Whole foods and increased dietary fibre improve blood glucose control in diabetic children

Low-Carbohydrate, High-Protein, High-Fat Diets Rich in Livestock, Poultry and Their Products Predict Impending Risk of Type 2 Diabetes in Chinese Individuals that Exceed Their Calculated Caloric Requirement

The evidence on the association between long-term low-carbohydrate, high-fat and high-protein diets and type 2 diabetes (T2D) is controversial. Until now, data is limited for Chinese populations, especially in considering the influence of extra energy intake. In this paper, we aimed to investigate the association of low-carbohydrate, high-fat and high-protein diets with type 2 diabetes (T2D) risk in populations consuming extra calories and those with normal caloric intake, We also determined whether the association is mediated by insulin resistance (IR) or β-cell dysfunction. A total of 3644 subjects in the Harbin People’s Health Study (Cohort 1, 2008–2012) and 7111 subjects in the Harbin Cohort Study on Diet, Nutrition and Chronic Non-Communicable Diseases (Cohort 2, 2010–2015) were analyzed, with a median follow-up of 4.2 and 5.3 years, respectively. Multivariate relative risks (RRs) and their 95% confidence intervals (95% CIs) were calculated to estimate the association between low-carbohydrate, high-fat and high-protein diet and T2D in logistic regression models. The multivariate RRs (95% CIs) were 1.00, 2.24 (1.07, 4.72) and 2.29 (1.07, 4.88) (P_trend = 0.04), and 1.00, 1.45 (0.91, 2.31) and 1.64 (1.03, 2.61) (P_trend = 0.04) across tertiles of low-carbohydrate, high-fat and high-protein diet scores in the population consuming extra calories in Cohort 1 and Cohort 2, respectively. The association was no longer significant after adjustment for livestock and its products, or poultry and its products. The mediation analysis discovered that this association in the population consuming extra calories was insulin resistance mediated, in both Cohort 1 and Cohort 2. However, the association was not significant among participants overall and participants with normal caloric intake. Our results indicated that long-term low-carbohydrate, high-fat and high-protein diets were associated with increased T2D risk among the population consuming extra calories, which may be caused by higher intake of animal-origin fat and protein as well as lower intake of vegetables, fruit and fiber. Additionally, the association was mediated by IR. In the population consuming extra calories, reducing the intake of livestock, poultry and their products and increasing the intake of vegetables, fruit and fiber might protect this population from developing T2D.

Toward a more standardised and accurate evaluation of glycemic response to foods: recommendations for portion size calculation

This study aimed at evaluating the adequacy of calculation methods for portions to be provided to subjects in clinical trials evaluating glycemic response to foods. Portion sizes were calculated for 140 food samples, based on Nutrition Facts labels (current practice) and actual available carbohydrate content (current recommendation), and compared against the amount of monosaccharides yielded by the digestive breakdown of their actual available carbohydrate content (basis for glycemic response to food). The current practice can result in significant under- or over-feeding of carbohydrates in 10% of tested cases, as compared to the targeted reference dosage. The method currently recommended can result in significantly inadequate yields of monosaccharides in 24% of tested cases. The current and recommended calculation methods do not seem adequate for a standardised evaluation of glycemic response to foods. It is thus recommended to account for the amount of absorbable monosaccharides of foods for portion size calculation.

No association of dietary fiber intake with inflammation or arterial stiffness in youth with type 1 diabetes

AIM

To examine the association of dietary fiber intake with inflammation and arterial stiffness among youth with type 1 diabetes (T1D) in the US.

METHODS

Data are from youth ≥ 10 years old with clinically diagnosed T1D for ≥ 3 months and ≥ 1 positive diabetes autoantibody in the SEARCH for Diabetes in Youth Study. Fiber intake was assessed by food frequency questionnaire with measurement error (ME) accounted for by structural sub-models derived using additional 24-h dietary recall data in a calibration sample and the respective exposure-disease model covariates. Markers of inflammation, measured at baseline, included IL-6 (n=1405), CRP (n=1387), and fibrinogen (n=1340); markers of arterial stiffness, measured approximately 19 months post-baseline, were available in a subset of participants and included augmentation index (n=180), pulse wave velocity (n=184), and brachial distensibility (n=177).

RESULTS

Mean (SD) T1D duration was 47.9 (43.2) months; 12.5% of participants were obese. Mean (SD) ME-adjusted fiber intake was 15 (2.8) g/day. In multivariable analyses, fiber intake was not associated with inflammation or arterial stiffness.

CONCLUSION

Among youth with T1D, fiber intake does not meet recommendations and is not associated with measures of systemic inflammation or vascular stiffness. Further research is needed to evaluate whether fiber is associated with these outcomes in older individuals with T1D or among individuals with higher intakes than those observed in the present study.

Fructo-oligosaccharide effects on blood glucose: an overview

PURPOSE

To identify the current status of scientific knowledge in fructo-oligosaccharides (FOS), non-conventional sugars that play an important role in glycemia control.

