Dietary Glycemic Index and Load and the Risk of Type 2 Diabetes: Assessment of Causal Relations

Dietary Glycemic Index and Load and Semen Quality: A Cross-Sectional and Prospective Analysis within the FERTINUTS Trial

PURPOSE

Infertility is a global health issue and nutrition plays a significant role in fertility outcomes. We aimed to investigate the cross-sectional and prospective associations of glycemic index (GI) and glycemic load (GL) with semen quality parameters in a cohort of healthy young men.

MATERIALS AND METHODS

The study included 106 men aged 18-35 years from the FERTINUTS trial. Dietary intake was estimated through 3-day dietary records and several semen parameters were assessed. Multivariable linear regression analysis with the Least Absolute Shrinkage and Selection Operator (LASSO) approach was employed.

RESULTS

The cross-sectional analysis revealed positive associations between GI and GL and total sperm count, sperm concentration, and total motility. In the prospective analysis, baseline GI was associated with increases in pH, vitality, immotile sperm or abnormal midpiece and decreases in total sperm count and motility. Conversely, GL was positively associated with changes in vitality and total sperm count.

CONCLUSIONS

While these findings suggest that GI may have adverse effects on several sperm quality parameters, the results were not consistently observed in the cross-sectional analysis. However, GL was consistently associated with better sperm quality in both analyses. The impact of carbohydrate quality and quantity on fertility remains uncertain and larger prospective studies are needed.

An evidence-based assessment of the nutritional recommendations for the prevention of diabetes mellitus

There are accumulating levels of scientific knowledge concerning the dietary recommendations for the prevention of type 2 diabetes mellitus (T2DM).

PURPOSE

This systematic review presents the most recent scientific knowledge concerning dietary recommendations for T2DM published in the English language by various scientific societies during the past 10 years.

METHODS

The recommendations are herein presented and discussed in the light of a critical, evidence-based appraisal aiming to provide a comprehensive guide for the clinician in daily practice.

RESULTS

In the case of overweight or obesity, the cornerstone of the primary prevention of T2DM is the combination of a healthy body weight (body mass index < 25 kg/m2) or a reduction of fat by at least 7% and the implementation of at least 150 min of moderate physical activity per week. Restriction of calories and of dietary fat is recommended, the latter as well as several dietary patterns providing a holistic approach to dieting and all having been correlated with decreased risk of T2DM. Among these dietary patterns are the Mediterranean diet, the DASH diet (Dietary Approaches to Stop Hypertension), the low-glycemic diet, and the HEI-Healthy Eating Index and AHEI-Alternative Healthy Eating Index. Micronutrient deficiencies of, for example, vitamin D, chromium and magnesium, may be associated with insulin resistance in T2DM.

CONCLUSION

Overall, the combination of nutrition through dietary patterns that are mainly plant-based and which emphasize wholegrains, legumes, nuts, fruits, and vegetables and that include only small percentages of refined and processed foods, together with physical activity, has been associated with decreased T2DM risk.

The Effect of Adding Protein to a Carbohydrate Meal on Postprandial Glucose and Insulin Responses: A Systematic Review and Meta-Analysis of Acute Controlled Feeding Trials

BACKGROUND

Protein influences acute postprandial glucose and insulin responses, but the effects of dose, protein type, and health status are unknown.

OBJECTIVES

We aimed to determine the acute effect of adding protein to carbohydrate on postprandial responses and identify effect modifiers.

METHODS

We searched MEDLINE, EMBASE, and Cochrane databases through 30 July, 2023 for acute, crossover trials comparing acute postprandial responses elicited by carbohydrate-containing test meals with and without added protein in adults without diabetes or with type 2 (T2DM) or type 1 (T1DM) diabetes mellitus. Group data were pooled separately using generic inverse variance with random-effects models and expressed as the ratio of means with 95% confidence interval. Risk of bias and certainty of evidence (Grading of Recommendations Assessment, Development, and Evaluation) were assessed.

RESULTS

In 154 trial comparisons of animal, dairy, and plant proteins (without diabetes, n = 22, 67, 32, respectively; T2DM, n = 14, 16, 3, respectively), each gram protein per gram available carbohydrate (g/g) reduced the glucose area under the curve (AUC) less in adults with T2DM than in those without diabetes (-10% compared with -50%, P < 0.05) but increased the insulin AUC similarly (+76% compared with +56%). In subjects without diabetes, each g/g of dairy and plant protein reduced glucose AUC by 52% and 55%, respectively, and increased the insulin AUC by 64% and 45%, respectively (all P < 0.05). Animal proteins significantly reduced the glucose AUC by 31% and increased the insulin AUC by 37% (pooled effects) but without a significant dose-response. In adults with T2DM, animal protein reduced the glucose AUC by 13% and increased the insulin AUC by 105%, with no significant dose-response. Dairy protein reduced the glucose AUC by 18% (no dose-response), but each g/g increased the insulin AUC by 34% (P < 0.05). In adults with T1DM, protein increased the glucose AUC by 40% (P < 0.05, n = 5). Data source (reported AUC compared with calculated AUC) and study methodology quality significantly modified some outcomes and contributed to high between-study heterogeneity.

CONCLUSIONS

In people without diabetes, adding dairy or plant protein to a carbohydrate-containing meal elicits physiologically significant reductions in glucose AUC and increases insulin AUC. Animal protein may slightly reduce the glucose AUC and may increase the insulin AUC. In people with T2DM, protein may not have such large and consistent effects. Further research is needed to determine if the effects of protein differ by health status and protein source. This study was registered at PROSPERO as CRD42022322090.

Food processing according to the NOVA classification is not associated with glycemic index and glycemic load: results from an analysis of 1995 food items

BACKGROUND

Ultraprocessed foods (UPFs) comprise most calories in the United States diet. Glycemic index (GI) and glycemic load (GL) are measures of the quality and quantity of carbohydrates in food based on their effect on postprandial blood glucose. Diets high in UPFs and GI/GL are associated with chronic metabolic diseases but the relationship between them is unclear.

OBJECTIVES

Our objective was to examine the GI and GL of foods assigned to NOVA food processing groups. We hypothesized that GI and GL would be lowest in minimally processed foods (MPFs) compared to processed food (PRF) and UPF (with no difference between PRF and UPF).

METHODS

GI and GL values produced by healthy individuals for 1995 food items were collated from published sources. Food items were manually coded by processing levels according to NOVA classification. In addition, as the effects of processing on glycemic potential may vary between types of foods, food items were coded into 8 groups (beans, nuts, and seeds; beverages; dairy; fats and sweets; fruit; grains; fish, meat, and poultry; and vegetables). Multilevel linear modeling was used to determine significance with an α value of 0.05.

RESULTS

The effect of food processing on GI and GL was contrary to our hypothesis as means did not differ significantly across processing levels: GI-MPF: 54.1 ± 19.5, PRF: 53.2 ± 18.9, UPF: 49.3 ± 18.1 (P = 0.712); GL-MPF: 17.1 ± 10.3, PRF: 15.8 ± 12.4, UPF; 11.5 ± 7.9 (P = 0.890). Within food groups, there was no significant association between processing level and GI (P = 0.184), but GL was inversely associated with grains and vegetables (P < 0.001).

CONCLUSIONS

Across analyzed foods, GI and GL do not differ between processing levels, whereas GL was lower in ultraprocessed grains and vegetables than MPF. Any potential adverse outcomes associated with UPF are unlikely to be related to effects on glycemia. This project was preregistered at the Open Science Framework (OSF) Registries through the Center for Open Science as 10.17605/OSF.IO/PJWG9.

The Portfolio Diet and HbA1c in Adults Living with Type 2 Diabetes Mellitus: A Patient-Level Pooled Analysis of Two Randomized Dietary Trials

