Diabetes Nutrition and Complications Trial: Trends in nutritional pattern between 1993 and 2000 and targets of diabetes treatment in a sample of Spanish people with diabetes

Influence of Strict Lockdown on Vitamin D Deficiency in Pregnant Women: A Word of Caution

The main source of vitamin D results from skin sunlight exposure. Vitamin D deficiency (VDD) is linked to several adverse events during pregnancy. While performing a cross-sectional study with 886 pregnant women in Elda (Spain) from September 2019 to July 2020 to determine the association of VDD with gestational diabetes mellitus in relation to body mass index, a strict lockdown (SL) due to the COVID-19 pandemic was declared from 15 March 2020 to 15 May 2020. To determine if VDD prevalence in the local population of pregnant women was influenced by SL, a retrospective cross-sectional study was conducted to estimate the prevalence odds ratio (POR) for the association of VDD and SL. A crude logistic regression model was calculated, and then further adjusted by the biweekly measured vitamin D-specific UVB dose in our geographical area. The POR during SL was 4.0 (95%CI = 2.7-5.7), with a VDD prevalence of 77.8% in the quarantine period. Our results revealed that VDD prevalence in pregnant women was influenced by SL. This valuable information could guide us in future if public officials order the population to stay indoors for any given reason.

The Relationship between Serum Adipokines, miR-222-3p, miR-103a-3p and Glucose Regulation in Pregnancy and Two to Three Years Post-Delivery in Women with Gestational Diabetes Mellitus Adhering to Mediterranean Diet Recommendations

The San Carlos Gestational Diabetes Mellitus (GDM) prevention study, a nutritional intervention RCT based on a Mediterranean Diet (MedDiet), has been shown to reduce the incidence of GDM. The objective of this study is to investigate the relationship of leptin, adiponectin, interleukin-6 (IL-6), tumour necrosis factor-alpha (TNF-α), insulin and HOMA-IRand circulating miRNAs (miR-29a-3p, miR-103a-3p, miR-132-3p, miR-222-3p) with the appearance of GDM and with MedDiet-based nutritional intervention, at 24−28 gestational weeks (GW), and in glucose regulation 2−3 years post-delivery (PD). A total of 313 pregnant women, 77 with GDM vs. 236 with normal glucose tolerance (NGT), 141 from the control group (CG, MedDiet restricting the consumption of dietary fat including EVOO and nuts during pregnancy) vs. 172 from the intervention group (IG, MedDiet supplemented with extra virgin olive oil (EVOO) and pistachios during pregnancy) were compared at Visit 1 (8−12 GW), Visit 2 (24−28 GW) and Visit 3 (2−3 years PD). Expression of miRNAs was determined by the Exiqon miRCURY LNA RT-PCR system. Leptin, adiponectin, IL-6 and TNF-α, were measured by Milliplex® immunoassays on Luminex 200 and insulin by RIA. Women with GDM vs. NTG had significantly higher leptin median (Q1−Q3) levels (14.6 (9.2−19.4) vs. 9.6 (6.0−15.1) ng/mL; p < 0.05) and insulin levels (11.4 (8.6−16.5) vs. 9.4 (7.0−12.8) µUI/mL; p < 0.001) and lower adiponectin (12.9 (9.8−17.2) vs. 17.0 (13.3−22.4) µg/mL; p < 0.001) at Visit 2. These findings persisted in Visit 3, with overexpression of miR-222-3p (1.45 (0.76−2.21) vs. 0.99 (0.21−1.70); p < 0.05)) and higher levels of Il-6 and TNF-α. When the IG is compared with the CG lower levels of insulin, HOMA-IR-IR, IL-6 levels at Visit 2 and 3 and leptin levels only at Visit 2 were observed. An overexpression of miR-222-3p and miR-103a-3p were also observed in IG at Visit 2 and 3. The miR-222-3p and miR103a-3p expression correlated with insulin levels, HOMA-IR, IL-6 and TNF-α at Visit 2 (all p < 0.05). These data support the association of leptin, adiponectin and insulin/HOMA-IR with GDM, as well as the association of insulin/HOMA-IR and IL-6 and miR-222-3p and miR-103a-3p expression with a MedDiet-based nutritional intervention.

Dietary intake and physical activity in Japanese patients with type 2 diabetes: the Japan Diabetes Complication and its Prevention prospective study (JDCP study 8)

Medical nutrition therapy and exercise therapy are the cornerstones of treatment for patients with type 2 diabetes; however, there has not been a nationwide study on the actual dietary intake and physical activity status of patients since the 2000s. We aimed to clarify this in Japanese patients with type 2 diabetes using data from the Japan Diabetes Complication and its Prevention prospective (JDCP), a nationwide study launched in 2007. A total of 1992 patients with type 2 diabetes, aged 40-75 years, completed either the Brief-type, self-administered Diet History Questionnaire (1643 patients) or International Physical Activity Questionnaire (1834 patients), and their data were analyzed in this study. Mean daily energy intake for all participants was 1686.8 kcal/day, and the mean proportions of carbohydrate, protein, and fat comprising total energy intake were 60.2, 16.2, and 23.6%, respectively. The patients in this study had similar energy and nutrient intake status to patients in the 1996 Japan Diabetes Complications Study; however, Japanese patients still had higher carbohydrate and lower fat consumption than patients with diabetes in Western countries. The physical activity questionnaire reported that 31.0% of patients did not have exercise habits; this was particularly noticeable in female patients and patients under the age of 65. BMI increased from 22.7 to 24.1 kg/m² in men and 23.2 to 24.8 kg/m² in women from 1996 to 2007, respectively. Further research is required to investigate how dietary intake and physical activity associates with the risk of developing complications in type 2 diabetes patients.

Vitamin D Deficiency and Gestational Diabetes Mellitus in Relation to Body Mass Index

A relationship between vitamin D deficiency (VDD) and gestational diabetes mellitus (GDM) has been described. Considering that GDM prevalence depends on body mass index (BMI), our main objective was to determine if VDD is associated with GDM, independent of BMI. A cross-sectional study with 886 pregnant women was conducted in Elda (Spain) from September 2019 to June 2020. To assess the association, Poisson regression models with robust variance were used to estimate the prevalence ratio (PR). The observed GDM prevalence was 10.5%, while the VDD prevalence was 55.5%. In the crude model, both VDD and obesity were associated with GDM, but in the adjusted model, only VDD was statistically significant (PR = 1.635, p = 0.038). A secondary event analysis did not detect differences in VDD, but BMI yielded a higher frequency of births by cesarean section and newborns with a >90 percentile weight in the obesity group. In conclusion, VDD is associated with GDM, independent of BMI. Future longitudinal studies could provide information on causality.

