulin therapy among ethnic groups.

CONCLUSIONS

Race/ethnicity affects glucose metabolism and insulin regulation.Until now, international guidelines addressing racial/ethnic-specific clinical recommendations are limited. Comprehensive updated insulin therapy guidelines by ethnicity are urgently needed.

A higher-protein nut-based snack product suppresses glycaemia and decreases glycaemic response to co-ingested carbohydrate in an overweight prediabetic Asian Chinese cohort: the Tū Ora postprandial RCT

Nut-based products may aid low-glycaemic dietary strategies that are important for diabetes prevention in populations at increased risk of dysglycaemia, such as Asian Chinese. This randomised cross-over trial assessed the postprandial glycaemic response (0-120 min) of a higher-protein nut-based (HP-NB) snack formulation, in bar format (1009 kJ, Nutrient Profiling Score, NPS, -2), when compared with an iso-energetic higher-carbohydrate (CHO) cereal-based bar (HC-CB, 985 kJ, NPS +3). It also assessed the ability to suppress glucose response to a typical CHO-rich food (white bread, WB), when co-ingested. Ten overweight prediabetic Chinese adults (mean, sd: age 47⋅9, 15⋅7 years; BMI 25⋅5, 1⋅6 kg/m2), with total body fat plus ectopic pancreas and liver fat quantified using dual-energy X-ray absorptiometry and magnetic resonance imaging and spectroscopy, received the five meal treatments in random order: HP-NB, HC-CB, HP-NB + WB (50 g available CHO), HC-CB + WB and WB only. Compared with HC-CB, HP-NB induced a significantly lower 30-120 min glucose response (P < 0⋅05), with an approximately 10-fold lower incremental area under the glucose curve (iAUC0-120; P < 0⋅001). HP-NB also attenuated glucose response by approximately 25 % when co-ingested with WB (P < 0⋅05). Half of the cohort had elevated pancreas and/or liver fat, with 13-21 % greater suppression of iAUC0-120 glucose in the low v. high organ fat subgroups across all five treatments. A nut-based snack product may be a healthier alternative to an energy equivalent cereal-based product with evidence of both a lower postprandial glycaemic response and modulation of CHO-induced hyperglycaemia even in high-risk, overweight, pre-diabetic adults.

One-hour plasma glucose concentration can identify elderly Chinese male subjects at high risk for future type 2 diabetes mellitus: A 20-year retrospective and prospective study

AIM

There have been few reports regarding the association between 1 h-PG concentration and type 2 diabetes mellitus (T2DM) in the elderly. This study was performed to assess the efficacy of 1 h-PG and 2 h-PG values in predicting future risk of T2DM in elderly.

METHODS

The study population consisted of 928 male volunteers ≥ 55 years old without diabetes who were involved in a retrospective-prospective cohort study over 20 years with a baseline fasting plasma glucose (FPG) and OGTT that included measurement of 1 h-PG and 2 h-PG. The predictive capabilities of FPG and 1 h-PG, 2 h-PG values obtained during OGTT alone and added to a clinical prediction model consisting of traditional diabetes risk factors were assessed.

RESULTS

Overall, 577 of all the 928 study participants (62%) developed T2DM over the 20-year follow-up. 1 h-PG and 2 h-PG values predicted T2DM and remained independent predictors of T2DM after adjusting for various traditional risk factors [HR = 1.269 (95% CI = 1.214-1.327), P < 0.001; HR = 1.269 (95% CI = 1.179-1.366), P < 0.001, respectively]. C-statistics for 1-h PG (C-statistics 0.794 [95% CI 0.765-0.823]) was significantly greater than that for 2-h PG (C-statistic 0.747 [95% CI 0.716-0.779]) in models adjusting for various traditional risk factors. 1 h-PG had the greatest area under the ROC curve (AUC, 0.766), which was greater than that of 2 h-PG (0.719).

CONCLUSIONS

1 h-PG is useful as a predictor of future development of T2DM independently of traditional risk factors in an elderly Chinese male population.

Opposite Effects of Work-Related Physical Activity and Leisure-Time Physical Activity on the Risk of Diabetes in Korean Adults

The object of this study was to examine the effects of domestic and work-related physical activity (DWPA) and leisure-time physical activity (LTPA) on the risk of diabetes, by categorizing fasting blood glucose (FBG) levels into normal, Impaired Fasting Glucose (IFG), and diabetes. The sample consisted of 4661 adults aged 30 years or above, and was chosen from the 2017 Korean National Health and Nutrition Examination Survey (KNHANES) data. Of all the subjects, 14.6% engaged in high-intensity DWPA and 6.25% in moderate-intensity DWPA; while 11.68% and 24.80% engaged in high- and moderate-intensity LTPA, respectively. The effects of both types of physical activities on the risk of diabetes were analyzed using a Bayesian ordered probit model. For those with high-intensity DWPA, the probability of the FBG level being normal was 5.10% (SE = 0.25) lower than for those with non-high-intensity DWPA, and the probabilities of IFG and diabetes were 3.30% (SE = 0.15) and 1.79% (SE = 0.09) higher, respectively. However, for those with high-intensity LTPA, the probability of the FBG level being normal was 2.54% (SE = 0.09) higher, and the probabilities of IFG and diabetes were 1.74% (SE = 0.07) and 0.80% (SE = 0.03) lower, respectively, than those with non-high-intensity LTPA. Likewise, for moderate-intensity DWPA and LTPA, the results were the same compared to low-intensity physical activities though the magnitude of the effects were smaller than for high-intensity. Thus, the activities related to work have a negative effect and those related to leisure have a positive effect. The criteria for physical activities to reduce the risk of diabetes should be set by separating these domains of physical activity, and new management strategies for diabetes are needed for people with moderate- or high-intensity DWPA.