METHODS

We performed a search for scientific articles in MEDLINE and LILACS databases, from January 1962 to December 2011, using English/Portuguese key words: "blood glucose/glicemia", "prebiotics/prebióticos" and "dietary fiber/fibras na dieta". From an initial number of 434 references, some repeated, 43 references published from 1962 to 2011 were included in this study. The selected texts were distributed in three topics: (1) metabolism of FOS, (2) FOS and experimental studies involving glucose and (3) human studies involving glucose and FOS.

RESULTS

Five studies have shown that the use of FOS reduces the fecal content and increases intestinal transit time. Experimental studies have shown that dietary supplementation with high doses (60 g/Kg) of propionate, a short-chain fatty acid decreased glycemia. The use of lower doses (3 g/kg) did not produce the same results. Study in subjects with diabetes type II showed that the addition of 8 grams of FOS in the diet for 14 days, caused a reduction in serum glucose. In another study with healthy subjects, there were no changes in glycemic control.

CONCLUSIONS

This review demonstrates that consumption of FOS has a beneficial influence on glucose metabolism. The controversies appear to be due to inadequate methodological designs and/or the small number of individuals included in some studies.

The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults

This article reviews the evidence and nutrition practice recommendations from the American Dietetic Association's nutrition practice guidelines for type 1 and type 2 diabetes in adults. The research literature was reviewed to answer nutrition practice questions and resulted in 29 recommendations. Here, we present the recommendations and provide a comprehensive and systematic review of the evidence associated with their development. Major nutrition therapy factors reviewed are carbohydrate (intake, sucrose, non-nutritive sweeteners, glycemic index, and fiber), protein intake, cardiovascular disease, and weight management. Contributing factors to nutrition therapy reviewed are physical activity and glucose monitoring. Based on individualized nutrition therapy client/patient goals and lifestyle changes the client/patient is willing and able to make, registered dietitians can select appropriate interventions based on key recommendations that include consistency in day-to-day carbohydrate intake, adjusting insulin doses to match carbohydrate intake, substitution of sucrose-containing foods, usual protein intake, cardioprotective nutrition interventions, weight management strategies, regular physical activity, and use of self-monitored blood glucose data. The evidence is strong that medical nutrition therapy provided by registered dietitians is an effective and essential therapy in the management of diabetes.

Effect of non-oil-seed pulses on glycaemic control: a systematic review and meta-analysis of randomised controlled experimental trials in people with and without diabetes

AIMS/HYPOTHESIS

Dietary non-oil-seed pulses (chickpeas, beans, peas, lentils, etc.) are a good source of slowly digestible carbohydrate, fibre and vegetable protein and a valuable means of lowering the glycaemic-index (GI) of the diet. To assess the evidence that dietary pulses may benefit glycaemic control, we conducted a systematic review and meta-analysis of randomised controlled experimental trials investigating the effect of pulses, alone or as part of low-GI or high-fibre diets, on markers of glycaemic control in people with and without diabetes.

METHODS

We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Library for relevant controlled trials of >or=7 days. Two independent reviewers (A. Esfahani and J. M. W. Wong) extracted information on study design, participants, treatments and outcomes. Data were pooled using the generic inverse variance method and expressed as standardised mean differences (SMD) with 95% CIs. Heterogeneity was assessed by chi (2) and quantified by I (2). Meta-regression models identified independent predictors of effects.

RESULTS

A total of 41 trials (39 reports) were included. Pulses alone (11 trials) lowered fasting blood glucose (FBG) (-0.82, 95% CI -1.36 to -0.27) and insulin (-0.49, 95% CI -0.93 to -0.04). Pulses in low-GI diets (19 trials) lowered glycosylated blood proteins (GP), measured as HbA(1c) or fructosamine (-0.28, 95% CI -0.42 to -0.14). Finally, pulses in high-fibre diets (11 trials) lowered FBG (-0.32, 95% CI -0.49 to -0.15) and GP (-0.27, 95% CI -0.45 to -0.09). Inter-study heterogeneity was high and unexplained for most outcomes, with benefits modified or predicted by diabetes status, pulse type, dose, physical form, duration of follow-up, study quality, macronutrient profile of background diets, feeding control and design.

CONCLUSIONS/INTERPRETATION

Pooled analyses demonstrated that pulses, alone or in low-GI or high-fibre diets, improve markers of longer term glycaemic control in humans, with the extent of the improvements subject to significant inter-study heterogeneity. There is a need for further large, well-designed trials.

Whole grain and legume acceptability among youths with type 1 diabetes

PURPOSE

This pilot study investigated the acceptability of whole grain and legume foods in youths with type 1 diabetes and determined demographic and behavioral factors associated with their acceptability.

METHODS

Youths with type 1 diabetes (7.0 to 16.9 years) were recruited during a diabetes camp and completed self-report measures of food acceptability, eating behaviors, and demographics. An overall acceptability score for whole grains and for legumes was calculated as the sum of foods in each category rated as either "tried and liked" or "not tried and willing to try." Correlations of whole grain and legume acceptability with demographic characteristics were examined.