Secular Trends in Dietary Intake over a 20-Year Period in People with Type 2 Diabetes in Japan: A Comparative Study of Two Nationwide Registries; Japan Diabetes Complications Study (JDCS) and Japan Diabetes Clinical Data Management Study (JDDM)

Background: In order to provide effective dietary guidance, it is necessary to consider dietary intake, which can change over time. This study analyzed changes in the diet of Japanese patients with type 2 diabetes over a 20-year period. Methods: We compared the results of two dietary surveys that used the food frequency questionnaire format. The first was conducted in 1996 by the Japan Diabetes Complications Study (JDCS) (n = 1509; males 53.3%), and the second in 2014–2018 by the Japan Diabetes Clinical Data Management Study (JDDM) (n = 1145; males 65.6%). Both are nationwide representative registries of outpatients with type 2 diabetes in Japan. Results: Over a 20-year period, both men and women with type 2 diabetes had a significant increase in body mass index (BMI). Nonetheless, there was only a small change in energy intake. Conversely, there was a significant increase in fat intake and thus in the fat-to-energy ratio. With regard to food groups, there was a significant increase in meat intake and a decrease in the intake of fish, soybeans/soy products, vegetables, and fruits, with a particularly significant decrease in vegetables. Conclusions: Even in Japan, an industrialized country with a stable socioeconomic environment, there were many significant changes in the dietary intake of patients with type 2 diabetes over the 20-year period.

Does a MediDiet with additional extra virgin olive oil (EVOO) and pistachios reduce the incidence of gestational diabetes?

OBJECTIVE

The present study aimed to evaluate gestational diabetes mellitus (GDM) incidence in pregnant women following the Mediterranean diet with additional extra virgin olive oil (EVOO) and pistachios.

METHODS

560 pregnant patients were enrolled in the present study. The Mediterranean diet (MedDiet) was introduced in both the interventional group (IG) and control group (CG). The females received 40 ml of extra virgin olive oil (EVOO) every day along with 25 - 30 gm of roasted pistachios in the interventional group. The incidence of Gestational Diabetes Mellitus (GDM) was recorded along with specific maternal and neonatal outcomes.

MATERIALS AND METHODS

The nutritional and MEDAS scores were not statistically different among the groups at baseline, but the difference was statistically significant and higher in IG at 24-28 weeks (p = 0.001) and 36-38 weeks (p = 0.001). GDM was diagnosed in 51(20.4%) females in the Control group and 34 (13.6%) females in the Interventional group. The MedDiet significantly reduced the GDM incidence (p=0.02) after adjusting the confounding factors.

CONCLUSION

The present study depicts that dietary intervention in pregnant women, including MedDiet and increased consumption of EVOO and pistachios, decreased the incidence of GDM.

Improved adherence to Mediterranean Diet in adults with type 1 diabetes mellitus

PURPOSE

We aimed to assess food intake and adherence to the Mediterranean Diet in patients with T1D compared with nondiabetic individuals.

METHODS

This was an observational, multicenter study in 262 T1D subjects and 254 age- and sex-matched nondiabetic subjects. A validated food-frequency questionnaire was administered. The alternate Mediterranean Diet Score (aMED) and alternate Healthy Eating Index (aHEI) were assessed. The clinical variables were also collected. The analysis of data included comparisons between groups and multivariate models.

RESULTS

Compared to the controls, the patients with T1D had a higher intake of dairy products (p < 0.001), processed meat (p = 0.001), fatty fish (p = 0.009), fruits and vegetables (p < 0.001), nuts (p = 0.011), legumes (p < 0.001), potatoes (p = 0.045), and bread (p = 0.045), and a lower intake of seafood (p = 0.011), sweets (p < 0.001), and alcohol drinks (p = 0.025). This intake pattern resulted in a higher consumption of complex carbohydrates (p = 0.049), fiber (p < 0.001), protein (p < 0.001), polyunsaturated fatty acids (PUFA) (p = 0.007), antioxidants (p < 0.001), vitamins (p < 0.001), and minerals (p < 0.001). The frequency of patients with T1D and low aMED score (23.2%) was lower than that of the controls (35.4%; p = 0.019). The overall multivariate analysis showed that, among other factors, being a T1D subject was associated with improved aMED and aHEI scores (p = 0.006 and p < 0.001). In patients with T1D, residing in a nonurban area was associated with improved aMED and aHEI scores (p = 0.001 and p < 0.001).

CONCLUSIONS

Adult patients with T1D showed healthier dietary habits and a higher adherence to the Mediterranean Diet than nondiabetic subjects. Residing in a nonurban area is associated with an improved dietary pattern.

Effectiveness of Following Mediterranean Diet Recommendations in the Real World in the Incidence of Gestational Diabetes Mellitus (GDM) and Adverse Maternal-Foetal Outcomes: A Prospective, Universal, Interventional Study with a Single Group. The St Carlos Study