(1) Background: The Portfolio Diet, a dietary pattern of cholesterol-lowering foods, is also rich in low glycemic index (GI) foods. While strong evidence supports clinically meaningful reductions in cholesterol, evidence on the relationship between the Portfolio Diet and diabetes management is lacking. (2) Objective: To evaluate the relationship between the Portfolio Diet and glycated hemoglobin (HbA1c) as a determinant of glycemic control among adults living with type 2 diabetes mellitus (T2DM). (3) Methods: Patient-level data was pooled from two randomized dietary trials of low glycemic index interventions compared to high cereal fibre control diets in adults living with T2DM where HbA1c was collected (clinicaltrials.gov identifiers: NCT00438698, NCT00438698). Dietary exposure was assessed using weighed 7-day diet records. Adherence to the Portfolio Diet and its pillars (nuts and seeds, plant protein, viscous fibre, plant sterols, monounsaturated fatty acid [MUFA] oils) was determined using the validated clinical Portfolio Diet Score (c-PDS). Multiple linear regression was used to assess the association between change in the c-PDS and change in HbA1c over 6-months with covariate adjustments. (4) Results: A total of 267 participants, predominantly White (67%) and male (63%), were included, with a mean ± standard error age of 62 ± 0.5 years, baseline BMI of 30.2 ± 0.3 kg/m2, HbA1c of 7.08 ± 0.03%, and a c-PDS of 4.1 ± 0.3 points out of 25. Change in the c-PDS was significantly associated with a change in HbA1c (β: -0.04% per point, 95% CI: -0.07, -0.02, p = 0.001). A 7.5-point (30%) increase in the c-PDS was associated with a 0.3% reduction in HbA1c. Of the individual pillars, a 1-point change in nut and seeds intake (β: -0.07%, 95% CI: -0.12, -0.02, p = 0.009) or in plant protein intake (β: -0.11%, 95% CI: -0.18, -0.03, p = 0.009) was associated with a change in HbA1c. Further analysis of plant protein intake revealed that an increase in dietary pulse intake, a particularly low-GI food, was significantly associated with a reduction in HbA1c (β: -0.24% per 1-cup points cooked pulses (226 g) or 2 c-PDS points, 95% CI: -0.45, -0.03, p = 0.028). (5) Conclusions: Among adults living with T2DM, the Portfolio Diet was associated with lower HbA1c over a 6-month period, predominantly driven by two pillars: nuts and seeds and plant protein, particularly dietary pulses. These data have implications for including the Portfolio Diet in dietary recommendations for glycemic control in T2DM. A trial demonstrating the direct causal effect of the Portfolio Diet in a diverse group is warranted.

Development of a national database for dietary glycemic index and load for nutritional epidemiologic studies in the United States

BACKGROUND

The quality of carbohydrate intake, as measured by the glycemic index (GI), has not been evaluated nationally over the past 2 decades in the United States.

OBJECTIVES

We aimed to develop a comprehensive and nationally representative dietary GI and glycemic load (GL) database from 1999 to 2018 National Health and Nutrition Examination Survey (NHANES) and to examine GI and GL time trends and subpopulation differences.

METHODS

We used an artificial intelligence (AI)-enabled model to match GI values from 2 GI databases to food codes from United States Department of Agriculture, which were manually validated. We examined nationally representative distributions of dietary GI and GL from 1999 to 2018 using the multistage, clustered sampling design of NHANES.

RESULTS

Assigned GI values covered 99.9% of total carbohydrate intake. The initial AI accuracy was 75.0%, with 31.3% retained after manual curation guided by substantive domain expertise. A total of 7976 unique food codes were matched to GI values, of which soft drinks and white bread were top contributors to dietary GI and GL. Of the 49,205 NHANES adult participants, the mean dietary GI was 55.7 (95% confidence interval [CI]: 55.5, 55.8) and energy-adjusted dietary GL was 133.0 (95% CI: 132.3, 133.8). From 1999 to 2018, dietary GI and GL decreased by 4.6% and 13.8%, respectively. Dietary GL was higher among females (134.6; 95% CI: 133.8, 135.5) than among males (131.3; 95% CI: 130.3, 132.3), those with ≤high school degree (137.7; 95% CI: 136.8, 138.7) than among those with ≥college degree (126.5; 95% CI: 125.3, 127.7), and those living under the poverty level (140.9; 95% CI: 139.6, 142.1) than among those above the poverty level. Differences in race were observed (Black adults, 139.4; 95% CI: 138.2, 140.7; White adults, 131.6; 95% CI: 130.5, 132.6).

CONCLUSIONS

The national GI and GL database facilitates large-scale and high-quality surveillance or cohort studies of diet and health outcomes in the United States.

From diabetes to diverse domains: the multifaceted roles of GLP-1 receptor agonists

Glucagon-like Peptide-1 (GLP-1) receptor agonists (GLP-1RAs) emerged as a primary treatment for type-2 diabetes mellitus (T2DM), however, their multifaceted effects on various target organs beyond glycemic control opened a new era of treatment. We conducted a comprehensive literature search using databases including Scopus, Google Scholar, PubMed, and the Cochrane Library to identify clinical, in-vivo, and in-vitro studies focusing on the diverse effects of GLP-1 receptor agonists. Eligible studies were selected based on their relevance to the varied roles of GLP-1RAs in T2DM management and their impact on other physiological functions. Numerous studies have reported the efficacy of GLP-1RAs in improving outcomes in T2DM, with demonstrated benefits including glucose-dependent insulinotropic actions, modulation of insulin signaling pathways, and reductions in glycemic excursions. Additionally, GLP-1 receptors are expressed in various tissues and organs, suggesting their widespread physiological functions beyond glycemic control potentially include neuroprotective, anti-inflammatory, cardioprotective, and metabolic benefits. However, further scientific studies are still underway to maximize the benefits of GLP-1RAs and to discover additional roles in improving health benefits. This article sought to review not only the actions of GLP1RAs in the treatment of T2DM but also explore its effects on potential targets in other disorders.

Reflections on the discovery GLP-1 as a satiety hormone: Implications for obesity therapy and future directions

Scientists were chasing an incretin hormone, and when GLP-1 was finally discovered, we found that it had a pronounced satiety effect, slowed down gastric emptying, and actually reduced postprandial insulin response. These mechanisms are the basis for the highly efficacious GLP-1 analogues that today offer safe and effective treatment in millions of people living with obesity. Moreover, the combined GLP-1 mechanisms of weight loss and delayed carbohydrate absorption may also be the key drivers of remission of type 2 diabetes and reduced cardiovascular events found by GLP-1 analogues.

Comparison of food intake pattern of diabetic patients and healthy individuals in a sample of Saudi population: a case-control study

BACKGROUND

There has been a significant rise in the number of individuals diagnosed with type 2 diabetes mellitus (T2DM), with the condition reaching epidemic proportions globally. This study examined the dietary pattern of a sample of Saudi Arabian adults with T2DM compared to control non-diabetics.

METHODS

Data from 414 participants, 207 control and 207 T2DM was analyzed. Anthropometric measurements, foods intake such as vegetables, fruits, whole grains, fried foods, sweetened juice, sweets, and pastries consumption as well as physical activity were obtained by an interview-survey.

RESULTS

The consumption of vegetables, green and leafy vegetables, starchy vegetables, fruits, proteins, and milk was significantly higher in the diabetics (p< 0.0001 for all and p<0.01 for starchy vegetables). Of the case group, 79.7% of them consumed whole-wheat bread while 54.6% of them consumed low fat milk (p<0.0001). There was a significant decrease in the percentage of cases who consumed discretionary foods and sweetened juices and soft drinks (24.1%), avoided sweets (75.8%) and pastries (37.1%), (p<0.0001). There were also significant increases in the percentages of participants who use healthy fat (as olive oil) in the case group (78.7%) (p<0.001). There was a significant increase in the percentage of diabetics who followed a diet to lose weight (15%) (p<0.05). The majority of the two study groups were physically inactive (control 95.2% & case 94.2%).

CONCLUSIONS

The results of this study provide insight on that diabetics generally follow a healthy diet, yet their engagement in physical activity may not be optimal.

Understanding the Impact of Different Doses of Reducose® Mulberry Leaf Extract on Blood Glucose and Insulin Responses after Eating a Complex Meal: Results from a Double-Blind, Randomised, Crossover Trial

Non-communicable diseases (NCDs) are becoming an increasingly important health concern due to a rapidly ageing global population. The fastest growing NCD, type 2 diabetes mellitus (T2DM), is responsible for over 2 million deaths annually. Lifestyle changes, including dietary changes to low glycemic response (GR) foods, have been shown to reduce the risk of developing T2DM. The aim of this study was to investigate whether three different doses of Reducose®, a mulberry leaf extract, could lower the GR and insulinemic responses (IR) to a full meal challenge in healthy individuals. A double-blind, randomised, placebo-controlled, repeat-measure, crossover design trial was conducted by the Oxford Brookes Centre for Nutrition and Health; 37 healthy individuals completed the study. Participants consumed capsules containing either 200 mg, 225 mg, 250 mg Reducose® or placebo before a test meal consisting of 150 g white bread and egg mayo filler. Capillary blood samples were collected at 15-min intervals in the first hour and at 30-min intervals over the second and third hours to determine glucose and plasma insulin levels. The consumption of all three doses of Reducose® resulted in significantly lower blood glucose and plasma insulin levels compared to placebo. All three doses of Reducose® (200 mg, 225 mg, 250 mg) significantly lowered glucose iAUC 120 by 30% (p = 0.003), 33% (p = 0.001) and 32% (p = 0.002), respectively, compared with placebo. All three doses of Reducose® (200 mg, 225 mg, 250 mg) significantly lowered the plasma insulin iAUC 120 by 31% (p = 0.024), 34% (p = 0.004) and 38% (p < 0.001), respectively. The study demonstrates that the recommended dose (250 mg) and two lower doses (200 mg, 225 mg) of Reducose® can be used to help lower the GR and IR of a full meal containing carbohydrates, fats and proteins.