RESULTS

One hundred twenty-eight youths participated (70% females, mean age 11.6 +/- 2.3 years). Whole grain foods with the highest acceptability were corn bread (85% tried/liked and 11% willing to try) and whole wheat bread (72% tried/liked and 3% willing to try). Total whole grain acceptability was negatively associated with days per week of fast food consumption (r = -0.21; P < .02) and living in an urban environment (r = -0.24; P < .01). Chili with beans (66% tried/liked and 8% willing to try) and baked beans (57% tried/liked and 19% willing to try) were the legume-containing foods with the highest acceptability. There were no significant associations between demographic factors and total legume acceptability.

CONCLUSIONS

These findings demonstrate the variability in acceptability among whole grains and legumes in youths with type 1 diabetes and the importance of addressing acceptability when counseling youths or designing nutrition interventions to improve consumption of these foods.

The effect of a low-glycemic diet vs a standard diet on blood glucose levels and macronutrient intake in children with type 1 diabetes

A low-glycemic index (GI) diet may lower postprandial hyperglycemia and decrease the risk for postabsorptive hypoglycemia in people with type 1 diabetes. However, insufficient evidence exists on the efficacy of a low-GI diet to support practice recommendations. The goal of this study was to examine the blood glucose response to and the macronutrient composition of low-GI meals vs usual meals consumed ad libitum at home in children with type 1 diabetes. A within-subject, crossover design was employed. Twenty-three participants were recruited between June and August 2006. Participants wore a continuous blood glucose monitoring system and completed diet diaries on 2 days. On 1 day, participants consumed their usual meal; on another day, participants consumed low-GI meals ad libidum. Order of the 2 days was counterbalanced. The mean GI was 34+/-6 for the low-GI day and 57+/-6 for the usual meal day (P<0.0001). During the low-GI day, mean daytime blood glucose values (125+/-28 mg/dL [6.9+/-1.5 nmol/L] vs 185+/-58 mg/dL [10.3+/-3.2 nmol/L], P<0.001), blood glucose area above 180 mg/dL (4,486+/-6,138 vs 26,707+/-25,038, P<0.006), and high blood glucose index (5.1+/-5.1 vs 13.6+/-7.6, P<0.001) were lower compared to the usual mean day. During the low-GI day, subjects consumed more fiber (24.5+/-12.3 g vs 14.5+/-6.1 g, P<0.007) and less fat (45.7+/-12.2 g vs 76.8+/-32.4 g, P<0.005); however, there were no differences in energy, carbohydrate, or protein intake. In this pilot study, a low-GI diet was associated with improved diet quality and a reduction in hyperglycemia.

Effect of varying glycemic index meals on blood glucose control assessed with continuous glucose monitoring in youth with type 1 diabetes on basal-bolus insulin regimens

OBJECTIVE

The purpose of this study was to test the effect of high glycemic index (HGI) and low glycemic index (LGI) meals on blood glucose levels using continuous blood glucose monitoring in youths with type 1 diabetes.

RESEARCH DESIGN AND METHODS

A total of 20 youths on basal-bolus regimens consumed macronutrient-matched HGI and LGI meals 1 day each in a controlled setting in varying order following consumption of a standardized evening meal. Medtronic MiniMed Continuous Glucose Monitoring Systems were used to assess blood glucose (BG) profiles.

RESULTS

Participants demonstrated significantly lower daytime mean BG, BG area >180 mg/dl, and high BG index when consuming LGI meals but no differences for daytime BG area <70 mg/dl, daytime low BG index, or any nighttime values. Significantly more BG values <80 mg/dl were treated on LGI days.

CONCLUSIONS

Findings indicate that consumption of an LGI diet may reduce glucose excursions, improving glycemic control.

Food habits, energy and nutrient intake in adolescents with Type 1 diabetes mellitus

AIMS

The aims were to describe the food habits of adolescents with Type 1 diabetes (Type 1 DM) and to compare them with healthy control subjects; to describe the distribution of energy-providing nutrients in patients and compare it with current recommendations and previous reports; and finally, to investigate associations between dietary intake and glycaemic control.

METHODS

One hundred and seventy-four adolescents with Type 1 DM and 160 age- and sex-matched healthy control subjects completed a validated food frequency questionnaire, and 38 randomly chosen patients completed a prospective 4-day food record.

RESULTS

Patients ate more regularly, and more often ate fruit and fruit juice, potatoes and root vegetables, meat, fish, egg, offal and sugar-free sweets than control subjects. Control subjects more often ate ordinary sweets and snacks. Patients chose coarse rye bread and dairy products with less fat to a greater extent than control subjects. Patients were heavier than control subjects. The intake of saturated fat was higher in patients compared with recommendations and, for boys with diabetes, the intake of protein was higher than recommended. Patients with poorer glycaemic control ate vegetables, fruit and fish less often than patients with better control.