We reported that a Mediterranean Diet (MedDiet), supplemented with extra-virgin olive oil (EVOO) and pistachios, reduces GDM incidence and several other adverse outcomes. In order to assess its translational effects in the real world we evaluated the effect of MedDiet from 1st gestational visit in GDM rate compared with control (CG) and intervention (IG) groups from the previously referred trial. As secondary objective we also compared adverse perinatal outcomes between normoglycemic and diabetic women. This trial is a prospective, clinic-based, interventional study with a single group. 1066 eligible normoglycaemic women before 12 gestational weeks were assessed. 932 women (32.4 ± 5.2 years old, pre-gestational BMI 22.5 ± 3.5 kg/m2) received a motivational lifestyle interview with emphasis on daily consumption of EVOO and nuts, were followed-up and analysed. Binary regression analyses were used to examine the risk for each pregnancy outcome, pregnancy-induced hypertension, preeclampsia, gestational weight gain (GWG), caesarean-section, perineal trauma, preterm delivery, small (SGA) and large for gestational age (LGA), and Neonatal Intensive Care Unit admissions. GDM was diagnosed in 13.9%. This rate was significantly lower than the CG: RR 0.81 (0.73-0.93), p < 0.001 and no different from the IG: RR 0.96 (0.85-1.07), p = 0.468. GWG was lower in diabetic women (10.88 ± 6.46 vs. 12.30 ± 5.42 Kg; p = 0.013). Excessive weight gain (EWG) was also lower in GDM [RR 0.91 (0.86-0.96); p < 0.001] without a significant increase of insufficient weight gain. LGA were also lower (1 (0.8%) vs. 31 (3.9%); p < 0.05)), and SGA were similar (5 (3.8%) vs. 30 (3.7%)). LGA were associated to EWG (RR 1.61 (1.35-1.91), p < 0.001). Differences in other maternal-foetal outcomes were not found. In conclusions an early MedDiet nutritional intervention reduces GDM incidence and maternal-foetal adverse outcomes and should be universally applied as 1st line therapy. GDM might not be consider as a high risk pregnancy any longer.

A High Adherence to Six Food Targets of the Mediterranean Diet in the Late First Trimester is Associated with a Reduction in the Risk of Materno-Foetal Outcomes: The St. Carlos Gestational Diabetes Mellitus Prevention Study

A prenatal diet affects materno-foetal outcomes. This is a post hoc analysis of the St. Carlos gestational diabetes mellitus (GDM) Prevention Study. It aims to evaluate the effect of a late first-trimester (>12 gestational weeks) degree of adherence to a MedDiet pattern-based on six food targets-on a composite of materno-foetal outcomes (CMFCs). The CMFCs were defined as having emergency C-section, perineal trauma, pregnancy-induced hypertension and preeclampsia, prematurity, large-for-gestational-age, and/or small-for-gestational-age. A total of 874 women were stratified into three groups according to late first-trimester compliance with six food targets: >12 servings/week of vegetables, >12 servings/week of fruits, <2 servings/week of juice, >3 servings/week of nuts, >6 days/week consumption of extra virgin olive oil (EVOO), and ≥40 mL/day of EVOO. High adherence was defined as complying with 5⁻6 targets; moderate adherence 2⁻4 targets; low adherence 0⁻1 targets. There was a linear association between high, moderate, and low adherence, and a lower risk of GDM, CMFCs, urinary tract infections (UTI), prematurity, and small-for-gestational-age (SGA) newborns (all p < 0.05). The odds ratios (95% CI) for GDM and CMFCs in women with a high adherence were 0.35((0.18⁻0.67), p = 0.002) and 0.23((0.11⁻0.48), p < 0.001), respectively. Late first-trimester high adherence to the predefined six food targets is associated with a reduction in the risk of GDM, CMFCs, UTI, prematurity, and SGA new-borns.

A Mediterranean Diet with an Enhanced Consumption of Extra Virgin Olive Oil and Pistachios Improves Pregnancy Outcomes in Women Without Gestational Diabetes Mellitus: A Sub-Analysis of the St. Carlos Gestational Diabetes Mellitus Prevention Study

AIMS

The aim of the study was to evaluate the effect of a Mediterranean diet (MedDiet), enhanced with extra virgin olive oil (EVOO) and nuts, on a composite of adverse maternofoetal outcomes of women with normoglycemia during pregnancy.

METHODS

This was a sub-analysis of the St Carlos gestational diabetes mellitus Prevention Study. Only normoglycemic women were analysed (697). They were randomized (at 8-12th gestational weeks) to: standard-care control group (337), where fat consumption was limited to 30% of total caloric intake; or intervention group (360), where a MedDiet, enhanced with EVOO and pistachios (40-42% fats of total caloric intake) was recommended. The primary outcome was a composite of maternofoetal outcomes (CMFOs): at least having 1 event of emergency C-section, perineal trauma, pregnancy-induced hypertension and preeclampsia, prematurity, large-for-gestational-age and small-for gestational-age.

RESULTS

Crude relative risk showed that the intervention was associated with a significant reduction in the risk of CMFOs (0.48 [0.37-0.63]; p = 0.0001), with a number-needed-to-treat = 5. Risk of urinary tract infections, emergency C-sections, perineal trauma, large-for-gestational-age and small-for gestational age new-borns were also significantly reduced.

CONCLUSION

A MedDiet, enhanced with EVOO and nuts, was associated with a risk reduction of CMFOs in over 50% in normoglycemic pregnant women. Therefore, it might be a potentially adequate diet for pregnant women.

TRIAL REGISTRATION

Identifier ISRCTN84389045. The study was registered on September 27, 2013. Last edited on September 26, 2018.

A Mediterranean diet with additional extra virgin olive oil and pistachios reduces the incidence of gestational diabetes mellitus (GDM): A randomized controlled trial: The St. Carlos GDM prevention study

BACKGROUND

Gestational diabetes mellitus (GDM) prevalence is increasing and becoming a major public health concern. Whether a Mediterranean diet can help prevent GDM in unselected pregnant women has yet to be studied.

METHODS

We conducted a prospective, randomized controlled trial to evaluate the incidence of GDM with two different dietary models. All consecutive normoglycemic (<92 mg/dL) pregnant women at 8-12 gestational weeks (GW) were assigned to Intervention Group (IG, n = 500): MedDiet supplemented with extra virgin olive oil (EVOO) and pistachios; or Control Group (CG, n = 500): standard diet with limited fat intake. Primary outcome was to assess the effect of the intervention on GDM incidence at 24-28 GW. Gestational weight gain (GWG), pregnancy-induced hypertension, caesarean section (CS), preterm delivery, perineal trauma, small and large for gestational age (SGA and LGA) and admissions to neonatal intensive care unit were also assessed. Analysis was by intention-to-treat.

RESULTS

A total of 874 women completed the study (440/434, CG/IG). According to nutritional questionnaires and biomarker analysis, women in the IG had a good adherence to the intervention. 177/874 women were diagnosed with GDM, 103/440 (23.4%) in CG and 74/434(17.1%) in IG, p = 0.012. The crude relative risk (RR) for GDM was 0.73 (95% CI: 0.56-0.95; p = 0.020) IG vs CG and persisted after adjusted multivariable analysis, 0.75(95% CI: 0.57-0.98; p = 0.039). IG had also significantly reduced rates of insulin-treated GDM, prematurity, GWG at 24-28 and 36-38 GW, emergency CS, perineal trauma, and SGA and LGA newborns (all p<0.05).