Skeletal Muscle Ratio: A Complete Mediator of Physical Activity and HbA1C in Type 2 Diabetes

BACKGROUND

An increase in the physical activity level reduces body weight, decreases body fat, increases skeletal muscle mass, and improves serum glucose; however, the influence of body composition parameters on the relationship between physical activity and serum glucose remains unclear.

OBJECTIVE

This study investigated whether skeletal muscle and visceral fat affect the relationship between high physical activity and long-term serum glucose goals.

METHOD

This cross-sectional study recruited patients with type 2 diabetes. The Chinese version of the International Physical Activity Questionnaire was used for estimating the physical activity level, and a bioimpedance device was used to measure the skeletal muscle ratio (skeletal muscle mass/total body weight, %) and visceral fat area (cm²). Hierarchical logistic regression models and mediation tests were conducted according to Hayes' procedures.

RESULTS

Of the total 543 Chinese individuals with type 2 diabetes enrolled, HbA1C levels of fewer than half (n = 243, 44.8%) met the target of ≤7.0%. The skeletal muscle ratio was found to be a complete mediator (OR = 0.920, 95% CI: 0.848 to 0.998; indirect effect: -0.238, 95% CI: -0.525 to -0.020) of the relationship between high physical activity and the target HbA1C level after controlling for visceral fat area (indirect effect: -0.013, 95% CI: -0.183 to 0.156), age, time since diabetes diagnosis, and rice intake.

CONCLUSION

Nurses should include an increase in the skeletal muscle ratio as an objective in physical activity interventions for patients with type 2 diabetes to help them achieve their long-term serum glucose goals.

Discharge pharmacotherapy for Type 2 diabetic inpatients at two hospitals of different tiers in Zhejiang Province, China

Objects

To look into the discharge pharmacotherapy for type 2 diabetics admitted to two general hospitals of different ranks and inspect current real-world management of discharge pharmacology and its related factors.

Methods

Type 2 diabetics admitted to a tertiary general hospital (Ningbo Medical Treatment Centre Lihuili Hospital, LHLH) or a secondary general hospital (Simen Hospital, SMH) for intensification of their anti-diabetics were included for retrospective analysis. Patients’ demographics, clinical characteristics, admission diabetes therapy and discharge diabetes pharmacology were analyzed and compared among patients in each hospital as well as between two hospitals.

Results

391 patients from LHLH and 164 patients from SMH were included for analyzing. Compared with patients from LHLH, patients from SMH were older, more illiterate and had higher HbA1c concentrations. While there was a nearly equal split of oral anti-diabetes drugs (OADs)-only and Insulin treatment in LHLH’s discharge pharmacotherapy, insulin treatment dominated SMH’s. Basal-and-bolus insulin assumed the majority of SMH’s insulin regimens but only accounted for less than 20% of LHLH’s. The principal discrepancy in OADs-only treatment existed in the utilization of newer classes of OADs. Cost and body mass index (BMI) were the main differentiating factors among OADs-only treatments while duration, BMI and HbA1c differ among insulin treatments at LHLH. Clinical characteristics didn’t significantly differ among OADs-only treatments and HbA1c was the only differentiating factor among insulin treatments at SMH. Overall, hospital, duration, HbA1c, and vascular diseases were main factors that affect discharge pharmacology.

Conclusions

Great disparities exist in the discharge pharmacotherapy at two hospitals. Diabetes management is mostly glucose-oriented at SMH while multifactorial considerations were reflected in LHLH’s discharge pharmacotherapy. Besides differences in patients’ demographics, medication availability and diagnosis of early-stage vascular complications, lack of practical algorithm for discharge management in T2DM may be the underlying deficiency and a key part for future improvement.