CONCLUSIONS

The food habits of adolescents with Type 1 DM were healthier than those of control subjects. The intake of energy-providing nutrients was in line with current recommendations and showed improvements compared with previous reports, with the exception of fibre intake. The association between dietary intake and glycaemic control needs further investigation in prospective studies.

Cereal grains, legumes and diabetes

This review examines the evidence for the role of whole grain foods and legumes in the aetiology and management of diabetes. MedLine and SilverPlatter ('Nutrition' and 'Food Science FSTA') databases were searched to identify epidemiological and experimental studies relating to the effects of whole grain foods and legumes on indicators of carbohydrate metabolism. Epidemiological studies strongly support the suggestion that high intakes of whole grain foods protect against the development of type II diabetes mellitus (T2DM). People who consume approximately 3 servings per day of whole grain foods are less likely to develop T2DM than low consumers (<3 servings per week) with a risk reduction in the order of 20-30%. The role of legumes in the prevention of diabetes is less clear, possibly because of the relatively low intake of leguminous foods in the populations studied. However, legumes share several qualities with whole grains of potential benefit to glycaemic control including slow release carbohydrate and a high fibre content. A substantial increase in dietary intake of legumes as replacement food for more rapidly digested carbohydrate might therefore be expected to improve glycaemic control and thus reduce incident diabetes. This is consistent with the results of dietary intervention studies that have found improvements in glycaemic control after increasing the dietary intake of whole grain foods, legumes, vegetables and fruit. The benefit has been attributed to an increase in soluble fibre intake. However, prospective studies have found that soluble fibre intake is not associated with a lower incidence of T2DM. On the contrary, it is cereal fibre that is largely insoluble that is associated with a reduced risk of developing T2DM. Despite this, the addition of wheat bran to the diets of diabetic people has not improved indicators of glycaemic control. These apparently contradictory findings might be explained by metabolic studies that have indicated improvement in glucose handling is associated with the intact structure of food. For both grains and legumes, fine grinding disrupts cell structures and renders starch more readily accessible for digestion. The extent to which the intact structure of grains and legumes or the composition of foods in terms of dietary fibre and other constituents contribute to the beneficial effect remains to be quantified. Other mechanisms to help explain improvements in glycaemic control when consuming whole grains and legumes relate to cooking, type of starch, satiety and nutrient retention. Thus, there is strong evidence to suggest that eating a variety of whole grain foods and legumes is beneficial in the prevention and management of diabetes. This is compatible with advice from around the world that recommends consumption of a wide range of carbohydrate foods from cereals, vegetables, legumes and fruits both for the general population and for people with diabetes.

Nondigestible carbohydrates in the diets of infants and young children: a commentary by the ESPGHAN Committee on Nutrition

The consumption of nondigestible carbohydrates is perceived as beneficial by health professionals and the general public, but the translation of this information into dietary practice, public health recommendations, and regulatory policy has proved difficult. Nondigestible carbohydrates are a heterogeneous entity, and their definition is problematic. Without a means to characterize the dietary components associated with particular health benefits, specific attributions of these cannot be made. Food labeling for "fiber" constituents can be given only in a general context, and the development of health policy, dietary advice, and education, and informed public understanding of nondigestible carbohydrates are limited. There have, however, been several important developments in our thinking about nondigestible carbohydrates during the past few years. The concept of fiber has expanded to include a range of nondigestible carbohydrates. Their fermentation, fate, and effects in the colon have become a defining characteristic; human milk, hitherto regarded as devoid of nondigestible carbohydrates, is now recognized as a source for infants, and the inclusion of nondigestible carbohydrates in the diet has been promoted for their "prebiotic" effects. Therefore, a review of the importance of nondigestible carbohydrates in the diets of infants and young children is timely. The aims of this commentary are to clarify the current definitions of nondigestible carbohydrates, to review published evidence for their biochemical, physiologic, nutritional, and clinical effects, and to discuss issues involved in defining dietary guidelines for infants and young children.

Effect of low-glycemic-index dietary advice on dietary quality and food choice in children with type 1 diabetes

BACKGROUND

The practicality of diets with a low glycemic index (GI) is controversial. Theoretically, low-GI diets may limit food choice and increase dietary fat intake, but there is little objective evidence to support such a theory.

OBJECTIVE

The objective was to determine the effect of low-GI dietary advice on dietary quality and food choice in children with diabetes.

DESIGN

Children aged 8-13 y with type 1 diabetes (n = 104) were recruited to a prospective, randomized study comparing the effects of traditional carbohydrate-exchange dietary advice (CHOx) with those of more flexible low-GI dietary advice (LowGI). We determined the effect on long-term macronutrient intake and food choice with the use of 3-d food diaries.