CONCLUSIONS

An early nutritional intervention with a supplemented MedDiet reduces the incidence of GDM and improves several maternal and neonatal outcomes.

The impact of switching to the one-step method for GDM diagnosis on the rates of postpartum screening attendance and glucose disorder in women with prior GDM. The San Carlos Gestational Study

AIMS

To compare rates of FPG-HbA1C-based postpartum-glucose disorder (PGD) of women with prior gestational diabetes mellitus (GDM) by Carpenter-Coustan criteria (CCc) versus International Association of Diabetes and Pregnancy Study Groups criteria (IADPSGc).

METHODS

1620 women with GDM were divided into CCc group (2007-March 2012, n=915), and IADPSGc group (April 2012-2013, n=705). Pregravid (PG) body weight (BW) and body mass index (BMI) and postdelivery (PD) BW, BMI, waist circumference (WC), HOMA-insulin resistance (HOMA-IR), HbA1c, glucose and lipid profile were analysed. PGD definition: HbA1c ≥5.7% and/or FPG ≥5.6mmol/l.

RESULTS

Postpartum screening attendance rates (PSAr) were similar in both groups, CCc: 791 (86.5%) and IADPSGc: 570 (81%) as in PGD rates (PGDr), CCc: 233 (29.5%) and IADPSGc: 184 (32.3%). Both cohorts had similar PG-BMI, WC and PD-BMI. Both CCc and IADPSGc women had a significantly higher probability of having PGD when PG-BMI ≥25Kg/m(2) (CCc: OR: 1.55; IC 95% 1.06-2.26; p=0.016), (IADPSGc: OR: 1.42; IC 95% 1.03-2.38; p=0.046) as well as when WC ≥89.5cm, and age ≥34years, and in CCc women when PD-WG >0Kg, all adjusted by ethnicity and parity.

CONCLUSIONS

Changing GDM diagnostic methodology did not affect PSAr and PGDr, in spite of screening more women. Thus, using IADPSGc allowed the identification of a larger number of women with PGD.

Diet in 45- to 74-year-old individuals with diagnosed diabetes: comparison to counterparts without diabetes in a nationally representative survey (Etude Nationale Nutrition Santé 2006-2007)

A healthy diet has been shown to prevent diabetes complications. However, the eating habits of individuals with diabetes who are aware of their glycemic condition have been poorly studied. This study's objective was to assess the dietary behavior overall and according to dietary recommendations in adults diagnosed with diabetes compared with those of a general population of the same age (45 to 74 years) in a nationally representative survey carried out in France in 2006-2007 (Etude Nationale Nutrition Santé) (n=1,476 including 101 patients with diabetes). Trained dietitians assessed diet using three 24-hour recalls and diabetes was self-declared. After weighting and using multiple adjustments, mean food and nutrient intakes were compared according to diabetes status. Interactions with age and sex were sought. Adults with diabetes had lower intakes of sweetened foods (40 g/day vs 125 g/day), alcohol (1.45 g/day vs 1.64 g/day), energy (1,790 kcal/day vs 1,986 kcal/day), and simple sugar (63.1 g/day vs 89.8 g/day) and higher intakes of meat (126 g/day vs 109 g/day), complex carbohydrates (26.3% energy intake vs 23.6% energy intake), and vitamins B and E (628 μg/day vs 541 μg/day). In addition, 45- to 59-year-old individuals with diabetes ate more fruits and vegetables, fiber, beta carotene, folate, vitamin C, and potassium than adults of the same age who did not have diabetes. Overall, 45- to 74-year-old adults with diabetes had a higher-quality diet than individuals without diabetes. However, compared with recommendations, a healthy diet continues to represent a public health challenge in terms of preventing diabetes complications.

Recent findings on the effects of marine-derived n-3 polyunsaturated fatty acids on urinary albumin excretion and renal function

Albuminuria (this includes microalbuminuria and macroalbuminuria) and reduced glomerular filtration rate are present not only in high-risk populations, but also in the general population. These manifestations of renal disease are associated with an increased risk of cardiovascular disease and may reflect subclinical vascular disease. Long-chain n-3 polyunsaturated fatty acids have been vigorously studied for their potential cardioprotective effects. These fatty acids reduce the levels of serum lipids, blood pressure, inflammation, and endothelial dysfunction, all of which are associated with albuminuria and renal impairment; therefore, marine-derived n-3 fatty acids may potentially play a role in their prevention. This report reviews the recent findings relating marine-derived n-3 fatty acids to urinary albumin excretion and renal function and their risk factors. Although some evidence suggests that marine-derived n-3 fatty acids are associated with a lower incidence of albuminuria in diabetes, there is inadequate evidence supporting their role in glomerular filtration.

Validation of a food frequency questionnaire in Spanish patients with familial hypercholesterolaemia

BACKGROUND AND AIMS

The aim of this study is to validate a semi-quantitative Food Frequency Questionnaire (FFQ) used for general population in Spain, in patients with familial hypercholesterolaemia (FH).

SUBJECTS AND METHODS

Subjects with genetic diagnosis of FH were randomly selected from the Spanish FH Registry. They completed an FFQ based in 113 food items at inclusion (FFQ1) and after 1 year (FFQ2), and a 3-day dietary records (DR) every 3 months. Detailed instruction about how to register foods and beverages was given by a trained nutritionist. Each DR and FFQ was systematically coded, and the daily nutrients intake in absolute, percentage and nutrient density terms were estimated using a software system based on food composition tables. Pearson correlation coefficient was calculated with correction-repeated measurements to assess the reproducibility of both FFQ and the four 3-day DRs, as well as the validity of FFQ comparing to the mean of 3 days' DR.

RESULTS

A total of 112 subjects (58 females and 54 males, aged 43 ± 16 years) finished the study. There were no differences between FFQ1, FFQ2 and mean FFQ (FFQa) in mean absolute and percentage values of selected daily nutrients' intake. Comparison between FFQ1, FFQ2, FFQa and the mean of four 3-day DRs was statistically significant in all absolute values, but not in percentage or nutrient density terms. Corrected Pearson correlation coefficient ranged from 0.470 to 0.952 for mean values of all nutrients, except alcohol.