Reducing the glycemic impact of carbohydrates on foods and meals: Strategies for the food industry and consumers with special focus on Asia

Type 2 diabetes is increasingly prevalent in Asia, which can be attributed to a carbohydrate-rich diet, consisting of foods in the form of grains, for example, rice, or a food product made from flours or isolated starch, for example, noodles. Carbohydrates become a health issue when they are digested and absorbed rapidly (high glycemic index), and more so when they are consumed in large quantities (high glycemic load). The principal strategies of glycemic control should thus aim to reduce the amount of carbohydrate available for digestion, reduce the rate of digestion of the food, reduce the rate of glucose absorption, and increase the rate of glucose removal from blood. From a food perspective, the composition and structure of the food can be modified to reduce the amount of carbohydrates or alter starch digestibility and glucose absorption rates via using different food ingredients and processing methods. From a human perspective, eating behavior and food choices surrounding a meal can also affect glycemic response. This review therefore identifies actionable strategies and opportunities across foods and meals that can be considered by food manufacturers or consumers. They are (a) using alternative ingredients, (b) adding functional ingredients, and (c) changing processing methods and parameters for foods, and optimizing (a) eating behavior, (b) preloading or co-ingestion of other macronutrients, and (c) meal sequence and history. The effectiveness of a strategy would depend on consumer acceptance, compatibility of the strategy with an existing food product, and whether it is economically or technologically feasible. A combination of two or more strategies is recommended for greater effectiveness and flexibility.

Vildagliptin Versus α-Glucosidase Inhibitor as Add-On to Metformin for Type 2 Diabetes: Subgroup Analysis of the China Prospective Diabetes Study

INTRODUCTION

The effect of dipeptidyl peptidase-4 (DDP-4) inhibitors versus α-glucosidase inhibitors (AGIs) on the treatment of type 2 diabetes mellitus (T2DM) in a real-world setting is unknown. The aim of this real-world study was to compare the glucose-lowering effect and tolerability of vildagliptin as add-on to metformin monotherapy (VM) and AGI as add-on to metformin monotherapy (AM) in Chinese patients with T2DM.

METHODS

This was a subgroup analysis of the China Prospective Diabetes Study, a post-marketing, prospective, observational, real-world study conducted at 52 centers in China. T2DM patients with inadequate glycemic control on metformin monotherapy who received VM or AM were included. The composite primary endpoint was glycemic control (hemoglobin A1c [HbA1c] < 7%) after 12 months in the absence of tolerability events (hypoglycemia, weight gain ≥ 3%, or gastrointestinal events leading to treatment discontinuation). Propensity score matching (PSM) was used to balance the two groups.

RESULTS

The success rates of the composite endpoint were higher in the VM group (n = 604/159 before/after PSM) than in the AM group (n = 159/157 before/after PSM), but the difference was not statistically significant (before PSM: 53.0 vs. 46.5%, P = 0.148; after PSM: 56.7 vs. 45.9%, P = 0.055). The glycemic control rate and HbA1c reduction were similar between groups at 3, 6, and 12 months. Compared with the AM group, the VM group had lower risks of any tolerability event (relative risk [RR] 0.53, 95% confidence interval [CI] 0.33-0.83, P = 0.006), of any adverse event (AE) (RR 0.64, 95% CI 0.41-1.00, P = 0.049), and of any serious AE (RR  0.45, 95% CI 0.25-0.81, P = 0.007).

CONCLUSION

The results of this real-world study suggest that vildagliptin as add-on to metformin monotherapy had a similar glucose-lowering effect to AGI as add-on to metformin monotherapy, but with better safety.

Disparities in gastric emptying and postprandial glycaemia between Han Chinese and Caucasians with type 2 diabetes

AIMS

Gastric emptying is a major determinant of postprandial glycaemia in both health and type 2 diabetes (T2DM); the potential impact of ethnicity on gastric emptying is unclear. We compared the rate of gastric emptying of a standardised meal and the associated glycaemic response in Han Chinese and Caucasian patients with T2DM.

METHODS

14 Han Chinese and 14 Caucasian T2DM patients, managed by diet and/or metformin monotherapy, underwent concurrent measurements of gastric emptying and blood glucose for 240 min after a 99mTc-calcium phytate-labelled mashed potato meal.

RESULTS

Han Chinese patients were slightly younger (P < 0.05), and had a lower BMI (P < 0.05), than Caucasians. There were no differences in either HbA1c or fasting blood glucose between them. Gastric half-emptying time (T50) was shorter (P < 0.05) and the postprandial blood glucose increment greater (P < 0.05) in Han Chinese than Caucasian patients. Both the increment in blood glucose from baseline at 60 min and peak blood glucose were related inversely to T50 (P < 0.05 each).

CONCLUSIONS

Han Chinese with relatively well-controlled T2DM have more rapid gastric emptying compared to Caucasians, which is associated with a greater postprandial glycaemic excursion. These differences may inform the choice of management, e.g. Han Chinese may particularly benefit from therapies that slow gastric emptying.

A High-Throughput In Vitro Assay for Screening Rice Starch Digestibility

The development of rice that can produce slow and steady postprandial glucose in the bloodstream is a response to alarmingly high global rates of obesity and related chronic diseases. However, rice grain quality programs from all over the world currently do not have access to a high-throughput method to distinguish rice breeding materials that are digested slowly. The objective of this study was to develop a high-throughput in vitro assay to screen the digestibility of cooked white rice grains and to investigate its ability to differentiate rice genotypes with a low starch digestibility rate. The digestibility rate and extent of three commercial rice genotypes with diverse GI values (Doongara, Reiziq and Waxy) were successfully differentiated using the protocol. Further investigations with eight rice genotypes indicated the percentage of starch hydrolysed at a single time point of the assay (SH-60) successfully differentiated genotypes with a low digestibility rate (the SH-60 of Doongara and YRL127 was 50% and 59%, respectively) from genotypes with an intermediate or high digestibility rate (SH-60 values were between 64% and 93%). Application of this methodology in rice breeding programs may assist in the screening and development of new varieties with a desirable postprandial glycaemic response.