RESULTS

There were no differences in reported macronutrient intakes during any of the recording periods. After 12 mo, intakes of dietary fat (33.5 +/- 5.6% and 34.2 +/- 6.7% of energy, P = 0.65), carbohydrate (48.8 +/- 5.4% and 48.6 +/- 6.5% of energy, P = 0.86), protein (17.6 +/- 2.5% and 17.3 +/- 3.7% of energy, P = 0.61), total sugars, and fiber did not differ significantly between the CHOx and LowGI groups, respectively. The average number of different carbohydrate food choices per day also did not differ significantly. Subjects in the lowest-GI quartile consumed less carbohydrate as potato and white bread, but more carbohydrate as dairy-based foods and whole-grain breads than did subjects in the highest-GI quartile.

CONCLUSION

Children with diabetes who receive low-GI dietary advice do not report more limited food choices or a diet with worse macronutrient composition than do children who consume a traditional carbohydrate-exchange diet.

Glycaemic responses to commonly ingested breakfasts in children with insulin-dependent diabetes mellitus

The glycaemic response to commonly ingested breakfast with different glycaemic index (cornflakes, white bread, dark rye bread and muesli) was investigated in 14 children with insulin-dependent diabetes mellitus. The blood glucose response after cornflakes was significantly higher than after the other breakfasts, whereas the areas under the blood glucose curve were not statistically different. We observed no difference in blood glucose rise between the other breakfast types.

CONCLUSION

Postprandial blood glucose measurements after meals with high glycaemic index may be useful in order to minimize the postprandial rise in blood glucose.

Dietary recommendations for children and adolescents with diabetes: an implementation paper. British Diabetic Association's Professional Advisory Committee

General Recommendations: 1. Children with diabetes mellitus have the same basic nutritional requirements as other children. 2. Dietary recommendations should be based on good eating habits for the whole family. Radical changes in diet involving unusual foods or eating patterns for the child with diabetes alone are not appropriate. 3. Energy requirements of children vary widely and the energy content of the diet should be based on what the child usually eats. The diet should be reviewed regularly to meet the changing needs of growth and physical exercise without obesity. 4. The insulin regimen should, as far as is possible, be chosen to fit the child's daily lifestyle and preferred eating habits. Insulin type, dose, and frequency should be reviewed with the diet as the child develops. 5. Regular distribution of meals and snacks throughout the day remains the most important way to avoid extremes of hyperglycaemia and hypoglycaemia. This distribution should be based on an exchange system, using handy measures and taking into account food and meal type, the particular insulin regimen and the child's exercise patterns and usual eating habits. Currently this exchange system is based on carbohydrate foods but in the future the energy and fat contents will need further consideration. 6. Most special 'diabetic foods' are unnecessary. Low calorie sweeteners, as used in low calorie fruit squashes and fizzy drinks, are useful. 7. Children with diabetes from specific ethnic minority groups, or on vegan diets or living in deprived circumstances require special dietary attention for their diabetes. Those with coexisting chronic disorders such as cystic fibrosis or coeliac disease, should receive dietary advice from professionals with specialist knowledge. 8. Translating the principles of diabetic dietary management into a varied diet, arranged readily by the parents and eaten by the child, is demanding. It can best be met by a skilled dietitian working in close co-operation with child, parents, diabetes specialist nurse and doctor. Infancy 9. The diet should not differ from that of infants without diabetes. Breast feeding should be encouraged or a standard infant formula-feed used. Solids may be introduced from 3-6 months, but breast milk or a modified infant formula is encouraged as part of the increasingly mixed diet to at least the end of the first year. 10. Diabetes is rare in infancy so expert advice should be sought from dietitians experienced in paediatric diabetes. Under fives: 11.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of muesli or cornflakes at breakfast on carbohydrate metabolism in type 2 diabetic patients

Fourteen overweight insulin-treated type 2 diabetic patients ate a breakfast, consisting of either muesli (slow release starch: SRS) or cornflakes (fast release starch: FRS), in either case with milk (46 g carbohydrate), during two consecutive randomized crossover periods of two weeks. The rest of the diet remained unchanged. At the end of each period the patients underwent a glucose tolerance test after an overnight fast without their usual evening insulin injection. Both mean plasma glucose responses curves were identical after the two dietary periods, but plasma insulin was significantly lower at zero (-17%, P less than 0.05) and 2 h (-21%, P less than 0.05) at the end of the muesli (SRS) period as compared to the cornflakes (FRS) period. The mean day-long plasma glucose level (four measurements) at the end of the muesli period was 21% (P = 0.023) lower than after the cornflakes period. These results show that switching, at breakfast only, from standard cereals to slow release starch cereals improves the carbohydrate metabolism of diabetic patients. In addition, the fact that diabetic patients could reduce their insulin requirement (P less than 0.05) with concomitant reduction of their daily blood glucose level implies that sensitivity to insulin was improved by slow release starct foods consumed at breakfast.

