Low-Carbohydrate Diet Scores and Mortality Among Adults With Incident Type 2 Diabetes

Grocery Delivery to Support Individuals With Type 2 Diabetes: Protocol for a Pilot Quality Improvement Program

BACKGROUND

People with low income are disproportionately affected by type 2 diabetes (T2D), and 17.6% of US adults with T2D experience food insecurity and low diet quality. Low-carbohydrate eating plans can improve glycemic control, promote weight loss, and are associated with improved cardiometabolic health and all-cause mortality. Little is known about supporting low-carbohydrate eating for people with T2D, although food-as-medicine interventions paired with nutrition education offer a promising solution.

OBJECTIVE

This program aims to support the initiation of dietary changes by using grocery delivery and low-carbohydrate education to increase the quality of low-carbohydrate nutrition among people with T2D and food insecurity.

METHODS

This program was a nonrandomized pilot conducted at 21 primary care practices in Michigan. Adults with T2D and food insecurity or low income were eligible to enroll. Patients were referred by primary care clinic staff. All participants received the 3-month program, which included monthly US $80 credits for healthy foods, free grocery delivery from Shipt, and low-carbohydrate nutrition education. Food credits were restricted to the purchase of healthy foods. Education materials, developed in collaboration with providers and patients, included print, digital, interactive web, and video formats. At enrollment, participants completed a survey including demographics, diabetes health, diet and physical activity, and diabetes management and knowledge. After the 3-month program, participants completed a survey with repeat assessments of diabetes health, diet and physical activity, and diabetes management and knowledge. Perspectives on participant experience and perceived program impact, food purchasing behaviors, and use of educational materials were also collected. Diabetes health information was supplemented with data from participant medical records. We plan to perform mixed methods analysis to assess program feasibility, acceptability, and impact. Primary quality improvement (QI) measures are the number of patients referred and enrolled, use of US $80 food credits, analysis of food purchasing behavior, participant experience with the program, and program costs. Secondary QI measures include changes in hemoglobin A1c, weight, medications, self-efficacy, diabetes and carbohydrate knowledge, and activity between baseline and follow-up.

RESULTS

This program started in October 2022. Data collection is expected to be concluded in June 2024. A total of 151 patients were referred to the program, and 83 (55%) were enrolled. The average age was 57 (SD 13; range 18-86) years, 72% (57/79) were female, 90% (70/78) were White, and 96% (74/77) were of non-Hispanic ethnicity. All participants successfully ordered grocery delivery during the program.

CONCLUSIONS

This pilot QI program aimed to improve diet quality among people with T2D and food insecurity by using grocery delivery and low-carbohydrate nutrition education. Our findings may help inform the implementation of future QI programs and research studies on food-as-medicine interventions that include grocery delivery and education for people with T2D.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54043.

Associations of Lower-Carbohydrate and Lower-Fat Diets with Mortality among People with Cardiovascular Disease

BACKGROUND

Although low-carbohydrate and low-fat diets have been shown to have short-term metabolic benefits, the associations of these dietary patterns, particularly different food sources and macronutrient quality, with mortality in people with cardiovascular disease (CVD) remain unclear.

OBJECTIVES

To examine the associations of different types of lower-carbohydrate diets (LCDs) and lower-fat diets (LFDs) with mortality in individuals with CVD.

METHODS

This study included 3971 adults with CVD from the NHANES 1999-2014. Mortality status was linked to National Death Index mortality data through 31 December 2019. Overall, unhealthy and healthy LCD and LFD scores were determined based on the percentages of energy from total and subtypes of carbohydrate, fat, and protein. Cox proportional hazards regression models were applied to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Higher healthy LCD score was associated with favorable blood lipids and higher homeostasis model assessment of insulin resistance, whereas higher unhealthy LFD score was associated with lower high-density lipoprotein and higher C-reactive protein at baseline (all P-trend < 0.05). During 35,150 person-years of follow-up, 2163 deaths occurred. For per 20-percentile increment in dietary scores, the multivariate-adjusted HRs of all-cause mortality were 0.91 (95% CI: 0.86, 0.96) for healthy LCD score (P < 0.001), 0.94 (95% CI: 0.89, 1.00) for healthy LFD score (P = 0.04), and 1.07 (95% CI: 1.00, 1.14) for unhealthy LFD score (P = 0.04).

CONCLUSIONS

Overall LCD and LFD scores are not associated with total mortality. Unhealthy LFD scores are associated with higher total mortality, whereas healthy LCD and LFD scores are associated with lower mortality in people with CVD.

Diabetes-Specific Complete Smoothie Formulas Improve Postprandial Glycemic Response in Obese Type 2 Diabetic Individuals: A Randomized Crossover Trial

This study aimed to compare newly developed diabetes-specific complete smoothie formulas with a standard diabetes-specific nutritional formula (DSNF) regarding their effects on glucose homeostasis, insulin levels, and lipid metabolism in obese type 2 diabetes (T2DM) patients. We conducted a randomized, double-blind, crossover study with 41 obese T2DM participants to compare two developed diabetes-specific complete smoothie formulas, a soy-based regular smoothie (SM) and a smoothie with modified carbohydrate content (SMMC), with the standard DSNF, Glucerna. Glycemic and insulin responses were assessed after the participants randomly consumed 300 kilocalories of each formulation on three separate days with a 7-day gap between. Postprandial effects on glycemic control, insulin levels, and lipid metabolism were measured. SMMC resulted in a significantly lower glucose area under the curve (AUC0-240) compared to Glucerna and SM (p < 0.05 for both). Insulin AUC0-240 after SMMC was significantly lower than that after SM and Glucerna (p < 0.05). During the diets, the suppression of NEFA was more augmented on SM, resulting in a less total AUC0-240 of NEFA compared to the SMMC diet (p < 0.05). C-peptide AUC0-240 after SMMC was significantly lower than that after Glucerna (p < 0.001). Conversely, glucagon AUC0-240 after SMMC was significantly higher than that after SM and Glucerna (p < 0.05). These results highlight SMMC as the better insulin-sensitive formula, potentially achieved through increased insulin secretion or a direct reduction in glucose absorption. The unique composition of carbohydrates, amino acids, and fats from natural ingredients in the smoothies may contribute to these positive effects, making them promising functional foods for managing diabetes and obesity.

Low-Carbohydrate and Low-Fat Diet with Metabolic-Dysfunction-Associated Fatty Liver Disease

BACKGROUND

This observational cross-sectional study was designed to explore the effects of a low-carbohydrate diet (LCD) and a low-fat diet (LFD) on metabolic-dysfunction-associated fatty liver disease (MAFLD).

METHODS

This study involved 3961 adults. The associations between LCD/LFD scores and MAFLD were evaluated utilizing a multivariable logistic regression model. Additionally, a leave-one-out model was applied to assess the effect of isocaloric substitution of specific macronutrients.

RESULTS

Participants within the highest tertile of healthy LCD scores (0.63; 95% confidence interval [CI], 0.45-0.89) or with a healthy LFD score (0.64; 95%CI, 0.48-0.86) faced a lower MAFLD risk. Furthermore, compared with tertile 1, individuals with unhealthy LFD scores in terile 2 or tertile 3 had 49% (95%CI, 1.17-1.90) and 77% (95%CI, 1.19-2.63) higher risk levels for MAFLD, respectively.

CONCLUSIONS

Healthy LCD and healthy LFD are protective against MAFLD, while unhealthy LFD can increase the risk of MAFLD. Both the quantity and quality of macronutrients might have significant influences on MAFLD.