Dietary Patterns and New-Onset Diabetes Mellitus in Southwest China: A Prospective Cohort Study in the China Multi-Ethnic Cohort (CMEC)

(1) Background: There is little known about the relationship between Dietary Approaches to Stop Hypertension (DASH) pattern and diabetes in cohort studies, and the dietary patterns in the Chongqing natural population are unknown. (2) Methods: 14,176 Chinese adults, aged 30-79 years old, participated in this prospective study, from September 2018 to October 2023. A dietary assessment was conducted using a food frequency questionnaire, and three main dietary patterns were extracted from the principal component analysis. DASH patterns were calculated by standards. (3) Results: During the 4.64 y follow-up, 875 developed diabetes (11.3/1000 person-years). Each posteriori diet pattern is named after its main dietary characteristics (meat pattern, dairy products-eggs pattern, and alcohol-wheat products pattern). The high consumption of DASH pattern diet reduced the risk of diabetes (Q5 vs. Q1 HR: 0.71; 95% CI: 0.40-0.56) while high consumption of alcohol-wheat product pattern diet was associated with a high risk of diabetes (Q5 vs. Q1 HR: 1.32; 95% CI: 1.04, 1.66). The other two dietary patterns were not associated with diabetes. In subgroup analysis, there was an interaction between DASH pattern and sex (P for interaction < 0.006), with a strong association in females. (4) Conclusions: DASH pattern may be associated with a reduced new-onset diabetes risk and Alcohol-wheat products pattern may be positively associated with new-onset diabetes. These findings may provide evidence for making dietary guidelines in southwest China to prevent diabetes.

The role of food structure in gastric-emptying rate, absorption and metabolism

The high levels of non-communicable diseases such as CVD and type 2 diabetes mellitus are linked to obesity and poor diet. This continuing emphasis on health in relation to food is proving a powerful driver for the development of cheap but palatable and more functional foods. However, the efficacy of such foods is often hard to prove in human subjects. Thus, a suite of tools has been developed including in silico and in vitro simulations and animal models. Although animal models offer physiologically relevant platforms for research, their use for experimentation is problematic for consumers. Thus, in vitro methods such as Infogest protocols have been developed to provide digestion endpoints or even an indication of the kinetics of digestion. These protocols have been validated for a range of food systems but they still miss the final absorption step. This review discusses the use of such in vitro models and what further steps need to be included to make the bioaccessibility determination more relevant to bioavailability and human health.

CT findings and clinical characteristics in distinguishing renal urothelial carcinoma mimicking renal cell carcinoma from clear cell renal cell carcinoma

BACKGROUND

We aimed to characterize the clinical and multiphase computed tomography (CT) features, which can distinguish renal urothelial carcinoma (RUC) mimicking renal cell carcinoma (RCC) from clear cell renal cell carcinoma (ccRCC) with collecting system invasion (CSI).

METHODS

Data from 56 patients with RUC (46 men and 10 women) and 366 patients with ccRCC (262 men and 104 women) were collected and assessed retrospectively. The median age was 65.50 (IQR: 56.25-69.75) and 53.50 (IQR: 42.25-62.5) years, respectively. Univariate and multivariate logistic regression analyses were performed on clinical and CT characteristics to determine independent factors for distinguishing RUC and ccRCC, and an integrated predictive model was constructed. Differential diagnostic performance was assessed using the area under the receiver operating characteristic curve (AUC).

RESULTS

The independent predictors for differentiating RUC from ccRCC were infiltrative growth pattern, hydronephrosis, heterogeneous enhancement, preserving reniform contour, and hematuria. The differential diagnostic performance of the integrated predictive model-1 (AUC: 0.947, sensitivity: 89.07%, specificity: 89.29%) and model-2 (AUC: 0.960, sensitivity: 92.1%, specificity: 89.3%) were both better than that of the infiltrative growth pattern (AUC: 0.830, sensitivity: 71.9%, specificity: 92.9%), heterogeneous enhancement (AUC: 0.771, sensitivity: 86.3%, specificity: 67.9%), preserving reniform contour (AUC = 0.758, sensitivity: 85.5%, specificity: 66.1%), hydronephrosis (AUC: 0.733, sensitivity: 87.7%, specificity: 58.9%), or hematuria (AUC: 0.706, sensitivity: 79.5%, specificity: 51.8%).

CONCLUSION

The CT and clinical characteristics showed extraordinary discriminative abilities in the differential diagnosis of RUC and ccRCC, which might provide helpful information for clinical decision-making.

Assessing the Postprandial Glycemic Response to Japonica Rice (Oryza sativa L. cv. Koshihikari) with a Small Amount of Lysolecithin and Canola Oil in Japanese Adult Men: a Double-blind, Placebo-controlled, Crossover Study

A double-blind, placebo-controlled, crossover trial was performed to analyze the effects of a small amount of lysolecithin and canola oil on blood glucose levels after consuming japonica rice. Overall, 17 Japanese adult men were assigned to consume 150 g of normally cooked japonica rice (placebo group) and 150 g of japonica rice cooked with 18 mg of lysolecithin and 1.8 g of canola oil (treatment group); these lipids were added as emulsified formulation (EMF) for stability and uniformity. Subsequently, blood samples were collected before and 30, 45, 60, 90, and 120 min after consuming test foods. There was no significant difference in blood glucose, insulin, and triglyceride levels between the groups. However, a stratified analysis of 11 subjects with body mass index (BMI) ≥ 22 revealed that blood glucose levels were significantly lower after 30 min in the treatment group than in the placebo group (p = 0.041). Through in vitro digestibility test, the rice sample of the treatment group was observed to release significantly less glucose within 20 min than that in the placebo group rice. These results suggest that the combination of a small amount of lysolecithin and canola oil modulated the increase in postprandial blood glucose levels induced by the intake of cooked japonica rice in adult men with BMI ≥ 22. This clinical trial was registered with the University Hospital Medical Information Network (UMIN) Center, (UMIN000045744; registered on 15/10/2021).

Clusters of carbohydrate-rich foods and associations with type 2 diabetes incidence: a prospective cohort study

BACKGROUND

About one in ten adults are living with diabetes worldwide. Intake of carbohydrates and carbohydrate-rich foods are often identified as modifiable risk factors for incident type 2 diabetes. However, strong correlation between food variables can make it difficult to identify true associations. The purpose of this study was to identify clusters of carbohydrate-rich foods and analyse their associations with type 2 diabetes incidence in the Malmö Diet and Cancer Study cohort in southern Sweden.

METHODS

Dietary intake of 26 622 participants was assessed using a validated three-part diet history method: a 7-day food diary, a 168-item food frequency questionnaire, and a 60-minute interview. K-means clustering analysis identified five clusters from 21 food variables. The Cox proportional hazard regression model was applied to calculate hazard ratios (HR) and 95% confidence intervals (CI) of the association between clusters and incident type 2 diabetes.

RESULTS

The cluster analysis resulted in five clusters; high vegetables/low added sugar, high sugar-sweetened beverages, high juice, high fruit, and high refined carbohydrates/low fruit & vegetables (reference). During mean follow-up of 18 years, 4046 type 2 diabetes cases were identified. After adjustment for potential confounding (including lifestyle, body mass index, and diet), a high fruit cluster (HR 0.86; 95% CI 0.78, 0.94) was inversely associated with type 2 diabetes compared to the reference cluster. No other significant associations were identified.

CONCLUSIONS

A dietary pattern defined by a high intake of fruits was associated with a lower incidence of type 2 diabetes. The findings provide additional evidence of a potential protective effect from fruit intake in reducing type 2 diabetes risk. Future studies are needed to explore this association further.

The Health Effects of Low Glycemic Index and Low Glycemic Load Interventions on Prediabetes and Type 2 Diabetes Mellitus: A Literature Review of RCTs

Diets with a low glycemic index (GI) and a low glycemic load (GL) can improve glycemic control, blood lipids, blood pressure and BMI in prediabetes and type 2 diabetes (T2DM), but evidence regarding other aspects of cardiometabolic health is limited. We searched the literature for RCTs published from 2013 to 2023 and reviewed the evidence on low-GI/GL diets and their effects on different aspects of health in prediabetes and T2DM, aiming to build a report on all relevant outcomes included in the studies. We included 14 RCTs with 1055 participants, who were mostly middle-aged individuals with T2DM. Interventions were mostly low GI and lasted 1-36 months. Low-GI/GL foods and diets showed benefits in terms of short-term glycemic control, weight and adiposity. Longer-term trials would be necessary to determine whether these benefits persist over time and/or lead to lower CVD risk and mortality. Effects on lipid profile were inconsistent. Some studies also reported positive effects of low-GI/GL interventions on blood pressure, inflammatory biomarkers, renal function and gut microbiota composition. Future trials should focus on some of these novel outcome measures, which may provide important insights into the metabolic effects of low-GI diets on individuals with diabetes.

Diabetes risk reduction diet and ovarian cancer risk: an Italian case-control study

PURPOSE

To investigate the relation between a diabetes risk reduction diet (DRRD) and ovarian cancer.