The influence of dietary education in diabetic children

The aim of our study was to evaluate the efficacy of dietary education in inducing modification of the diet and to measure biochemical parameters in 36 children and adolescents with IDDM. At the beginning of the study, each patient was evaluated as follows: food intake (by the method of the 24-h recall for 3 days), auxological parameters, biochemical parameters. Thereafter a program of nutritional guidelines was provided. Subsequent meetings took place at 1-month-intervals. The study ended 3 months later, when all the parameters were completely revalued. We observed improved nutrition in our patients both in terms of total caloric intake and calorie distribution. In particular there was an increase in carbohydrates and a reduction in lipids, reaching the percentage levels recently recommended. With a reduction in lipid intake a significant decrease in LDL cholesterol and a significant increase in HDL cholesterol were noticed in our patients. These modifications are very important for the prevention of arteriosclerosis and thus macrovascular disease. We maintain that dietary education plays an important role in helping children and adolescents with IDDM to follow a suitable diet.

The glycaemic effect of simple sugars in mid-morning and afternoon snacks in childhood diabetes

Eighteen diabetic children ate three different snacks (free sucrose, sucrose plus fibre, fructose plus fibre) or had no snack on each of 4 mornings. Subsequently 10 children from this group took a standard snack (free sucrose) or no snack on two afternoons. In other respects the day of testing was standardised, the children going to school as normal and collecting their blood spots on filter paper for glucose analysis. There was no difference in the blood glucose profiles between different snacks or when no snack was taken either in the mornings or afternoon. This suggests both that moderate amounts of simple sugar do not have a detrimental effect on glycaemic control and that snacks can generally be omitted without serious hypoglycaemic problems.

A project in diabetes education for children

Forty-eight families with children less than 13 years old attending a paediatric diabetic clinic volunteered for a 2-year randomized crossover trial to determine whether an informal education programme (diabetic club) could improve diabetic control. Group A attended the diabetic club for 10 afternoons of informal education in the first year, while Group B continued at the routine clinic (5 visits per year). For the second year Group A returned to the clinic, Group B attended the club. Glycosylated haemoglobin (HbA1) remained stable while attending the club but rose significantly (p less than 0.01) while attending the clinic in both groups (HbA1 at baseline, 1 year, and 2 years: Group A, 9.6 (SD 1.2), 9.6(1.4), 10.7(2.1)%; Group B 8.9(1.3), 10.4(1.4), 10.5(1.4)% (normal reference range 4.7-7.9%)). Other indices of control were unchanged. Diabetic problem-solving scores of parents improved (p less than 0.01) but their knowledge of diabetes did not correlate with their child's HbA1. Dietary intake showed a reduction in percentage of energy taken as fat (40% vs 37.7%, p less than 0.05) during club attendance. The percentage of parents reporting helpful social contact between families increased during their club year (Group A 50 to 78%, Group B 32 to 57%, p less than 0.001). Psychological measurements remained unchanged. An education programme for diabetic children may stabilize diabetic control in the short term but this effect is not sustained. The main benefit was the support provided by increased social contact with families of other diabetic children within the informal framework of the diabetic club.

Comparison of high fibre diets, basal insulin supplements, and flexible insulin treatment for non-insulin dependent (type II) diabetics poorly controlled with sulphonylureas

OBJECTIVE

To compare high fibre diet, basal insulin supplements and a regimen of insulin four times daily in non-insulin dependent (type II) diabetic patients who were poorly controlled with sulphonylureas.

DESIGN

Run in period lasting 2-3 months during which self monitoring of glucose concentration was taught, followed by six months on a high fibre diet, followed by six months' treatment with insulin in those patients who did not respond to the high fibre diet.

SETTING

Teaching hospital diabetic clinics.

PATIENTS

33 patients who had had diabetes for at least two years and had haemoglobin A1 concentrations over 10% despite receiving nearly maximum doses of oral hypoglycaemic agents. No absolute indications for treatment with insulin.

INTERVENTIONS

During the high fibre diet daily fibre intake was increased by a mean of 16 g (95% confidence interval 12 to 20 g.) Twenty five patients were then started on once daily insulin. After three months 14 patients were started on four injections of insulin daily.

ENDPOINT

Control of diabetes (haemoglobin A1 concentration less than or equal to 10% and fasting plasma glucose concentration less than or equal to 6 mmol/l) or completion of six months on insulin treatment.

MEASUREMENTS AND MAIN RESULTS

No change in weight, diet, or concentrations of fasting glucose or haemoglobin A1 occurred during run in period. During high fibre diet there were no changes in haemoglobin A1 concentrations, but mean fasting glucose concentrations rose by 1.7 mmol/l (95% confidence interval 0.9 to 2.5, p less than 0.01). With once daily insulin mean concentrations of fasting plasma glucose fell from 12.6 to 7.6 mmol/l (p less than 0.001) and haemoglobin A1 from 14.6% to 11.2% (p less than 0.001). With insulin four times daily concentrations of haemoglobin A1 fell from 11.5% to 9.6% (p less than 0.02). Lipid concentrations were unchanged by high fibre diet. In patients receiving insulin the mean cholesterol concentrations fell from 7.1 to 6.4 mmol/l (p less than 0.0001), high density lipoprotein concentrations rose from 1.1 to 1.29 mmol/l (p less than 0.01), and triglyceride concentrations fell from 2.67 to 1.86 mmol/l (p less than 0.05). Patients taking insulin gained weight and those taking it four times daily gained an average of 4.2 kg.