Efficacy and safety of insulin degludec/insulin aspart versus biphasic insulin aspart 30 in Chinese adults with type 2 diabetes: A phase III, open-label, 2:1 randomized, treat-to-target trial

AIMS

To assess the efficacy and safety of twice-daily insulin degludec/insulin aspart (IDegAsp) versus biphasic insulin aspart 30 (BIAsp 30) twice daily, both ± metformin, in Chinese adults (N = 543) with type 2 diabetes (T2D) inadequately controlled on premixed/self-mixed or basal insulin ± metformin.

MATERIALS AND METHODS

We conducted a 26-week, phase III, open-label, treat-to-target, 2:1 randomized trial. Hierarchical testing was used with non-inferiority of glycated haemoglobin (HbA1c) change from baseline to week 26 as the primary endpoint and superiority for the confirmatory secondary endpoints which were as follows: change from baseline in fasting plasma glucose (FPG); nocturnal confirmed hypoglycaemic episodes (12:01-5:59 am, inclusive); total confirmed hypoglycaemic episodes (severe or plasma glucose <3.1 mmol/L with/without symptoms); body weight; and percentage of responders (HbA1c <53 mmol/mol [<7.0%]) without confirmed hypoglycaemic episodes.

RESULTS

Non-inferiority for change from baseline to week 26 in HbA1c and superiority of IDegAsp twice daily versus BIAsp 30 twice daily for change in FPG, nocturnal confirmed and total confirmed hypoglycaemic episodes, was demonstrated. Estimated rates of nocturnal confirmed and total confirmed hypoglycaemic episodes were 47% and 43% lower, respectively, with IDegAsp twice daily versus BIAsp 30 twice daily. Superiority for change in body weight was not confirmed. Participants were more likely to reach the HbA1c goal of <53 mmol/mol (<7.0%) without confirmed hypoglycaemia with IDegAsp twice daily versus BIAsp 30 twice daily by trial end. No new safety signals were identified.

CONCLUSIONS

The efficacy and safety of IDegAsp in Chinese patients with T2D was demonstrated, confirming results from international trials.

Expert Opinion: Patient Selection for Premixed Insulin Formulations in Diabetes Care

Premixed insulins are an important tool for glycemic control in persons with diabetes. Equally important in diabetes care is the selection of the most appropriate insulin regimen for a particular individual at a specific time. Currently, the choice of insulin regimens for initiation or intensification of therapy is a subjective decision. In this article, we share insights, which will help in rational and objective selection of premixed formulations for initiation and intensification of insulin therapy. The glycemic status and its variations in a person help to identify the most appropriate insulin regimen and formulation for him or her. The evolution of objective glucometric indices has enabled better glycemic monitoring of individuals with diabetes. Management of diabetes has evolved from a 'glucocentric' approach to a 'patient-centered' approach; patient characteristics, needs, and preferences should be evaluated when considering premixed insulin for treatment of diabetes.Funding: Novo Nordisk, India.

Postprandial Glycaemic, Hormonal and Satiety Responses to Rice and Kiwifruit Preloads in Chinese Adults: A Randomised Controlled Crossover Trial

Controlling postprandial glycaemia helps to prevent and manage non-communicable diseases. One strategy in controlling glycaemia may be to consume meals in two parts; a preload, followed by the remainder of the meal. Our aim was to test preloading a rice meal given for breakfast and lunch on different days, either by splitting the meal (rice preload followed by rice meal) or by using kiwifruit as a preload compared with consuming the rice meal in one sitting. Primary outcomes were glycaemic and insulinaemic responses with secondary outcomes of other hormonal responses, subjective satiety, and subsequent energy intake. Following breakfast, postprandial glycaemic peak concentration was 0.9 (95% CI: 0.2, 1.6) mmol/L lower for the kiwifruit preload compared with the rice meal eaten in one sitting. Following lunch, glycaemic peak concentrations were 1.0 (0.7, 1.4) and 1.1 (0.5, 1.7) mmol/L lower for the rice-split and kiwifruit preload compared with the rice meal alone, respectively. Postprandial insulinaemia area-under-the-curve was 1385 (87, 2684) mU/L·min less for the kiwifruit preload compared with the rice-split. There were no differences among treatments for subsequent energy intake. Meal splitting is useful for lowering postprandial glycaemia, and replacing part of a meal with kiwifruit may help with insulin efficiency without detriment to subsequent energy intake.

Mulberry leaf extract reduces the glycemic indexes of four common dietary carbohydrates

BACKGROUND

1-Deoxynojirimycin (DNJ), a component of mulberry leaf extract (MLE), reduces postprandial hyperglycemia by inhibiting intestinal a-glycosidase. The aim of this exploratory study was to investigate the effects of MLE on the glycemic indexes (GI) of common dietary carbohydrates.