METHODS

We used data from a multicentric case-control study conducted in Italy, including 1031 incident ovarian cancer cases and 2411 controls admitted to hospital centres for acute non-malignant disease. Subjects' diet prior to hospital admission was collected using a validated food frequency questionnaire. Adherence to the DRRD was measured using a score based on 8 dietary components, giving higher scores for greater intakes of cereal fiber, coffee, fruit, nuts, higher polyunsaturated to saturated fatty acids ratio, lower glycemic index of diet, and lower intakes of red/processed meat, and sweetened beverages/and fruit juices. Higher scores indicated greater adherence to the DRRD. Multiple logistic regression models were fitted to calculate the odds ratios (OR) of ovarian cancer and the corresponding 95% confidence intervals (CI) for approximate quartiles of the DRRD score.

RESULTS

The DRRD score was inversely related to ovarian cancer, with an OR of 0.76 (95%CI: 0.60-0.95) for the highest versus the lowest quartile of the score (p for trend = 0.022). The exclusion of women with diabetes did not change the results (OR = 0.75, 95%CI: 0.59-0.95). Inverse associations were observed in strata of age, education, parity, menopausal status, and family history of ovarian/breast cancer.

CONCLUSION

Higher adherence to a diet aimed at reducing the risk of diabetes was inversely associated with ovarian cancer. Further evidence from prospective investigations will be useful to support our findings.

Effect of Artificial Intelligence-based Health Education Accurately Linking System (AI-HEALS) for Type 2 diabetes self-management: protocol for a mixed-methods study

BACKGROUND

Patients with type 2 diabetes (T2DM) have an increasing need for personalized and Precise management as medical technology advances. Artificial intelligence (AI) technologies on mobile devices are being developed gradually in a variety of healthcare fields. As an AI field, knowledge graph (KG) is being developed to extract and store structured knowledge from massive data sets. It has great prospects for T2DM medical information retrieval, clinical decision-making, and individual intelligent question and answering (QA), but has yet to be thoroughly researched in T2DM intervention. Therefore, we designed an artificial intelligence-based health education accurately linking system (AI-HEALS) to evaluate if the AI-HEALS-based intervention could help patients with T2DM improve their self-management abilities and blood glucose control in primary healthcare.

METHODS

This is a nested mixed-method study that includes a community-based cluster-randomized control trial and personal in-depth interviews. Individuals with T2DM between the ages of 18 and 75 will be recruited from 40-45 community health centers in Beijing, China. Participants will either receive standard diabetes primary care (SDPC) (control, 3 months) or SDPC plus AI-HEALS online health education program (intervention, 3 months). The AI-HEALS runs in the WeChat service platform, which includes a KBQA, a system of physiological indicators and lifestyle recording and monitoring, medication and blood glucose monitoring reminders, and automated, personalized message sending. Data on sociodemography, medical examination, blood glucose, and self-management behavior will be collected at baseline, as well as 1,3,6,12, and 18 months later. The primary outcome is to reduce HbA1c levels. Secondary outcomes include changes in self-management behavior, social cognition, psychology, T2DM skills, and health literacy. Furthermore, the cost-effectiveness of the AI-HEALS-based intervention will be evaluated.

DISCUSSION

KBQA system is an innovative and cost-effective technology for health education and promotion for T2DM patients, but it is not yet widely used in the T2DM interventions. This trial will provide evidence on the efficacy of AI and mHealth-based personalized interventions in primary care for improving T2DM outcomes and self-management behaviors.

TRIAL REGISTRATION

Biomedical Ethics Committee of Peking University: IRB00001052-22,058, 2022/06/06; Clinical Trials: ChiCTR2300068952, 02/03/2023.

Adherence to diet with higher dietary diabetes risk reduction score is associated with reduced risk of type 2 diabetes incident in Iranian adults

BACKGROUND

The Dietary diabetes risk reduction score (DDRRS) has recently been considered by researchers as a diet quality index to predict the risk of chronic diseases, such as type 2 diabetes (T2D). In this study, we aimed to assess the association of DDRRS with T2D risk in Iranian adults.

METHODS

Subjects aged ≥ 40 years without T2D (n = 2081) were selected for the current study from participants of the Tehran Lipid and Glucose Study (2009-2011) and followed for a mean of 6.01 years. We used the food frequency questionnaire to determine the DDRRS that is characterized by eight components, including higher consumption of nuts, cereal fiber, coffee, and polyunsaturated to saturated fat ratio and lower consumption of red or processed meats, trans fats, sugar-sweetened beverages, and high glycemic index foods. The multivariable logistic regression analysis was used to determine the odds ratio (ORs) and 95% confidence interval (CI) of T2D across the DDRRS tertiles.

RESULTS

The mean ± SD age of individuals was 50.4 ± 8.2 years at baseline. The Median (25-75 interquartile range) DDRRS of the study population was 24(22-27). During the study follow-up, 233(11.2%) new cases of T2D were ascertained. In the age and sex-adjusted model, the odds of T2D were decreased across tertiles of DDRRS (OR = 0.68; 95%CI: 0.48-0.97, P for trend = 0.037). Based on the multivariable-adjusted model, after controlling all potential confounders, the risk of T2D is reduced across tertiles of DDRRS (OR = 0.66; 95%CI: 0.44-0.98, P for trend = 0.047). Also, higher scores (lower consumption) of red and processed meat (OR = 0.59; 95%CI: 0.39-0.88, P = 0.012) and sugar-sweetened beverages (OR = 0.49; 95%CI: 0.32-0.76, P = 0.002) as DDRRS components were associated with decreased T2D incident.

CONCLUSIONS

Our findings suggested that a diet with a higher score of DDRRS may be related to reducing the risk of T2D in Iranian adults.

Effect of the Pasta Making Process on Slowly Digestible Starch Content

The rate at which starch is digested in the human intestine elicits different glycemic responses and reflects the glycemic index (GI) of foods. In vitro measurement of starch digestibility can reflect the GI of food. Differences in starch digestibility among four durum wheat pasta samples, couscous, and bread were evaluated to better describe the role of the pasta making process in affecting starch digestibility. Statistical differences in RDS (rapidly digestible starch), SDS (slowly digestible starch), and RS (resistant starch) of products were found (p < 0.05). As expected, pasta samples showed the highest value of SDS/av starch compared to couscous and bread. Fusilli and cavatelli samples presented the highest SDS/av starch ratio (55.80 ± 3.06% and 53.91 ± 3.50%, respectively), then came spaghetti 49.39 ± 2.83% and penne 45.93 ± 1.19%, while couscous presented the lowest value of SDS/av starch (2.64 ± 0.50%), followed by bread (11.78 ± 2.63%). Our study confirmed that the pasta making process efficiently mediates an increase in SDS/Av starch content, which has been specifically quantified above 40%, therefore strongly related to a lowered glycemic response in vivo. Our results strengthened the concept that pasta is a good source of SDS, which makes it useful for glycemic control.

The Association of Specific Dietary Patterns with Cardiometabolic Outcomes in Women with a History of Gestational Diabetes Mellitus: A Scoping Review

Gestational diabetes mellitus is associated with a significantly increased risk of later type 2 diabetes (T2DM) and cardiovascular disease (CVD). Post-natal interventions aim to reduce this risk by addressing diet and lifestyle factors and frequently focus on restricting energy or macronutrient intake. With increased interest in the role of complete dietary patterns in the prevention of cardiometabolic disease, we sought to evaluate what is known about the role of dietary patterns in reducing cardiometabolic risk in women with previous GDM. A systematic search was conducted to identify studies relating to dietary pattern and cardiometabolic parameters in women with a history of GDM. The search criteria returned 6014 individual studies. In total, 71 full texts were reviewed, with 24 studies included in the final review. Eleven individual dietary patterns were identified, with the Alternative Health Eating Index (AHEI), Mediterranean diet (MD), and low glycaemic index (GI) as the most commonly featured dietary patterns. Relevant reported outcomes included incident T2DM and glucose tolerance parameters, as well as several cardiovascular risk factors. Dietary patterns which have previously been extensively demonstrated to reduce the risk of cardiovascular and metabolic disorders in the general population, including AHEI, MD, and DASH, were found to be associated with a reduction in the incidence of T2DM, hypertension, and additional risk factors for cardiometabolic disease in women with a history of GDM. Notable gaps in the literature were identified, including the relationship between dietary patterns and incident CVD, as well as the relationship between a low GI diet and the development of T2DM in this population.