CONCLUSION

This study demonstrated that FFQ is a reliable tool to assess the dietary pattern in FH patients.

The diet of diabetic patients in Spain in 2008-2010: accordance with the main dietary recommendations--a cross-sectional study

BACKGROUND

No previous study has assessed the diet of the diabetic patients in the general population of an entire country in Europe. This study evaluates accordance of the diet of diabetic adults in Spain with nutritional recommendations of the European Association for the Study of Diabetes (EASD), American Diabetes Association (ADA), and the Mediterranean diet (MD).

METHODS AND FINDINGS

Cross-sectional study conducted in 2008-2010 among 12,948 persons representative of the population aged ≥18 years in Spain. Usual food consumption was assessed with a dietary history. EASD accordance was defined as ≥6 points on a score of 12 nutritional goals, ADA accordance as ≥3 points on a score of 6 goals, and MD accordance as ≥7 points on the Mediterranean Diet Adherence Screener. In the 609 diagnosed diabetic individuals, the diet was rich in saturated fat (11.2% of total energy), but trans fat intake was relatively low (1.1% energy) and monounsaturated fat intake was high (16.1% energy). Carbohydrate intake was relatively low (41.1% energy), but sugar intake was high (16.9% energy). Intake of cholesterol (322 mg/day) and sodium (3.1 g/day) was also high, while fiber intake was insufficient (23.8 g/day). EASD accordance was observed in 48.7% diabetic patients, ADA accordance in 46.3%, and MD accordance in 57.4%. The frequency of EASD, ADA and MD accordance was not statistically different between diagnosed and undiagnosed diabetic individuals.

CONCLUSIONS

Only about half of diabetic patients in Spain have a diet that is consistent with the major dietary recommendations. The lack of dietary differences between diagnosed and undiagnosed diabetic individuals reflects deficiencies in diabetes management.

Associations between diet quality, health status and diabetic complications in patients with type 2 diabetes and comorbid obesity

OBJECTIVE

Patients with type 2 diabetes (T2DM) demonstrate low dietary adherence and this is further aggravated with comorbid obesity. The aim of the present study was to assess diet quality in patients with T2DM and comorbid obesity compared to patients with T2DM alone and to examine the associations between comorbidities and diet quality.

METHODS

The sample consisted of 59 adult patients with diabesity (T2DM and comorbid obesity) and 94 patients with T2DM alone. All diabetes comorbidities and complications were recorded and diet quality was assessed with the Healthy Eating Index (HEI).

RESULTS

Mean raw HEI of the diabese subjects was 81.9±7.1 and the diabetic subjects was 80.2±6.9. When HEI was adjusted to the sex, age and weight status, the diabese demonstrated a higher HEI. Among comorbidities, only renal disease decreased HEI. According to the principal component analysis of the total sample, adequate diet quality was explained by cardiovascular disease, cigarette smoking, alcohol consumption, peptic ulcer, sex, diabesity and diabetic foot syndrome. In the diabese, adequate HEI was explained by diabetic foot syndrome, smoking, drinking alcohol and having a family history of diabetes.

CONCLUSIONS

Adult patients with T2DM demonstrate adequate diet quality. Different factors are associated with the adoption of a high quality diet between the diabese and the T2DM alone.

Benefits of self-monitoring blood glucose in the management of new-onset Type 2 diabetes mellitus: the St Carlos Study, a prospective randomized clinic-based interventional study with parallel groups

BACKGROUND

Intensive treatment of patients with Type 2 diabetes mellitus (T2DM) from the moment of diagnosis facilitates β-cell recovery. Self-monitoring of blood glucose (SMBG)-based educational and pharmacological intervention may be better than conventional HbA1c algorithms in the treatment of newly diagnosed T2DM.

METHODS

Newly diagnosed T2DM patients were randomized to either an SMBG-based intervention or an HbA1c-based control group (n = 99 and 62, respectively) and were followed for 1 year.

RESULTS

Higher rates of diabetes regression (HbA1c < 6% on metformin alone) and remission (HbA1c between 6.0% and 6.4%) were achieved in the intervention compared with the control group (39% vs 5% (P < 0.001) and 37% vs 30% (P < 0.01), respectively). Furthermore, significantly greater reductions in median HbA1c (6.6% to 6.1%; P < 0.05) and body mass index (29.6-27.9 kg/m(2) ; P < 0.001) were seen in the intervention over the 1 year of therapy. The percentage of patients achieving a lifestyle score >12 was significantly greater in the SMBG compared with the control group (38.4% vs 9.7% respectively; P < 0.001). An inverse correlation was observed between SMBG and HbA1c levels (P < 0.04).

CONCLUSIONS

The results indicate that SMBG-based structured educational and pharmacological programs empower patients to achieve nutritional and physical activity goals, and encourage physicians and patients to use SMBG to optimize therapy. We believe that the concept of intensive treatment of T2DM patients should be modified; instead of referring to the type of treatment (insulin use), the term should reflect the intensity with which we work to reach glucose objectives.

Action for Health in Diabetes (Look AHEAD) trial: baseline evaluation of selected nutrients and food group intake

BACKGROUND

Little has been reported regarding food and nutrient intake in individuals diagnosed with type 2 diabetes, and most reports have been based on findings in select groups or individuals who self-reported having diabetes.

OBJECTIVE

To describe the baseline food and nutrient intake of the Look AHEAD (Action for Health in Diabetes) trial participants, compare participant intake to national guidelines, and describe demographic and health characteristics associated with food group consumption.

METHODS

The Look AHEAD trial is evaluating the effects of a lifestyle intervention (calorie control and increased physical activity for weight loss) compared with diabetes support and education on long-term cardiovascular and other health outcomes. Participants are 45 to 75 years old, overweight or obese (body mass index [BMI] > or = 25), and have type 2 diabetes. In this cross-sectional analysis, baseline food consumption was assessed by food frequency questionnaire from 2,757 participants between September 2000 and December 2003.

STATISTICAL ANALYSIS

Descriptive statistics were used to summarize intake by demographic characteristics. Kruskal-Wallis tests assessed univariate effects of characteristics on consumption. Multiple linear regression models assessed factors predictive of intake. Least square estimates were based on final models, and logistic regression determined factors predictive of recommended intake.