METHODS

This single-center, randomized, open-label, 7-cycle self-controlled crossover study enrolled 15 healthy volunteers at the National Drug Clinical Trial Institution, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine (June 2014 to December 2014). The participants were randomized to receive glucose (3 occasions), glucose+MLE, sucrose+MLE, maltose+MLE, and maltodextrin+MLE orally during 7 visits (every 3 days). Blood glucose level was tested at 15 minutes before and at 15, 30, 45, 60, 90, and 120 minutes after carbohydrate intake. The GI of each carbohydrate relative to glucose (GI = 100) was calculated using the incremental area under the curve method. Safety was assessed at each visit.

RESULTS

All participants completed the protocol. After carbohydrate ingestion, blood glucose level peaked at 30 minutes (glucose, glucose+MLE, sucrose+MLE, and maltose+MLE) or 45 minutes (maltodextrin+MLE) before returning to preprandial levels at 120 minutes. At 30 minutes, the change in blood glucose level was lower for sucrose+MLE, maltose+MLE, and maltodextrin+MLE than for glucose or glucose+MLE (P < .05). GI was lowest for sucrose+MLE (43.22 ± 17.47) and maltose+MLE (49.23 ± 22.39), intermediate for maltodextrin+MLE (75.90 ± 26.01), and higher for glucose+MLE (91.88 ± 27.24). MLE reduced the GIs for maltose, sucrose, maltodextrin, and glucose by 53.11%, 33.51%, 31.00%, and 8.12%, respectively. MLE was well tolerated.

CONCLUSIONS

Coconsumption of MLE with sucrose, maltose, or maltodextrin can reduce the GI values of these carbohydrates.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Platform, no. ChiCTR-IPR-15006484. Registered on May 28, 2015.

A Double-Blind, Randomized Controlled, Acute Feeding Equivalence Trial of Small, Catalytic Doses of Fructose and Allulose on Postprandial Blood Glucose Metabolism in Healthy Participants: The Fructose and Allulose Catalytic Effects (FACE) Trial

Recent literature suggests that catalytic doses (≤10 g/meal or 36 g/day) of D-fructose and D-allulose may reduce postprandial blood glucose responses to carbohydrate loads in people with and without type 2 diabetes by inducing glycogen synthesis. To assess the effect of small single doses of fructose and allulose on postprandial blood glucose regulation in response to a 75 g-oral glucose tolerance test (75 g-OGTT) in healthy individuals, we conducted an acute randomized, crossover, equivalence trial in healthy adults. Each participant randomly received six treatments, separated by a minimum one-week washout. Treatments consisted of a 75 g-OGTT with the addition of fructose or allulose at 0 g (control), 5 g or 10 g. A standard 75 g-OGTT protocol was followed with blood samples at −30, 0, 30, 60, 90, 120 min. The primary outcome was the difference in plasma glucose incremental area under the curve (iAUC). A total of 27 participants underwent randomization with data available from 25 participants. Small doses of fructose or allulose did not show a significant effect on plasma glucose iAUC or other secondary markers of postprandial blood glucose regulation in response to a 75 g-OGTT in healthy individuals. These results were limited by the low power to detect a significant difference, owing to greater than expected intra-individual coefficient of variation (CV) in plasma glucose iAUC. Overall, we failed to confirm the catalytic effects of small doses of fructose and allulose in healthy individuals. Future trials may consider recruiting larger sample sizes of healthy individuals. Trial registration: clinicaltrials.gov identifier, NCT02459834.

Greater Glycaemic Response to an Oral Glucose Load in Healthy, Lean, Active and Young Chinese Adults Compared to Matched Caucasians

There are ethnic differences recorded in glycaemic response and rates of type 2 diabetes mellitus (DM) between Chinese and Caucasian populations. Whether these differences are evident in matched healthy, lean, active, young adults is unclear. This study compares the postprandial glycaemic response of a group of Chinese participants (n = 49) with a group of similar Caucasians, (n = 48) aged 23.8 (±4.35 years), body mass index (BMI) 22.7 (±2.6) kg/m², healthy (free from non-communicable disease), and lean (body fat % 23.28% (±5.04)). Participants undertook an oral glucose tolerance test to identify any significant differences in postprandial blood glucose response. Body fat percentage, body mass, age, physical activity, baseline glucose and HbA1c did not significantly differ between groups. Data from food frequency questionnaires indicated that the Chinese participants consumed less starchy foods, candy and “other” sweets and sugary drinks, and more rice than the Caucasians (all p ≤ 0.001), but not a greater overall intake of carbohydrates or any other macronutrient (all p > 0.05). The two groups’ postprandial blood glucose responses and 2-h incremental area under the curve values (iAUC)—156.67 (74.12) mmol/L 120 min for Caucasians versus 214.03 (77.49) mmol/L 120 min for Chinese—indicate significant differences (p = 0.003 and p < 0.001 respectively) between groups. Findings suggest that the difference between the two groups’ iAUC values do not relate to obvious lifestyle factors. The Chinese group were eating the least sugary and starchy food but had the highest iAUC. It is argued that the Chinese group in this investigation have the most favourable BMI, body fat percentage, and body mass, yet “poorest” glycaemic response.