Eating Vegetables First Regardless of Eating Speed Has a Significant Reducing Effect on Postprandial Blood Glucose and Insulin in Young Healthy Women: Randomized Controlled Cross-Over Study

People with fast eating habits have been reported to have an increased risk of diabetes and obesity. To explore whether the speed of eating a test meal (tomato, broccoli, fried fish, and boiled white rice) influences postprandial blood glucose, insulin, triglyceride, and free fatty acid levels, 18 young, healthy women consumed a 671 kcal breakfast at fast speed (10 min) and slow speed (20 min) with vegetables first and slow speed (20 min) with carbohydrate first on three separate days. This study was conducted using a within-participants cross-over design in which all participants consumed identical meals of three different eating speeds and food orders. Significant ameliorations of both fast and slow eating with vegetables first regimen on postprandial blood glucose and insulin levels at 30 and 60 min were observed compared with those of slow eating with carbohydrates first. In addition, the standard deviation, large amplitude of excursion, and incremental area under the curve for blood glucose and insulin in both fast and slow eating with vegetables first were all significantly lower than those of slow eating with carbohydrate first. Interestingly, there was no significant difference between fast and slow eating on postprandial blood glucose and insulin levels as long as vegetables were consumed first, although postprandial blood glucose at 30 min was significantly lower in slow eating with vegetables first than that of fast eating with the same food order. These results suggest that food order with vegetables first and carbohydrate last ameliorates postprandial blood glucose and insulin concentrations even if the meal was consumed at fast speed.

The Association of Glycemic Index, Glycemic Load, and Daily Carbohydrates Intake with the Risk of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Background: Glycemic index (GI), glycemic load (GL) and daily carbohydrates intake have been associated with a variety of cancers, but their implications in hepatocellular carcinoma (HCC) remain controversial. The purpose of our study is to investigate the association of GI, GL and daily carbohydrates intake with the risk of HCC. Methods: Systematic searches were conducted in PubMed, Embase and Web of Science until November 2020. According to the degree of heterogeneity, random effect model or fixed effect model was chosen to obtain the pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs). Results: Four cohort studies and three case-control studies were eventually included. The pooled results showed no significant association of GI (RR = 1.11, 95% CI = 0.80-1.53), GL (RR = 1.09, 95% CI = 0.76-1.55), and daily carbohydrates intake (RR = 1.09, 95% CI = 0.84-1.32) with the risk of HCC in the general population. Subgroup analysis revealed that in hepatitis B virus (HBV) or/and hepatitis C virus (HCV)-positive group, GI was irrelevant to the risk of HCC (RR = 0.65, 95% CI = 0.32-1.32), while a high GL diet was associated with a higher risk of HCC (RR = 1.52, 95% CI = 1.04-2.23). In contrast, in HBV and HCV-negative group, both GI (RR = 1.23, 95% CI = 0.88-1.70) and GL (RR = 1.17, 95% CI = 0.83-1.64) were not associated with the risk of HCC. Conclusion: A high GL diet increases the risk of HCC in those with viral hepatitis. A low GL diet is recommended for them to reduce the risk of HCC.

Does the concept of "ultra-processed foods" help inform dietary guidelines, beyond conventional classification systems? NO

The Nova classification of ultra-processed foods (UPFs) rests on poorly defined food processes and the presence of food additives from a chemically heterogeneous group, easily leading to misclassification. UPFs are claimed to promote overconsumption of energy and obesity due to high palatability, but little evidence supports effects beyond those that can be accounted for by nutrient composition, energy density, and food matrices. Observational studies link dietary intake of UPFs with obesity, but none have demonstrated independent associations after controlling for likely confounders. A highly cited randomized controlled feeding study that compared a UPF diet with an unprocessed diet showed a rapidly weaning effect on energy intake that can be entirely explained by more conventional and quantifiable dietary factors, including energy density, intrinsic fiber, glycemic load, and added sugar. Clearly, many aspects of food processing can affect health outcomes, but conflating them into the notion of ultra-processing is unnecessary, because the main determinants of chronic disease risk are already captured by existing nutrient profiling systems. In conclusion, the Nova classification adds little to existing nutrient profiling systems; characterizes several healthy, nutrient-dense foods as unhealthy; and is counterproductive to solve the major global food production challenges.

Glycemic Index Versus Wheat Fiber on Arterial Wall Damage in Diabetes: A Randomized Controlled Trial

OBJECTIVE

High cereal fiber and low-glycemic index (GI) diets are associated with reduced cardiovascular disease (CVD) risk in cohort studies. Clinical trial evidence on event incidence is lacking. Therefore, to make trial outcomes more directly relevant to CVD, we compared the effect on carotid plaque development in diabetes of a low-GI diet versus a whole-grain wheat-fiber diet.

RESEARCH DESIGN AND METHODS

The study randomized 169 men and women with well-controlled type 2 diabetes to counseling on a low GI-diet or whole-grain wheat-fiber diet for 3 years. Change in carotid vessel wall volume (VWV) (prespecified primary end point) was assessed by MRI as an indication of arterial damage.

RESULTS

Of 169 randomized participants, 134 completed the study. No treatment differences were seen in VWV. However, on the whole-grain wheat-fiber diet, VWV increased significantly from baseline, 23 mm3 (95% CI 4, 41; P = 0.016), but not on the low-GI diet, 8 mm3 (95% CI -10, 26; P = 0.381). The low-GI diet resulted in preservation of renal function, as estimated glomerular filtration rate, compared with the reduction following the wheat-fiber diet. HbA1c was modestly reduced over the first 9 months in the intention-to-treat analysis and extended with greater compliance to 15 months in the per-protocol analysis.

CONCLUSIONS

Since the low-GI diet was similar to the whole-grain wheat-fiber diet recommended for cardiovascular risk reduction, the low-GI diet may also be effective for CVD risk reduction.

Measuring key human carbohydrate digestive enzyme activities using high-performance anion-exchange chromatography with pulsed amperometric detection

Carbohydrate digestion in the mammalian gastrointestinal tract is catalyzed by α-amylases and α-glucosidases to produce monosaccharides for absorption. Inhibition of these enzymes is the major activity of the drugs acarbose and miglitol, which are used to manage diabetes. Furthermore, delaying carbohydrate digestion via inhibition of α-amylases and α-glucosidases is an effective strategy to blunt blood glucose spikes, a major risk factor for developing metabolic diseases. Here, we present an in vitro protocol developed to accurately and specifically assess the activity of α-amylases and α-glucosidases, including sucrase, maltase and isomaltase. The assay is especially suitable for measuring inhibition by compounds, drugs and extracts, with minimal interference from impurities or endogenous components, because the substrates and digestive products in the enzyme activity assays are quantified directly by high-performance anion-exchange chromatography with pulsed amperometric detection (HPAE-PAD). Multiple enzyme sources can be used, but here we present the protocol using commercially available human α-amylase to assess starch hydrolysis with maltoheptaose as the substrate, and with brush border sucrase-isomaltase (with maltase, sucrase and isomaltase activities) derived from differentiated human intestinal Caco-2(/TC7) cells to assess hydrolysis of disaccharides. The wet-lab assay takes ~2-5 h depending on the number of samples, and the HPAE-PAD analysis takes 35 min per sample. A full dataset therefore takes 1-3 d and allows detection of subtle changes in enzyme activity with high sensitivity and reliability.

Effect of Tartary Buckwheat Bran Substitution on the Quality, Bioactive Compounds Content, and In Vitro Starch Digestibility of Tartary Buckwheat Dried Noodles

This study aimed to investigate the impact of partial replacement of Tartary buckwheat flour (TBF) with Tartary buckwheat bran flour (TBBF) on the quality, bioactive compounds content, and in vitro starch digestibility of Tartary buckwheat dried noodles (TBDNs). When the substitution of TBBF was increased from 0 to 35%, the cooking and textural properties decreased significantly (p < 0.05), while the content of bioactive compounds (phenolic, flavonoids and dietary fiber) increased significantly (p < 0.05). In addition, the substitution of TBBF decreased the starch digestibility of TBDNs. A 10.4% reduction in eGI values was observed in the TBDNs with 35% TBBF substitution compared to the control sample. The results of differential scanning calorimetry showed that with the increase of TBBF, TBDNs starch became more resistant to thermal processing. Meanwhile, the X-ray diffraction and Fourier transform infrared spectroscopy results revealed that the long- and short-range ordered structures of TBDN starch increased significantly (p < 0.05). Furthermore, the substitution of TBBF decreased the fluorescence intensity of α-amylase and amyloglucosidase. This study suggests that replacing TBF with TBBF could produce low glycemic index and nutrient-rich TBDNs.

Dietary Management Tools Improve the Dietary Skills of Patients with T2DM in Communities

Dietary management is of paramount importance in the prevention and control of type 2 diabetes mellitus (T2DM). This one-year cluster-randomized controlled trial aims to evaluate the effect of dietary management tools on the dietary skills of patients with T2DM. Twenty-two communities were randomly assigned to an intervention group and a control group, and participants in the intervention group received a food guiding booklet (G) and a dinner set (D). The frequency of dietary management tools usage was collected at baseline and every three months, and different use patterns were identified by a group-based trajectory model. A self-compiled diabetic dietary skills scale and blood glucose were collected at baseline, 3, and 12 months, and a using generalized linear mixed model (GLMM) to explore the influence factors of dietary skills and blood glucose. The finding revealed four dietary tool-usage patterns among the participants: Insist using G/D, Give up gradually G/D, Give up after use G, and Never use G/D. GLMM indicated that dietary skills were higher over time (p < 0.05), and in participants using the guiding booklet (p < 0.001) or dinner set (p < 0.001), or with higher education (p < 0.001). Additionally, blood glucose were lower among participants with higher dietary skills (p = 0.003), higher educational level (p = 0.046), and a 3000−5000 monthly income (p = 0.026). These findings support using food management tools like the guiding booklet and dinner set as a useful strategy in primary health care centers for individuals with T2DM to increase their dietary skills and blood glucose control.