CONCLUSIONS

High fibre diets worsen control of diabetes in patients who are poorly controlled with oral hypoglycaemic agents. Maximum improvements in control of diabetes were achieved by taking insulin four times daily.

Self-selected unrefined and refined carbohydrate diets do not affect metabolic control in pump-treated diabetic patients

This study investigated whether unrefined or refined carbohydrate diets have any effect on metabolic control and on insulin requirement in near-normoglycaemic Type 1 (insulin-dependent) diabetic out-patients on continuous subcutaneous insulin infusion therapy. Two females and 8 males (aged 27 +/- 9 years; diabetes duration 13 +/- 8 years; duration of insulin pump therapy 22 +/- 5 months; means +/- SD) participated in a randomised cross-over study with two 6-week periods on self-selected refined and unrefined carbohydrate diets respectively. As a result, energy intake differed between the experimental diets (2372 +/- 669 kcal/day on unrefined diet vs 2757 +/- 654 kcal/day on refined diet, p = 0.04), as did the fibre intake (18 +/- 5 g/day with the refined carbohydrate diet vs 35 +/- 13 g/day with the unrefined carbohydrate diet, p = 0.02). The composition of nutrients was approximately 40% carbohydrate, 45% fat, and 13% protein with both diets. Body weight, HbA1c, daily mean blood glucose (7.2 +/- 0.6 mmol/l) and serum lipids remained virtually unchanged during the entire study. Insulin requirement varied between 40.1 +/- 7.9 U/day with the unrefined carbohydrate diet, and 42.5 +/- 10.1 U/day with the refined carbohydrate diet (NS). Thus, neither the refined nor the unrefined carbohydrate diet affected insulin requirement and metabolic control in these near-normoglycaemic, normolipaemic, non-obese, insulin-pump-treated Type 1 diabetic patients.

Starchy foods and fiber: reduced rate of digestion and improved carbohydrate metabolism

The rate of the small intestine amylolytic digestion appears to be a major determinant of the glycemic response. Foods such as legumes appear to be digested less rapidly than many cereal foods although even amongst these large differences in rates of in vitro digestion exist. Studies of diabetes using high fibre, high legume diets have almost uniformly noted improvements in glycemic control and blood lipid profile. However, diets where changes in fibre content have been relatively small, but where the foods were selected on the basis of their slow rates of digestion and flatter glycemic response, have also produced similar beneficial effects. The reasons for the altered rates of digestion include fibre, food form, the nature of the starch, antinutrients etc. Through reducing the rate of digestion of starchy foods post prandially "slow release" starchy foods blunt many gut hormone responses, and prolong FFA and ketone body suppression. In addition increased starch losses to the colon may enhance production of SCFA. All these events may modify carbohydrate and lipid metabolism. Many foods which produce these effects are traditional starchy foods and so strengthen current recommendations of the diabetes association, heart foundations and cancer institutes to increase the use of starchy foods through reducing fat intake. Recognition of the nutritional value of these foods is however not new, but was well accepted in the ancient world and is still preserved in traditional cultures where freedom from many of the major non-infective Western diseases is a notable phenomenon.

Beneficial effects of palatable guar and guar plus fructose diets in diabetic children

This randomized cross-over study evaluates the effects of extended, guar and guar + fructose diets on the metabolic balance of children with insulin-dependent diabetes mellitus (IDDM). We studied 22 children; mean age 12.2 years, mean duration of diabetes 4.4 years. The diet was supplement for three weeks with guar in palatable form (5% of daily carbohydrate intake) and with guar + fructose (1 g of fructose/kg body weight, max 30 g/d) for another three weeks. A control group (8 children, mean age 12.3, duration of diabetes 4.3 years) followed the same experimental protocol without guar supplementation. The metabolic balance was assessed by glucosuria index (per cent of tests with less than 1% glucosuria from all urine tests) and measurements of red cell glycohaemoglobin A1c (HbA1c). Serum total and HDL-cholesterol, C-peptide, pancreatic and enteroglucagon were also measured. HbA1c decreased during guar (p less than 0.001) and guar + fructose diet (p less than 0.001). The glucosuria index improved (p less than 0.02) and the serum total cholesterol concentration decreased (p less than 0.02) during the experimental guar diets. Guar in acceptable form and quantity in the diet appears to improve metabolic control of diabetic children.