Factors That Influence Pancreatic Beta Cell Function and Insulin Resistance in Newly Diagnosed Type 2 Diabetes Patients: A Sub-Analysis of the MARCH Trial

INTRODUCTION

The Metformin and Acarbose in Chinese as the initial Hypoglycemic treatment (MARCH) trial has demonstrated a similar efficacy in HbA1c reduction between acarbose and metformin treatments in newly diagnosed type 2 diabetes mellitus (T2DM) patients. The current sub-analysis of the MARCH trail aims to evaluate the baseline characteristics that may influence the improvement of pancreatic β-cell function and insulin resistance after acarbose therapy in Chinese patients with newly diagnosed T2DM.

METHODS

Of the 784 patients who entered the MARCH trail, 391 were assigned to the acarbose therapy group; 304 of these completed 48 weeks of follow-up of acarbose therapy. At 48 weeks, on the basis of the tertiles of change in homeostasis model assessment-beta cell function (∆HOMA-β) and homeostasis model assessment-insulin resistance (∆HOMA-IR), the subjects were divided into lowly, mediumly, and highly improved groups.

RESULTS

In the highly improved HOMA-β group, patients had higher systolic blood pressure (SBP), 2-h postprandial blood glucose (PBG), hemoglobin A1c (HbA1c), and lower high-density lipoprotein cholesterol (HDL-c), fasting serum insulin (FINS) concentration, and HOMA-IR in comparison to the lowly improved group (p < 0.05). A positive correlation was observed between HbA1c, SBP, and highly improved ∆HOMA-β (p < 0.05), while an inverse correlation was evident between HDL-c and highly improved ∆HOMA-β (p < 0.05). The highly improved HOMA-IR group had a significantly higher body mass index (BMI), fasting blood glucose (FBG), FINS concentration, and HOMA-β in comparison to the lowly improved group (p < 0.05). A positive correlation was observed between FBG, waist circumference, and highly improved HOMA-IR (p < 0.05).

CONCLUSION

Newly diagnosed T2DM Chinese patients with lower baseline HDL-c and higher HbA1c and SBP values are more likely to achieve improvement in beta cell function whereas baseline fasting blood glucose and waist circumference were the significant factors associated with improvement in insulin resistance with acarbose therapy.

TRIAL REGISTRATION

The clinical trial registry number was ChiCTR-TRC-08000231.

The Impact of a Single Dose of a Polyphenol-Rich Seaweed Extract on Postprandial Glycaemic Control in Healthy Adults: A Randomised Cross-Over Trial

This study investigated the impact of a polyphenol-rich seaweed extract on postprandial glycaemia in healthy adults, and, as a secondary outcome, the influence of ethnicity on these outcomes. Thirty-eight volunteers (26 non-Asian, 12 Asian) aged 19 to 56 years participated in this double-blind, placebo-controlled, randomised cross-over trial. Participants each consumed a low (500 mg), and high (2000 mg) dose of the polyphenol-rich brown seaweed (Fucus vesiculosus) extract, as well as a cellulose placebo (2000 mg), 30 min prior to 50 g of available carbohydrate from white bread. Postprandial blood glucose and plasma insulin concentrations were measured over two hours (fasting, 15, 30, 45, 60, 90, and 120 min) from a finger prick blood sample. Data were analysed using a repeated measures analysis of variance. Compared with the placebo, neither dose had a lowering effect on postprandial glucose or insulin responses. However, individuals of an Asian background experienced consistently elevated plasma insulin responses, assessed using an incremental area under the curve, compared with non-Asian participants, irrespective of supplement (p = 0.016). These results suggest an increased risk of insulin resistance among Asian populations, compared with non-Asian, and that measurement of blood glucose levels alone may be insufficient to diagnose diabetes risk in this population.

Use of 50/50 Premixed Insulin Analogs in Type 2 Diabetes: Systematic Review and Clinical Recommendations

INTRODUCTION

Premixed insulin analogs represent an alternative to basal or basal-bolus insulin regimens for the treatment of type 2 diabetes (T2D). "Low-mix" formulations with a low rapid-acting to long-acting analog ratio (e.g., 25/75) are commonly used, but 50/50 formulations (Mix50) may be more appropriate for some patients. We conducted a systematic literature review to assess the efficacy and safety of Mix50, compared with low-mix, basal, or basal-bolus therapy, for insulin initiation and intensification.

METHODS

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, LillyTrials.com, and NovoNordisk-trials.com were searched (11 or 13 Dec 2016) using terms for T2D, premixed insulin analogs, and/or Mix50. Studies (randomized, nonrandomized, or observational; English only) comparing Mix50 with other insulins (except human) and reporting key efficacy [glycated hemoglobin (HbA1c), fasting and postprandial glucose] and/or safety (hypoglycemia, weight gain) outcomes were eligible for inclusion. Narrative reviews, letters, editorials, and conference abstracts were excluded. Risk of bias in randomized trials was assessed using the Cochrane tool.