Short-Clustered Maltodextrin Activates Ileal Glucose-Sensing and Induces Glucagon-like Peptide 1 Secretion to Ameliorate Glucose Homeostasis in Type 2 Diabetic Mice

Reconstructing molecular structure is an effective approach to attenuating glycemic response to starch. Previously, we rearranged α-1,4 and α-1,6-glycosidic bonds in starch molecules to produce short-clustered maltodextrin (SCMD). The present study revealed that SCMD slowly released glucose until the distal ileum. The activated ileal glucose-sensing enabled SCMD to be a potent inducer for glucagon-like peptide-1 (GLP-1). Furthermore, SCMD was found feasible to serve as the dominant dietary carbohydrate to rescue mice from diabetes. Interestingly, a mixture of normal maltodextrin and resistant dextrin (MD+RD), although it caused an attenuated glycemic response similar to that of SCMD, failed to ameliorate glucose homeostasis because it hardly induced GLP-1 secretion. The serum GLP-1 levels seen in MD+RD-fed mice (5.25 ± 1.51 pmol/L) were significantly lower than those seen in SCMD-fed mice (8.25 ± 2.01 pmol/L, p < 0.05). Further investigation revealed that the beneficial effects of SCMD could be abolished by a GLP-1 receptor (GLP-1R) antagonist. These results identify GLP-1R signaling as a critical contributor to SCMD-exerted health benefits and highlight the role of ileal glucose-sensing in designing dietary carbohydrates.

Red and processed meat intakes and cardiovascular disease and type 2 diabetes mellitus: An umbrella systematic review and assessment of causal relations using Bradford Hill's criteria

Observational research suggests higher red and processed meat intakes predict greater risks of developing or dying from cardiovascular diseases (CVD) and type 2 diabetes mellitus (T2DM), but this research limits causal inference. This systematic review of reviews utilizes both observational and experimental research findings to infer causality of these relations. Reviews from four databases were screened by two researchers. Reviews included unprocessed red meat (URM), processed meat (PM), or mixed URM + PM intake, and reported CVD or T2DM outcomes. Twenty-nine reviews were included, and causality was inferred using Bradford Hill's Criteria. Observational assessments of CVD outcomes and all meat types consistently reported weak associations while, T2DM outcomes and PM and Mixed URM + PM assessments consistently reported strong associations. Experimental assessments of Mixed URM + PM on CVD and T2DM risk factors were predominately not significant which lacked coherence with observational findings. For all meat types and outcomes, temporality and plausible mechanisms were established, but specificity and analogous relationships do not support causality. Evidence was insufficient for URM and T2DM. More experimental research is needed to strengthen these inferences. These results suggest that red and processed meat intakes are not likely causally related to CVD but there is potential for a causal relationship with T2DM.

Nutritional strategies to attenuate postprandial glycemic response

Maintaining good glycemic control to prevent complications is crucial in people with type 2 diabetes and in people with prediabetes and in the general population. Different strategies to improve glycemic control involve the prescription of blood glucose-lowering drugs and the modulation of physical activity and diet. Interestingly, lifestyle intervention may be more effective in lowering hyperglycemia than pharmaceutical intervention. Regulation of postprandial glycemia is complex, but specific nutritional strategies can be applied to attenuate postprandial hyperglycemia. These strategies include reducing total carbohydrate intake, consuming carbohydrates with a lower glycemic index, the addition of or substitution by sweeteners and fibers, using food compounds which delay or inhibit gastric emptying or carbohydrate digestion, and using food compounds which inhibit intestinal glucose absorption. Nevertheless, it must be noted that every individual may respond differently to certain nutritional interventions. Therefore, a personalized approach is of importance to choose the optimal nutritional strategy to improve postprandial glycemia for each individual, but this requires a better understanding of the mechanisms explaining the differential responses between individuals.

Bioactive Properties of Bread Formulated with Plant-based Functional Ingredients Before Consumption and Possible Links with Health Outcomes After Consumption- A Review

Bread is a commonly consumed staple and could be a viable medium to deliver plant-based ingredients that demonstrate health effects. This review brings together published evidence on the bioactive properties of bread formulated with plant-based ingredients. Health effects associated with the consumption of bread formulated with plant-based functional ingredients was also reviewed. Bioactive properties demonstrated by the functional ingredients fruits and vegetables, legumes, nuts and tea incorporated into bread include increased phenolic and polyphenolic content, increased antioxidant activity, and extension of bread shelf-life by impairment of lipid and protein oxidation. Acute health effects reported included appetite suppression, reduced diastolic blood pressure, improvements in glycaemia, insulinaemia and satiety effect. These metabolic effects are mainly short lived and not enough for a health claim. Longer term studies or comparison of those who consume and those who do not are needed. The incorporation of plant-based functional ingredients in bread could enhance the health-promoting effects of bread.

CT and clinical features for distinguishing endophytic clear cell renal cell carcinoma from urothelial carcinoma

PURPOSE We aimed to characterize the clinical and multiphase computed tomography (CT) features of the distinguishing endophytic clear cell renal cell carcinoma (ECCRCC) from endophytic renal urothelial carcinoma (ERUC). METHODS Data from 44 patients (35 men and 9 women) with ECCRCC and 21 patients (17 men and 4 women) with ERUC were retrospectively assessed. The mean patient age was 55 years (48.25- 59.50 years) and 68 years (63.00-73.00 years), respectively. Univariate and multivariate logistic regression analyses were performed to determine independent predictors for ECCRCC and to construct a predictive model that comprised clinical and CT characteristics for the differential diagnosis of ECCRCC and ERUC. Differential diagnostic performance was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS The independent predictors of ECCRCC were heterogeneous enhancement (odds ratio [OR]=0.027, P=.005), hematuria (OR for gross hematuria=53.995, P=.003; OR for microscopic hematuria=31.126, P = .027), and an infiltrative growth pattern (OR=24.301, P = .022). The AUC of the predictive model was 0.938 (P < .001, sensitivity=84.10%, specificity=95.20%), which had a better diagnostic performance than heterogeneous enhancement (AUC=0.766, P=.001, sensitivity=81.82%, specificity=71.43%), hematuria (AUC=0.786, P < .001, sensitivity=81.82%, specificity=66.67%), and infiltrative growth pattern (AUC=0.748, P=.001, sensitivity=90.48%, specificity=59.09%). CONCLUSION The independent predictors, as well as the predictive model of CT and clinical characteristics, may assist in the differential diagnosis of ECCRCC and ERUC and provide useful information for clinical decision-making.

Maternal Dietary Glycemic Index and Glycemic Load in Pregnancy and Offspring Cord Blood DNA Methylation

OBJECTIVE

Suboptimal nutrition in pregnancy is associated with worse offspring cardiometabolic health. DNA methylation may be an underlying mechanism. We meta-analyzed epigenome-wide association studies (EWAS) of maternal dietary glycemic index and load with cord blood DNA methylation.

RESEARCH DESIGN AND METHODS

We calculated maternal glycemic index and load from food frequency questionnaires and ran EWAS on cord blood DNA methylation in 2,003 mother-offspring pairs from three cohorts. Analyses were additionally stratified by maternal BMI categories. We looked-up the findings in EWAS of maternal glycemic traits and BMI as well as in EWAS of birth weight and child BMI. We examined associations with gene expression in child blood in the online Human Early Life Exposome eQTM catalog and in 223 adipose tissue samples.

RESULTS

Maternal glycemic index and load were associated with cord blood DNA methylation at 41 cytosine-phosphate-guanine sites (CpGs, P < 1.17 × 10-7), mostly in mothers with overweight/obesity. We did not observe overlap with CpGs associated with maternal glycemic traits, BMI, or child birth weight or BMI. Only DNA methylation at cg24458009 and cg23347399 was associated with expression of PCED1B and PCDHG, respectively, in child blood, and DNA methylation at cg27193519 was associated with expression of TFAP4, ZNF500, PPL, and ANKS3 in child subcutaneous adipose tissue.

CONCLUSIONS

We observed multiple associations of maternal glycemic index and load during pregnancy with cord blood DNA methylation, mostly in mothers with overweight/obesity; some of these CpGs were associated with gene expression. Additional studies are required to further explore functionality, uncover causality, and study pathways to offspring health.