RESULTS

Ninety-three percent of the participants exceeded the recommended percentage of calories from fat, 85% exceeded the saturated fat recommendation, and 92% consumed too much sodium. Also, fewer than half met the minimum recommended servings of fruit, vegetables, dairy, and grains.

CONCLUSIONS

These participants with pre-existing diabetes did not meet recommended food and nutrition guidelines. These overweight adults diagnosed with diabetes are exceeding recommended intake of fat, saturated fats, and sodium, which may contribute to increasing their risk of cardiovascular disease and other chronic diseases.

Family physician and endocrinologist coordination as the basis for diabetes care in clinical practice

BACKGROUND

To estimate the proportion of diabetic patients (DPts) with peripheral vascular disease treated at a primary health care site after an endocrinologist-based intervention, who meet ATP III and Steno targets of metabolic control, as well as to compare the outcome with the results of the patients treated by endocrinologists.

METHODS

A controlled, prospective over 30-months period study was conducted in area 7 of Madrid. One hundred twenty six eligible diabetic patients diagnosed as having peripheral vascular disease between January 2003 and June 2004 were included in the study. After a treatment period of three months by the Diabetes team at St Carlos Hospital, 63 patients were randomly assigned to continue their follow up by diabetes team (Group A) and other 63 to be treated by the family physicians (FP) at primary care level with continuous diabetes team coordination (Group B). 57 DPts from Group A and 59 from Group B, completed the 30 months follow-up period. At baseline both groups were similar in age, weight, time from diagnosis and metabolic control. The main outcomes of this study were the proportion of patients meeting ATP III and Steno goals for HbA1c (%), Cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, blood pressure, albumine-to-creatinine excretion ratio (ACR), body mass index (BMI), waist circumference (WC), anti-aggregation treatment and smoking status.

RESULTS

At the end of the follow up, no differences were found between the groups. More than 37% of diabetic patients assigned to be treated by FP achieved a HbA1c < 6.5%, more than 50% a ACR < 30 mg/g, and more than 80% reached low risk values for cholesterol, LDL cholesterol, triglycerides, diastolic blood pressure and were anti-aggregated, and 12% remained smokers. In contrast, less than 45% achieved a systolic blood pressure < 130 mm Hg, less than 12% had a BMI < 25 Kg.m-2 (versus 23% in group A; p < 0.05) and 49%/30% (men/women) had a waist circumference of low risk.

CONCLUSION

Improvements in metabolic control among diabetic patients with peripheral vascular disease treated at a primary health care setting is possible, reaching similar results to the patients treated at a specialized level. Despite such an improvement, body weight control remains more than poor in both levels, mainly at primary care level. General practitioner and endocrinologist coordination care may be important to enhance diabetes management in primary care settings.

TRIAL REGISTRATION

Clinical Trial number ISRCTN75037597.

Macronutrient intake and discrepancy with nutritional recommendations in a group of elderly diabetic subjects

Diet is a major aspect of glycaemic control in type 2 diabetes, particularly among the elderly. The objective of this study was to describe the food habits of elderly diabetic subjects compared with non-diabetic ones and to examine the difference between their nutritional behaviour and nutritional recommendations. This study was based on the Three City (3C) community-based cohort. The food habits of 1336 participants aged 65 or over, including 149 diabetic subjects, were evaluated using a FFQ and a 24 h recall of food consumption. For both sexes, intake of carbohydrates was lower for diabetic compared to non-diabetic subjects, essentially due to a lower intake of mono-/disaccharides. For diabetic men, this was compensated for by a higher intake of protein whereas women had a lower energy intake overall. Fibre intake was also higher in diabetic men. There was no absolute increase in fats intake, neither for men nor for women, and distribution of subtypes of fats (saturated, monounsaturated and polyunsaturated) did not differ between diabetic and non-diabetic subjects. Carbohydrates provided 40.5 % of energy intake in diabetic men and 43.9 % in diabetic women. Contrary to nutritional recommendations for diabetic subjects, for approximately two-thirds of the diabetic subjects carbohydrates represented less than 45 % of daily energy intake. Although food habits of elderly diabetic subjects differed from those of non-diabetic ones, these habits are not totally in line with nutritional recommendations. These results should be taken into account to adapt nutritional advice given to the diabetic population.

Serum phospholipid fatty acid profile and dietary intake in an adult Mediterranean population with cystic fibrosis

The relative importance of the usual diet in serum phospholipids in subjects with cystic fibrosis (CF) has been poorly studied. To compare the fatty acid profile in serum phospholipids from adult CF subjects with that of healthy subjects, and determine the role of the normal diet in this profile, we studied thirty-seven adult CF subjects with stable pulmonary disease and thirty-seven healthy controls matched for age, sex and nutritional status. A dietary questionnaire was obtained, anthropometric data were recorded, and the fatty acid profile measured by GLC. Compared with the controls, the percentages of myristic, palmitoleic and stearic acids and total MUFA were significantly higher in the CF group, and DHA, linoleic acid, total PUFA and n−6 fatty acids were significantly lower in the CF group. The CF subjects with worse pulmonary function and with pancreatic insufficiency had significantly lower levels of linoleic and n−6 fatty acids. The total energy intake was significantly higher in the CF subjects, although the energy distribution in the CF subjects and the controls was not different for the carbohydrates, lipids and proteins. No differences were detected in fat intake for MUFA (51 (sd 4) v. 52 (sd 4) %) or saturated fatty acids (33·5 (sd 5) v. 31·2 (sd 3·8) %), but the PUFA were slightly lower in the CF subjects (15·4 (sd 4·5) v. 17·4 (sd 4·2) %; P=0·02). The usual dietary intake of fatty acids by adult CF subjects does not appear to explain the difference in the fatty acid profile compared with controls. This suggests an abnormal fatty acid metabolism in CF subjects.

Diabetes Nutrition and Complications Trial: adherence to the ADA nutritional recommendations, targets of metabolic control, and onset of diabetes complications. A 7-year, prospective, population-based, observational multicenter study

OBJECTIVE

To know the adherence to the ADA nutritional recommendations and its relation to targets of metabolic control and onset of diabetic complications in a sample of diabetic people in Spain.