RESULTS

MEDLINE and EMBASE searches identified 716 unique studies, of which 32 met inclusion criteria. An additional three studies were identified in the other databases. All 19 randomized trials except one were open label; risk of other biases was generally low. Although not conclusive, the evidence suggests that Mix50 may provide better glycemic control (HbA1c reduction) and, particularly, postprandial glucose reduction in certain patients, such as those with high carbohydrate diets and Asian patients, than low-mix and basal therapy. Based on this evidence and our experience, we provide clinical guidance on factors to consider when deciding whether Mix50 is appropriate for individual patients.

CONCLUSIONS

Mix50 may be more suitable than low-mix therapy for certain patients. Clinicians should consider not only efficacy and safety but also patient characteristics and preferences when tailoring insulin treatment to individuals with T2D.

FUNDING

Eli Lilly.

Prevalence of Pre-Diabetes across Ethnicities: A Review of Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT) for Classification of Dysglycaemia

Prediabetes can be defined by the presence of impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT), or glycated haemoglobin (Hb_A1c) to identify individuals at increased risk of developing type 2 diabetes (T2D). The World Health Organization (WHO, 1999) and the American Diabetes Association (ADA, 2003) utilise different cut-off values for IFG (WHO: 6.1–6.9 mmol/L; ADA: 5.6–6.9 mmol/L) but the same cut-off values for IGT (7.8–11.0 mmol/L). This review investigates whether there are differences in prevalence of IFG, IGT, and combined IFG&IGT between ethnicities, in particular Asian Chinese and European Caucasians. In total, we identified 19 studies using the WHO₁₉₉₉ classification, for which the average proportional prevalence for isolated (i)-IFG, i-IGT, and combined IFG&IGT were 43.9%, 41.0%, and 13.5%, respectively, for Caucasian and 29.2%, 49.4%, and 18.2%, respectively, for Asian. For the 14 studies using ADA₂₀₀₃ classification, the average proportional i-IFG, i-IGT, and combined IFG&IGT prevalences were 58.0%, 20.3%, and 19.8%, respectively, for Caucasian; 48.1%, 27.7%, and 20.5%, respectively, for Asian. Whilst not statistically different, there may be clinically relevant differences in the two populations, with our observations for both classifications indicating that prevalence of i-IFG is higher in Caucasian cohorts whilst i-IGT and combined IFG&IGT are both higher in Asian cohorts.

Risk Score for Detecting Dysglycemia: A Cross-Sectional Study of a Working-Age Population in an Oil Field in China

Background

Dysglycemia (pre-diabetes or diabetes) in young adults has increased rapidly. However, the risk scores for detecting dysglycemia in oil field staff and workers in China are limited. This study developed a risk score for the early identification of dysglycemia based on epidemiological and health examination data in an oil field working-age population with increased risk of diabetes.

Material/Methods

Multivariable logistic regression was used to develop the risk score model in a population-based, cross-sectional study. All subjects completed the questionnaires and underwent physical examination and oral glucose tolerance tests. The performance of the risk score models was evaluated using the area under the receiver operating characteristic curve (AUC).

Results

The study population consisted of 1995 participants, 20–64 years old (49.4% males), with undiagnosed diabetes or pre-diabetes who underwent periodic health examinations from March 2014 to June 2015 in Dagang oil field, Tianjin, China. Age, sex, body mass index, history of high blood glucose, smoking, triglyceride, and fasting plasma glucose (FPG) constituted the Dagang dysglycemia risk score (Dagang DRS) model. The performance of Dagang DRS was superior to m-FINDRISC (AUC: 0.791; 95% confidence interval (CI), 0.773–0.809 vs. 0.633; 95% CI, 0.611–0.654). At the cut-off value of 5.6 mmol/L, the Dagang DRS (AUC: 0.616; 95% CI, 0.592–0.641) was better than the FPG value alone (AUC: 0.571; 95% CI, 0.546–0.596) in participants with FPG <6.1 mmol/L (n=1545, P=0.028).

Conclusions

Dagang DRS is a valuable tool for detecting dysglycemia, especially when FPG <6.1 mmol/L, in oil field workers in China.

Comparison of insulin lispro mix 25 with insulin lispro mix 50 as insulin starter in Chinese patients with type 2 diabetes mellitus (CLASSIFY study): Subgroup analysis of a Phase 4 open-label randomized trial

BACKGROUND

Premixed insulins are recommended starter insulins in Chinese patients after oral antihyperglycemic medication (OAM) failure. In the present study, we compared the efficacy and safety of insulin lispro mix 25 (LM25) twice daily (b.i.d.) and insulin lispro mix 50 (LM50) b.i.d. as a starter insulin regimen in Chinese patients with type 2 diabetes mellitus (T2DM) who had inadequate glycemic control with OAMs.

METHODS

The primary efficacy outcome in the present open-label parallel randomized clinical trial was change in HbA1c from baseline to 26 weeks. Patients were randomized in a ratio of 1:  1 to LM25 (n = 80) or LM50 (n = 76). A mixed-effects model with repeated measures was used to analyze continuous variables. The Cochran-Mantel-Haenszel test with stratification factor was used to analyze categorical variables.