Dietary Carbohydrate as Glycemic Load, Not Fat, Coupled with Genetic Permissiveness Favoring Rapid Growth and Extra Calories, Dictate Metabolic Syndrome and Diabetes Induction in Nile Rats (Arvicanthis niloticus)

Objective: Whether dietary carbohydrate (CHO) or fat is more involved in type 2 diabetes (T2DM) induction uncomplicated by dietary fiber was addressed in a spontaneous diabetic model, the diurnal Nile rat that mimics the human condition. Methods: A total of 138 male Nile rats were fed plant-based and animal-based saturated fat where 10% energy as CHO and fat were exchanged across 5 diets keeping protein constant, from 70:10:20 to 20:60:20 as CHO:fat:protein %energy. Diabetes induction was analyzed by: 1. diet composition, i.e., CHO:fat ratio, to study the impact of diet; 2. quintiles of average caloric intake per day to study the impact of calories; 3. quintiles of diabetes severity to study the epigenetic impact on diabetes resistance. Results: High glycemic load (GLoad) was most problematic if coupled with high caloric consumption. Diabetes severity highlighted rapid growth and caloric intake as likely epigenetic factors distorting glucose metabolism. The largest weanling rats ate more, grew faster, and developed more diabetes when the dietary GLoad exceeded their gene-based metabolic capacity for glucose disposal. Diabetes risk increased for susceptible rats when energy intake exceeded 26 kcal/day and the GLoad was >175/2000 kcal of diet and when the diet provided >57% energy as CHO. Most resistant rats ate <25 kcal/day independent of the CHO:fat diet ratio or the GLoad adjusted to body size. Conclusion: Beyond the CHO:fat ratio and GLoad, neither the type of fat nor the dietary polyunsaturated/saturated fatty acid (P/S) ratio had a significant impact, suggesting genetic permissiveness affecting caloric and glucose intake and glucose disposition were key to modulating Nile rat diabetes. Fat became protective by limiting GLoad when it contributed >40% energy and displaced CHO to <50% energy, thereby decreasing the number of diabetic rats and diabetes severity.

Quality of dietary carbohydrate is more important than its quantity in lipid peroxidation

BACKGROUND

High glycemic index (GI) diets have been linked to elevated risk of cardiometabolic diseases. One possible underlying mechanism comes from high GI diet's potential to promote lipid peroxidation.

OBJECTIVES

We aim to evaluate whether and to what extent dietary carbohydrate quality and quantity are associated with systemic levels of lipid peroxidation in females.

METHODS

In this cross-sectional analysis of 2163 middle-aged women, a subset of the Shanghai Women's Health Study, we measured lipid peroxidation biomarkers F2-isoprostanes (F2-IsoPs) and its metabolite, 2,3-dinor-5,6-dihydro-15-F2t-IsoP (F2-IsoP-M), in urine. The quality of carbohydrate was defined by dietary GI, assessed using a validated FFQ via in-person interviews. A multivariable linear regression model with restricted cubic spline functions was used to evaluate the association of measured biomarkers with carbohydrate intake and dietary GI.

RESULTS

After adjustment for potential confounding factors such as cigarette smoking, BMI, and comorbidities, among others, we found that F2-IsoP-M concentrations were positively associated with both carbohydrate intake and dietary GI. Carbohydrate intake and dietary GI were weakly correlated (r = 0.12). When further mutually adjusted for the 2 factors, the positive association with F2-IsoP-M remained statistically significant for GI (P = 0.004) but not for carbohydrate intake (P = 0.50). Compared with those in the 10th percentile of dietary GI, fold increases (95% CI) in F2-IsoP-M concentrations for those in the 30th, 50th, 70th, and 90th percentiles were 1.03 (1.00, 1.07), 1.06 (1.01, 1.10), 1.09 (1.03, 1.14), and 1.13 (1.05, 1.21), respectively. Moreover, there appeared a threshold regarding the association between dietary GI and F2-IsoP-M concentrations, with the dose-effect slope of GI being 2.3 times greater when GI was ≥75 relative to GI <75.

CONCLUSIONS

This study provides evidence that the quality of dietary carbohydrate may be more important than the quantity of the intake with regard to systemic lipid peroxidation.

Causal assessment in evidence synthesis: A methodological review of reviews

In fields (such as population health) where randomised trials are often lacking, systematic reviews (SRs) can harness diversity in study design, settings and populations to assess the evidence for a putative causal relationship. SRs may incorporate causal assessment approaches (CAAs), sometimes called 'causal reviews', but there is currently no consensus on how these should be conducted. We conducted a methodological review of self-identifying 'causal reviews' within the field of population health to establish: (1) which CAAs are used; (2) differences in how CAAs are implemented; (3) how methods were modified to incorporate causal assessment in SRs. Three databases were searched and two independent reviewers selected reviews for inclusion. Data were extracted using a standardised form and summarised using tabulation and narratively. Fifty-three reviews incorporated CAAs: 46/53 applied Bradford Hill (BH) viewpoints/criteria, with the remainder taking alternative approaches: Medical Research Council guidance on natural experiments (2/53, 3.8%); realist reviews (2/53, 3.8%); horizontal SRs (1/53, 1.9%); 'sign test' of causal mechanisms (1/53, 1.9%); and a causal cascade model (1/53, 1.9%). Though most SRs incorporated BH, there was variation in application and transparency. There was considerable overlap across the CAAs, with a trade-off between breadth (BH viewpoints considered a greater range of causal characteristics) and depth (many alternative CAAs focused on one viewpoint). Improved transparency in the implementation of CAA in SRs in needed to ensure their validity and allow robust assessments of causality within evidence synthesis.

Exploring the Mangrove Fruit: From the Phytochemicals to Functional Food Development and the Current Progress in the Middle East

Nowadays, the logarithmic production of existing well-known food materials is unable to keep up with the demand caused by the exponential growth of the human population in terms of the equality of access to food materials. Famous local food materials with treasury properties such as mangrove fruits are an excellent source to be listed as emerging food candidates with ethnomedicinal properties. Thus, this study reviews the nutrition content of several edible mangrove fruits and the innovation to improve the fruit into a highly economic food product. Within the mangrove fruit, the levels of primary metabolites such as carbohydrates, protein, and fat are acceptable for daily intake. The mangrove fruits, seeds, and endophytic fungi are rich in phenolic compounds, limonoids, and their derivatives as the compounds present a multitude of bioactivities such as antimicrobial, anticancer, and antioxidant. In the intermediary process, the flour of mangrove fruit stands as a supplementation for the existing flour with antidiabetic or antioxidant properties. The mangrove fruit is successfully transformed into many processed food products. However, limited fruits from species such as Bruguiera gymnorrhiza, Rhizophora mucronata, Sonneratia caseolaris, and Avicennia marina are commonly upgraded into traditional food, though many more species demonstrate ethnomedicinal properties. In the Middle East, A. marina is the dominant species, and the study of the phytochemicals and fruit development is limited. Therefore, studies on the development of mangrove fruits to functional for other mangrove species are demanding. The locally accepted mangrove fruit is coveted as an alternate food material to support the sustainable development goal of eliminating world hunger in sustainable ways.

New alternatives from sustainable sources to wheat in bakery foods: Science, technology, and challenges

Ongoing research in the food industry is striving to replace wheat flour with new alternatives from sustainable sources to overcome the disease burden in the existing population. Celiac disease, wheat allergy, gluten sensitivity, or non-celiac gluten sensitivity are some common disorders associated with gluten present in wheat. These scientific findings are crucial to finding appropriate alternatives in introducing new ingredients supporting the consumer's requirements. Among the alternatives, amaranth, barley, coconut, chestnut, maize, millet, teff, oat, rye, sorghum, soy, rice flour, and legumes could be considered appropriate due to their chemical composition, bioactive profile, and alternatives utilization in the baking industry. Furthermore, the enrichment of these alternatives with proper ingredients is considered effective. Literature demonstrated that the flours from these alternative sources significantly enhanced the physicochemical, pasting, and rheological properties of the doughs. These flours boost a significant reduction in gluten proteins associated with food intolerance, in comparison with wheat highlighting a visible market opportunity with nutritional and organoleptic benefits for food producers. PRACTICAL APPLICATIONS: New alternatives from sustainable sources to wheat in bakery foods as an approach that affects human health. Alternatives from sustainable sources are important source of nutrients and bioactive compounds. Alternatives from sustainable sources are rising due to nutritional and consumer demand in bakery industry. New alternatives from sustainable sources improve physicochemical, pasting, and rheological properties of dough. Non-wheat-based foods from non-traditional grains have a potential to increase consumer market acceptance.

Epigenetic Effects of Healthy Foods and Lifestyle Habits from the Southern European Atlantic Diet Pattern: A Narrative Review

Recent scientific evidence has shown the importance of diet and lifestyle habits for the proper functioning of the human body. A balanced and healthy diet, physical activity, and psychological well-being have a direct beneficial effect on health and can have a crucial role in the development and prognosis of certain diseases. The Southern European Atlantic diet, also named the Atlantic diet, is a unique dietary pattern that occurs in regions that present higher life expectancy, suggesting that this specific dietary pattern is associated with positive health effects. In fact, it is enriched with nutrients of high biological value, which, together with its cooking methods, physical activity promotion, reduction in carbon footprint, and promoting of family meals, promote these positive effects on health. The latest scientific advances in the field of nutri-epigenetics have revealed that epigenetic markers associated with food or nutrients and environmental factors modulate gene expression and, therefore, are involved with both health and disease. Thus, in this review, we evaluated the main aspects that define the Southern European Atlantic diet and the potential epigenetic changes associated with them based on recent studies regarding the main components of these dietary patterns. In conclusion, based on the information existing in the literature, we postulate that the Southern European Atlantic diet could promote healthy aging by means of epigenetic mechanisms. This review highlights the necessity of performing longitudinal studies to demonstrate this proposal.