Dietary carbohydrate deficits and hypoglycaemia in the young diabetic on holiday

On two British Diabetic Association Educational Holidays, 67 children aged 6-9 years had their diabetic management analysed and hypoglycaemic episodes recorded. The average pre-camp carbohydrate prescription of the children was found to be 44 g below minimal recommended values. Hypoglycaemic episodes were more frequent in those with greater carbohydrate deficits and morning insulin doses in excess of 0.7 U/kg. The management of the young diabetic at camp should include a pre-camp analysis with appropriate adjustment of diet and insulin to minimize hypoglycaemic crises. Guideline figures are proposed for average age-related carbohydrate intake.

Dietary survey of diabetics

This study of 168 diabetic children from Tyneside and Teeside aimed to record what the children actually ate and to compare this with both their prescribed diet and current recommendations. The amounts of energy consumed were similar to those expected of non-diabetic children, but the components of the diabetic children's diets were different, consisting of more fat and fibre, but less sugars and carbohydrates. They ate more carbohydrate than prescribed but less than current recommendations as there was a shortfall between the amount prescribed and that suggested in the recommendations. Diabetic control was related to the amount of fibre consumed and to compliance with the prescribed diet, but not to the proportion of energy taken as carbohydrate. The insulin dose was slightly lower in those children eating more fibre.

Acceptability of high-fibre diets in diabetic patients

Twenty-five diabetic patients were selected from Oxford Diabetic Clinics to assess their dietary compliance (Group A). All had been taught to follow diets rich in dietary fibre in which carbohydrate provided 50% of total energy. The results were compared with those obtained previously from a similar group of patients (Group B) all of whom had been instructed to follow a diet in which carbohydrate provided 40% of total energy. The patients of Group A had a significantly greater intake of carbohydrate (45.1% vs 34.7% of total energy) and dietary fibre (33.1 g vs 18.7 g) and a lower intake of fat (33.5% vs 42.1% of total energy) than the patients of Group B. The results of dietary assessment obtained from a third group of patients (Group C), who had been advised to follow a high-fibre diet before the widespread availability of dietary teaching aids and recipe books, showed that carbohydrate and fat provided 37.5% and 41.0% of total energy, with a dietary fibre intake of 25.6 g. The results suggest that patients are willing and able to change their dietary habits towards a distribution of food constituents likely to improve diabetic control and reduce the risk of coronary heart disease when given enthusiastic instruction and support in diabetic clinics.

Epidemiological and clinical studies on optimal nutrition in diabetes

There would seem to be little doubt that a diet high in fiber-rich carbohydrate can improve diabetic control and reduce levels of LDL cholesterol when compared with the more traditional low carbohydrate-high fat diabetic diet. The abnormalities of platelet function in diabetes and their association with certain essential fatty acids suggest that attention to the nature of the fat composition of the diet may be equally relevant in attempts to reduce the frequency of both micro- and macrovascular complications of diabetes. Only a very limited number of intervention studies have been carried out. More information is urgently required concerning the effects of modifying the fatty acid composition of the diabetic diet.

Social and emotional complications in a clinical trial among adolescents with diabetes mellitus

Observations are reported on the social and emotional events occurring among children with diabetes mellitus and their families while taking part in a demanding clinical trial. Participants were selected on the basis of: (1) age over 10 years, (2) "informed consent," (3) cooperation with diabetic care, and (4) family stability. Despite endeavours to apply these criteria, it subsequently emerged that one father had doubts about his daughter participating; one family was suffering from severe marital discord; a girl (11 years) and a boy (10 years) were unexpectedly distressed by the venepunctures required; and another girl (13 years) was falsifying the results of her urine tests. All the families wished to complete the trial, and only one did not because of recurrent hypoglycaemia. The psychosocial problems encountered during the trial were unpredictable and occurred despite selection. Documentation of these problems allowed appropriate emotional support to be offered to the children and their families and provided for a fuller and more reliable interpretation of the trial results than would have been possible from the numerical data alone.

Effects of dietary fibre and exercise on mid-morning diabetic control--a controlled trial

Twenty-one insulin-dependent diabetic children completed a trial of 4 different breakfasts, given in random order. Three diets differed in fibre content. The fourth diet contained soya beans as part (38%) of the dietary fibre source. Children collected capillary blood samples on to filter paper strips which were analysed for blood glucose content. Each morning the children were asked to exercise vigorously for an hour and to rest for an hour, resulting in comparable rest and exercise periods for each child. Mean initial blood glucose levels on the 4 diets were not significantly different. The low-fibre diet resulted in the highest blood glucose concentrations after breakfast. Blood glucose levels on the high-fibre diet did not differ from those on the medium-fibre diet. The bean diet produced the lowest mean blood glucose level and the smallest reduction in blood glucose level in the hour before lunch. All the children found the bean diet unacceptable but liked the high- and medium-fibre diets, which were as popular as the low-fibre diet. The level of prescribed exercise had no effect on the level of blood glucose. It appears that the potentially major benefits from beans are limited by their unpalatability. The more acceptable cereal fibre produces a smaller but important benefit on morning hyperglycaemia after breakfast.