RESULTS

At the end of the study, LM50 was more efficacious than LM25 in reducing mean HbA1c levels (least-squares [LS] mean difference 0.48; 95 % confidence interval [CI] 0.22, 0.74; P < 0.001). More subjects in the LM50 than LM25 group achieved HbA1c targets of <7.0 % (72.4 % vs 45.0 %; P = 0.001) or ≤6.5 % (52.6 % vs 20.0 %; P < 0.001). Furthermore, LM50 was more effective than LM25 at reducing HbA1c in patients with baseline HbA1c, blood glucose excursion, and postprandial glucose greater than or equal to median levels (P ≤ 0.001). The rate and incidence of hypoglycemic episodes and increase in weight at the end of the study were similar between treatment groups.

CONCLUSIONS

In Chinese patients with T2DM, LM50 was more efficacious than LM25 as a starter insulin.

Effect of Cold Storage and Reheating of Parboiled Rice on Postprandial Glycaemic Response, Satiety, Palatability and Chewed Particle Size Distribution

Background: Globally, hot cooked refined rice is consumed in large quantities and is a major contributor to dietary glycaemic load. This study aimed to compare the glycaemic potency of hot- and cold-stored parboiled rice to widely available medium-grain white rice. Method: Twenty-eight healthy volunteers participated in a three-treatment experiment where postprandial blood glucose was measured over 120 min after consumption of 140 g of rice. The three rice samples were freshly cooked medium-grain white rice, freshly cooked parboiled rice, and parboiled rice stored overnight at 4 °C. All rice was served warm at 65 °C. Chewing time was recorded. Results: incremental area under the curve (iAUC) of the control rice, freshly cooked medium-grain white rice, was the highest: 1.7-fold higher (1.2, 2.6) than reheated parboiled rice (p < 0.001) and 1.5-fold higher (1.0, 2.2) than freshly cooked parboiled rice (p = 0.001). No significant difference in postprandial glycaemic response was observed between freshly cooked and reheated parboiled rice samples (p = 0.445). Chewing time for 10 g cold-stored parboiled rice was 6 s (25%) longer and was considered more palatable, visually appealing and better tasting than freshly cooked medium-grain (all p < 0.05). Conclusions: For regular consumers of rice, reheating cooked rice after cold storage would lower the dietary glycaemic load and, in the long term, may reduce the risk for type 2 and gestational diabetes. More trials are needed to identify the significance.

Trajectories of Postload Plasma Glucose in the Development of Type 2 Diabetes in Japanese Adults

We aimed to clarify how the trajectories of 1-hour postload plasma glucose (PG) and 2-hour PG were different in the development of type 2 diabetes. Using data of repeated health checkups in Japanese workers from April 2006 to March 2016, longitudinal changes of fasting, 1-hour, and 2-hour PG on the oral glucose tolerance test were analyzed with a linear mixed effects model. Of the 1464 nondiabetic subjects at baseline, 112 subjects progressed to type 2 diabetes during the observation period (progressors). In progressors, 1-hour PG and 2-hour PG showed gradual increases with slopes of 1.33 ± 0.2 and 0.58 ± 0.2 mg/dL/year, respectively, followed by a steep increase by which they attained diabetes. Until immediately before the diabetes transition, age- and sex-adjusted mean level of 2-hour PG was 149 ± 2.7 mg/dL, 34 ± 2.7 (30%) higher compared to nonprogressors, while that of 1-hour PG was 206 ± 4.1 mg/dL, 60 ± 4.3 mg/dL (41%) higher compared to nonprogressors. In conclusion, diabetes transition was preceded by a mild elevation of 2-hour PG for several years or more. The elevation in 1-hour PG was larger than that of 2-hour PG until immediately before the transition to diabetes.

Glycaemic responses to liquid food supplements among three Asian ethnic groups

PURPOSE

A limited number of studies have compared the glycaemic index (GI) and glycaemic responses (GR) to solid foods between Caucasians and Asians. These studies have demonstrated that Asians have greater GI and GR values for solid foods than Caucasians. However, no study has compared the GI and GR to liquids among various Asian ethnic groups.

METHODS

A total of forty-eight males and females (16 Chinese, 16 Indians, and 16 Malay) took part in this randomised, crossover study. Glycaemic response to the reference food (glucose beverage) was measured on three occasions, and GR to three liquids were measured on one occasion each. Liquids with different macronutrient ratio's and carbohydrate types were chosen to be able to evaluate the response to products with different GIs. Blood glucose concentrations were measured in duplicate at baseline (-5 and 0 min) and once at 15, 30, 45, 60, 90, and 120 min after the commencement of beverage consumption.

RESULTS

There were statistically significant differences in GI and GR between the three liquids (P < 0.01 in all cases). However, there were no statistically significant differences in GI and GR for the liquids between the ethnic groups (Chinese vs. Indian vs. Malay).

CONCLUSION

The GR for three different types of liquid nutritional supplements did not differ between the three main ethnic groups in Asia. It appears that the GI of liquid food derived from one Asian ethnicity can be applicable to other Asian populations.