RESEARCH DESIGN AND METHODS

The Diabetes Nutrition and Complications Trial (DNCT) is a prospective, population-based, observational multicenter study designed to know the nutritional pattern, based on the 7-day food diaries, of a population with long-standing diabetes mellitus (93/99 type 1/type 2 diabetic patients, 20/18 years of duration of diabetes, and 6.9%/6.4% HbA(1c) values) and its relation with the onset of microvascular and macrovascular diabetes complications between 1993 and 2000.

RESULTS

After a median follow-up period of 6.5 years, more than 55% of diabetic people complied with the recommendation of protein intake between 15% and 20%, but only 27% consumed less than 10% of saturated fatty acids (SFAs), the 13% achieved up 10% of polyunsaturated fatty acids (PUFAs) intake, the 39% consumed more than 60% from carbohydrate and monounsaturated fatty acids (MUFAs), and the 30% consumed <300 mg/day of cholesterol. In spite of these, more than 90% had an optimal HDL cholesterol and non-HDL cholesterol level, and triglycerides level, while less than 41% of diabetic people had an HbA(1c) value >7.5%. Moreover, more than 69% consumed a MUFAs-to-SFAs ratio >1.5 and the 46% a PUFAs-to-SFAs ratio >0.4. Nonadherence to nutritional recommendation, but MUFAs/SFAs ratio >1.5 and PUFAs/SFAs ratio >0.4, was associated with a reduction between 3.4- and 8.2-fold in the risk of onset of diabetic complications.

CONCLUSIONS

The adherence to ADA nutritional recommendations for people with diabetes in Spain is rather poor except for the protein consumption. Only PUFAs/SFAs >0.4 and MUFAs/SFAs>1.5 were associated to near-optimal targets of metabolic control and a reduction in the risk of the onset of diabetic complications. These data suggest that other nutritional recommendations should be taken in mind.

Evaluation of the accuracy of a microdialysis-based glucose sensor during insulin-induced hypoglycemia, its recovery, and post-hypoglycemic hyperglycemia in humans

BACKGROUND

These studies were designed to evaluate the accuracy of a microdialysis-based subcutaneous glucose sensor (GlucoDay, A. Menarini Diagnostics, Firenze, Italy) compared with a standard reference method of plasma glucose measurement during insulin-induced hypoglycemia.

RESEARCH DESIGN AND METHODS

Nine subjects without diabetes were studied in eu-, hypo-, and hyperglycemia (clamp technique). The GlucoDay was calibrated against one arterialized plasma glucose measurement (Glucose Analyzer, Beckman, Brea, CA), and plasma glucose estimates every 3 min were compared with paired plasma glucose values.

RESULTS

Accuracy of glucose estimates was not homogeneously distributed among subjects and depended on stability of the sensor's current signal during spontaneous euglycemia (R +/- -0.68). Linear regression analysis showed a good correlation between the two methods of measurement (R = 0.9), Deming regression showed the inclusion of the unit in the confidence interval of the slope (slope 0.95, 95% confidence interval 0.87-1.02), and the accuracy of the GlucoDay reached 40 +/- 15% (American Diabetes Association criteria). The mean relative difference was 6 +/- 8% in euglycemia, 13 +/- 14% during plasma glucose fall, 5 +/- 22% in the hypoglycemic plateau, and -14 +/- 16% during recovery from hypoglycemia. The Bland-Altman analysis indicated a bias of -1.9 +/- 16.6 mg/dL, whereas the Error Grid Analysis showed 94% of the Gluco- Day measurements in the acceptable zones of the grid. The time to reach the glycemic nadir was longer when measured with the GlucoDay (90 +/- 5 vs. 72.5 +/- 9 min, P < 0.05). However, absolute values of glycemic nadir, time spent in hypoglycemia, and the rate of fall of glycemia and the rate of recovery from the hypoglycemia were not statistically different.

CONCLUSIONS

GlucoDay closely monitors changes in plasma glucose before, during, and after hypoglycemia. However, these results can be achieved only if calibration of the GlucoDay is performed under conditions of sensor signal stability. Similar studies have to be performed in subjects with diabetes to validate the GlucoDay system.

Real-time glucose sensing using transdermal fluid under continuous vacuum pressure in children with type 1 diabetes

BACKGROUND

This study was designed to evaluate the accuracy and tolerance in children of an experimental device for continuous glucose monitoring. This real-time glucose sensing (RTGS) system measures transdermal fluid glucose through micropores in the stratum corneum that are kept open by continuous vacuum pressure.

DESIGN AND METHODS

A comparison of self-monitored blood glucose values and RTGS values was obtained in 110 children with type 1 diabetes ranging in age from 2 to 18 years. The RTGS system was worn for two periods of 48-56 h each. Children went home and had no restrictions in diet during the data collection period. Physical activity also was not restricted, with the exception of swimming or other water immersion that would interfere with or damage the RTGS.

RESULTS

The procedure for obtaining transdermal fluid was well tolerated, and adequate flow was maintained out to 48 h or more in most study participants. Comparison of RTGS glucose and self-measured glucose paired values (3,064 values) indicated 69% within Clarke Error Grid Zone A and 21% within Grid Zone B when device tracking was maintained. Errors in tracking occurred with displacement of the vacuum device, or damage to the glucose sensor.

CONCLUSIONS

Transdermal fluid glucose measurements using a prototype device system were well tolerated by children with type 1 diabetes and showed good correlation with concomitant capillary glucose blood measurements. Changes in glucose as tracked by the RTGS system appeared accurate. The durability of the prototype system will need improvement.

Response to nocturnal alarms using a real-time glucose sensor

BACKGROUND

The objective of this study was to determine how subjects responded to alarms for hypo- and hyperglycemia while they were sleeping.

RESEARCH DESIGN AND METHODS

Twenty subjects with type 1 diabetes (4-17 years old) were admitted to a clinical research center for approximately 24 h. Each subject wore two GlucoWatch G2 Biographers (GW2B) (Cygnus, Inc., Redwood City, CA) and was videotaped using an infrared camera from 9 p.m. to 7 a.m. The videotapes were reviewed to determine if the GW2B alarms were audible on the tape and to document the subject's response to the alarms. Because many alarms can occur surrounding a change in blood glucose, GW2B alarm "events" are defined as a one or more alarms separated from previous alarms by more than 30 min.