Importance of Carbohydrate Quality: What Does It Mean and How to Measure It?

Dietary carbohydrates are our main source of energy. Traditionally, they are classified based on the polymer length between simple and complex carbohydrates, which does not necessarily reflect their impact on health. Simple sugars, such as fructose, glucose, and lactose, despite having a similar energy efficiency and caloric content, have very distinct metabolic effects, leading to increased risk for various chronic diseases when consumed in excess. In addition, beyond the absolute amount of carbohydrate consumed, recent data point out that the food form or processing level can modulate both the energy efficiency and the cardiometabolic risk associated with specific carbohydrates. To account for both of these aspects-the quality of carbohydrates as well as its food form-several metrics can be proposed to help identifying carbohydrate-rich food sources and distinguish between those that would favor the development of chronic diseases and those that may contribute to prevent these. This review summarizes the findings presented during the American Society of Nutrition Satellite symposium on carbohydrate quality, in which these different aspects were presented.

Effects of Diet, Lifestyle, Chrononutrition and Alternative Dietary Interventions on Postprandial Glycemia and Insulin Resistance

As years progress, we are found more often in a postprandial than a postabsorptive state. Chrononutrition is an integral part of metabolism, pancreatic function, and hormone secretion. Eating most calories and carbohydrates at lunch time and early afternoon, avoiding late evening dinner, and keeping consistent number of daily meals and relative times of eating occasions seem to play a pivotal role for postprandial glycemia and insulin sensitivity. Sequence of meals and nutrients also play a significant role, as foods of low density such as vegetables, salads, or soups consumed first, followed by protein and then by starchy foods lead to ameliorated glycemic and insulin responses. There are several dietary schemes available, such as intermittent fasting regimes, which may improve glycemic and insulin responses. Weight loss is important for the treatment of insulin resistance, and it can be achieved by many approaches, such as low-fat, low-carbohydrate, Mediterranean-style diets, etc. Lifestyle interventions with small weight loss (7-10%), 150 min of weekly moderate intensity exercise and behavioral therapy approach can be highly effective in preventing and treating type 2 diabetes. Similarly, decreasing carbohydrates in meals also improves significantly glycemic and insulin responses, but the extent of this reduction should be individualized, patient-centered, and monitored. Alternative foods or ingredients, such as vinegar, yogurt, whey protein, peanuts and tree nuts should also be considered in ameliorating postprandial hyperglycemia and insulin resistance. This review aims to describe the available evidence about the effects of diet, chrononutrition, alternative dietary interventions and exercise on postprandial glycemia and insulin resistance.

Dietary carbohydrate and the risk of type 2 diabetes: an updated systematic review and dose-response meta-analysis of prospective cohort studies

We did this study to clarify the association between carbohydrate intake and the risk of type 2 diabetes (T2D) and potential effect modification by geographical location. PubMed, Scopus and Web of Science were searched to find prospective cohort studies of dietary carbohydrate intake and T2D risk. A random-effects dose-response meta-analysis was performed to calculate the summary hazard ratios (HRs) and 95%CIs. The quality of cohort studies and the certainty of evidence was rated using the Newcastle-Ottawa Scale and GRADE tool, respectively. Eighteen prospective cohort studies with 29,229 cases among 607,882 participants were included. Thirteen studies were rated to have high quality, and five as moderate quality. The HR for the highest compared with the lowest category of carbohydrate intake was 1.02 (95%CI: 0.91, 1.15; I2 = 67%, GRADE = low certainty). The HRs were 0.93 (95%CI: 0.82, 1.05; I2 = 58%, n = 7) and 1.26 (95%CI: 1.11, 1.44; I2 = 6%, n = 6) in Western and Asian countries, respectively. Dose-response analysis indicated a J shaped association, with the lowest risk at 50% carbohydrate intake (HR50%: 0.95, 95%CI: 0.90, 0.99) and with risk increasing significantly at 70% carbohydrate intake (HR70%: 1.18, 95%CI: 1.03, 1.35). There was no association between low carbohydrate diet score and the risk of T2D (HR: 1.14, 95%CI: 0.89, 1.47; I2 = 90%, n = 5). Carbohydrate intake within the recommended 45-65% of calorie intake was not associated with an increased risk of T2D. Carbohydrate intake more than 70% calorie intake might be associated with a higher risk.

Associations of Glycemic Index and Glycemic Load with Cardiovascular Disease: Updated Evidence from Meta-analysis and Cohort Studies

PURPOSE OF REVIEW

Diet and lifestyle patterns are considered major contributory factors for cardiovascular disease (CVD) and mortality. In particular, consuming a diet higher in carbohydrates (not inclusive of fruits and vegetables, but more processed carbohydrates) has been associated with metabolic abnormalities that subsequently may increase the risk of CVD and related mortality. Glycemic index (GI) and glycemic load (GL) are values given to foods based on how fast the body converts carbohydrates into glucose also referred to as the glycemic burden of carbohydrates from foods. Conflicting associations of how high GI and GL influence CVDs have been observed even in high-quality meta-analysis studies. We synthesize and report the associations of high GI and GL with various CVDs by sex, obesity, and geographical locations using an updated review of meta-analysis and observational studies.

RECENT FINDINGS

We identified high GI or high GL is associated with an increased risk of CVD events including diabetes (DM), metabolic syndrome (MS), coronary heart disease (CHD), stroke, and stroke mortality in the general population, and the risk of CVD outcomes appears to be stratified by sex, obesity status, and preexisting CVD. Both high GI and GL are associated with DM and CHD in the general population. However, high GI is strongly associated with DM/MS, while high GL is strongly associated with an increased risk of CHD in females. In addition, high GL is also associated with incident stroke, and appears to be associated with CVD mortality in subjects with preexisting CVD or high BMI and all-cause mortality in non-obese DM subjects. However, high GI appears to be associated with CVD or all-cause mortality only in females without CVD. High GI/GL is an important risk factor for CVD outcomes in the general population. High GI seems to be markedly associated with DM/MS, and it may enhance the risk of CVD or all-cause mortality in both sexes and predominately females. Although both high GI and high GL are risk factors for CHD in females, high GL is associated with CVD outcomes in at-risk populations for CVD. These data suggest that while high GI increases the propensity of CVD risk factors and mortality in healthy individuals, high GL contributes to the risk of severe heart diseases including CVD or all-cause mortality, particularly in at-risk populations. These data indicate dietary interventions designed for focusing carbohydrate quality by lowering both GI and GL are recommended for preventing CVD outcomes across all populations.

Evaluation of the Quality of Evidence of the Association of Foods and Nutrients With Cardiovascular Disease and Diabetes: A Systematic Review

IMPORTANCE

Poor diet is a leading global factor associated with cardiometabolic disease (CMD). Understanding the quality of evidence of the associations between specific dietary factors and CMD, including effect size (relative risk [RR]) and uncertainty, is essential to guide policy and consumer actions to achieve healthy diet and public health goals.

OBJECTIVE

To assess the quality of evidence of the associations between specific dietary factors and CMD as well as the quantitative evidence for RRs and the uncertainty of these risk estimates.

EVIDENCE REVIEW

PubMed and the reference lists of eligible articles were searched between May 1, 2015, and February 26, 2021, for systematic reviews with meta-analyses of randomized clinical trials and prospective cohort studies that analyzed the consumption of 1 or more of the dietary factors of interest; reported dose-response meta-analyses; included healthy adults; and assessed 1 or more of the outcomes of interest. Study characteristics and RR estimates were extracted in duplicate. For identified associations, quality of evidence was assessed using the Bradford-Hill criteria for causation.

FINDINGS

A total of 2058 potentially relevant reports were identified, from which 285 full-text articles were assessed for eligibility. The final selection of articles included 28 meta-analyses representing 62 associations between diet and CMD. Among these associations, 10 foods, 3 beverages, and 12 nutrients had at least probable evidence of associations with coronary heart disease, stroke, and/or diabetes. Most RRs ranged from 0.87 to 0.96 per daily serving change for protective associations and from 1.06 to 1.15 per daily serving change for harmful associations. Most identified associations were protective (n = 38) and a smaller number were harmful (n = 24), with a higher risk associated with higher intake.

CONCLUSIONS AND RELEVANCE

This systematic review summarized the current quality of evidence of the associations of specific dietary factors with coronary heart disease, stroke, and diabetes. These findings may inform dietary guidance, the assessment of disease burden in specific populations, policy setting, and future research.