RESULTS

Downloaded data from the biographers identified 240 individual alarms, 75% of which occurred while the subject was sleeping. Of the 240 alarms 68% were audible on the videotape. Subjects awoke to 29% of individual alarms and to 66% of alarm events. Subjects 4-6 years old responded to 17% of alarms, 7-11 year olds responded to 20% of alarms, adolescents responded to 53% of alarms, and parents responded to 37% of alarms. Subjects awoke to 40% of the first alarm during the night, but to only 28% of subsequent alarms. There were 11 events when the glucose was confirmed to be < or = 70 mg/dL, and in each case the subject was awoken. Fifty-five percent of alarm events occurred when there was no hypo- or hyperglycemia confirmed by a reference glucose value.

CONCLUSIONS

Subjects awoke to 29% of individual alarms and to 66% of alarm events. Subjects awoke during all alarm events when hypoglycemia was confirmed, but there was a high incidence of false alarms.

Noninvasive and minimally invasive methods for transdermal glucose monitoring

Noninvasive and minimally invasive techniques for monitoring glucose via the skin are reviewed. These approaches rely either on the interaction of electromagnetic radiation with the tissue or on the extraction of fluid across the barrier. The structure and physiology of the skin make the technical realization of transdermal glucose monitoring a difficult challenge. The techniques involving transdermal fluid extraction circumvent and/or compromise the barrier function of skin's outermost and least permeable layer, the stratum corneum, by the application of physical energy. While sonophoresis and microporation methods, for example, are in relatively early-stage development, a device using reverse iontophoresis [the GlucoWatch Biographer (Cygnus, Inc., Redwood City, CA)] is already commercially available. Optical techniques to monitor glucose are truly noninvasive. The tissue is irradiated, the absorbed or scattered radiation is analyzed, and the information is processed, to provide a measure proportional to the concentration of glucose in the dermal tissue. These techniques include near-infrared and Raman spectroscopy, polarimetry, light scattering, and photoacoustic spectroscopy. By contrast, impedance spectroscopy measures changes in the dielectric properties of the tissue induced by blood glucose variation. Large-scale studies in support of efficacy of these methodologies are as yet unavailable. At present, therefore, transdermal fluid extraction technologies are offering greater promise in terms of practical and realizable devices for patient use. The truly noninvasive allure of the optical approach assures continued and intense research activity--for the moment, however, an affordable, efficient, and portable system is not on the immediate horizon.

A novel approach to mitigating the physiological lag between blood and interstitial fluid glucose measurements

BACKGROUND

Lag between blood and interstitial fluid (ISF) glucose levels can contribute significantly to accuracy error in current and anticipated continuous glucose monitoring systems. Mitigating this physiological lag can be an important and useful means for improving the accuracy, and hence the clinical utility, of continuous glucose monitors.

METHODS

In a test of 22 subjects with diabetes in which a glucose excursion was induced through oral ingestion of a glucose load, glucose levels in finger blood and forearm dermal ISF were monitored over a 5-6-h period. ISF was sampled from two types of sites: sites at which local blood perfusion was elevated through modulated pressure application (test ISF), and control sites at which no perfusion elevation technique was employed (control ISF).

RESULTS

Average lag times (mean +/- SD values) between the two ISF samples and finger capillary blood glucose were determined to be 38.3 +/- 11.5 and 2.5 +/- 6.6 min, respectively, for the control and test ISF samples. Modulated pressure application mitigated the ISF physiological error by an average of 95% in this test.

CONCLUSIONS

The methodology presented here of using a pressure modulation technique to create an elevation in blood flow holds promise for significantly mitigating one of the most significant components of accuracy error for continuous monitoring systems.

GlucoWatch G2 Biographer alarm reliability during hypoglycemia in children

BACKGROUND

The GlucoWatch G2 Biographer (GW2B) (Cygnus, Inc., Redwood City, CA) provides near-continuous monitoring of glucose values in near real time. This device is equipped with two types of alarms to detect hypoglycemia. The hypoglycemia alarm is triggered when the current glucose measurement falls below the level set by the user. The "down alert" alarm is triggered when extrapolation of the current glucose trend anticipates hypoglycemia to occur within the next 20 min.

METHODS

We used data from an inpatient accuracy study to assess the performance of these alarms. During a 24-h clinical research center stay, 89 children and adolescents with Type 1 diabetes mellitus (3.5-17.7 years old) wore 174 GW2B devices and had frequent serum glucose determinations during the day and night.

RESULTS

Sensitivity to detect hypoglycemia (reference glucose < or = 60 mg/dL) during an insulin-induced hypoglycemia test was 24% with the hypoglycemia alarm alone and 88% when combined with the down alert alarm. Overnight sensitivity from 11 p.m. to 6 a.m. was 23% with the hypoglycemia alarm alone and 77% when combined with the down alert alarm. For 16% of hypoglycemia alarms, the reference glucose was above 70 mg/dL for 30 min before and after the time of the alarm. For the two alarm types combined, the corresponding false-positive rate increased to 62%.

CONCLUSIONS

The down alert alarm substantially improves the sensitivity of the GW2B to detect hypoglycemia at the price of a large increase in the false alarm rate. The utility of these alarms in the day-to-day management of children with diabetes remains to be determined.

The public health impact of the MiniMed Continuous Glucose Monitoring System (CGMS)-an assessment of the literature

The Medtronic MiniMed (Northridge, CA) Continuous Glucose Monitoring System (CGMS) was approved by the U. S. Food and Drug Administration in 1999, for the continuous tracking of glucose concentration. The rationale for the use of this device is that frequent glucose measurements allow a more precise understanding of daily glucose fluctuations, without the inconvenience of frequent needle sticks. A review of the medical literature was undertaken to assess the public health impact of this device. Glucose readings from the MiniMed CGMS were found to correlate well with blood glucose (r = 0.73-0.92) and with hemoglobin A(1c) (HBA(1c)) (r = 0.53-0.59). Most important from a public health standpoint is the ability of the MiniMed device to detect episodes of asymptomatic hypoglycemia, and to lower HBA(1c) (absolute decline of 0.3%), as compared with controls. If these findings hold, the use of the MiniMed CGMS could result in a substantial reduction of morbidity and mortality associated with diabetes. The limitations of this analysis, most importantly the paucity of controlled studies that assess the ability of this device to result in improved control of diabetes over long periods of time, are discussed.