The effect of cognitive behavioral stress management on perceived stress, biological stress markers and weight loss/regain, from a diet-induced weight loss program: A randomized controlled trial

Obesity and psychosocial stress are inter-related chronic conditions which lead to increased cardiovascular morbidity and mortality. The aim of this parallel randomized controlled trial was to determine whether the addition of a structured cognitive behavioral stress management (CBSM) on to a commercial online weight loss program, resulted in greater weight loss than the standard weight loss program in isolation. Eligible participants were adults between the ages 18–65, BMI 30–45 kg/m², with no major systemic or psychiatric conditions. Seventy-four participants were assigned according to simple randomization using computer generated random numbers to either a 3-month online Weight Watchers® program (n = 36), or Weight Watchers® plus 10 weekly sessions of CBSM (n = 38). The primary outcome was weight at 3 months compared to baseline. Secondary outcomes were weight at 12 months and subjective/objective stress system measures and metabolic markers at 3 and 12 months. The study was powered at 90% to detect a 5 kg difference in weight between the two groups at 3 months. Independent sample t-tests were used to analyze the difference in weight (in kg) between the groups and paired sample t-tests were used to analyze the difference within group at different time intervals. At follow-up, there was no significant difference in weight loss between the groups (1.8 kg, 2.1 kg). However, CBSM was effective in reducing psychological measures of stress (p < 0.05) and salivary cortisol (waking, 20-min post-waking) at 3-months; with the effect on stress persisting at 12-months within the CBSM group. The reduction in PSS at 3 months was significantly greater in the CBSM group (3.84, p = 0.028) compared to WW only group at 3 months. Addition of CBSM to a standard weight loss intervention did not improve the weight loss over the standard approach on its own, but the CBSM intervention improved psychological stress parameters and cortisol secretion in participants living with obesity.

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Cognitive behavioral stress management (CBSM) reduced morning cortisol levels.

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Addition of CBSM to a weight loss program did not augment weight loss.

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CBSM reduced stress scores.

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CBSM improved psychometric parameters –SF–12, AAQ-II and PSS.

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Weight loss may have an effect on reducing stress.

Acute CTX-1 Suppression With Milk Calcium or Calcium Carbonate is Independent of Visceral Fat in A Randomized Crossover Study in Lean and Overweight Postmenopausal Women

BACKGROUND

Postmenopausal women with higher visceral adipose tissue (VAT) present with suppressed bone resorption (lower c-terminal cross-linking telopeptide of type I collagen, CTX-1) and turnover (lower osteocalcin) but whether this blunts the effect of calcium is unknown.

OBJECTIVE

The primary outcome of this study was the effect of VAT on changes in CTX-1 after intake of two forms of calcium. Secondary outcomes included changes in parathyroid hormone (PTH), serum calcium, phosphorus, and alkaline phosphatase (ALP).

DESIGN

Randomized open three period crossover trial conducted between 2017-2019 at the University of South Australia among 77 lean and overweight postmenopausal women (53-79 y) with body mass index (BMI) less than 25 kg/m2 and greater than 27 kg/m2, respectively. Participants received a single dose of milk (1000 mg calcium), calcium carbonate tablet (1000 mg calcium), and fruit juice (no calcium) in random order with a seven-day washout period. Blood samples were collected at baseline and hourly for 5h. Data was analysed by repeated measures analysis of variance (ANOVA) of log-transformed data.

RESULTS

At baseline, women with higher VAT had significantly lower CTX-1 and higher PTH (44% lower and 30% higher, respectively between Q4 and Q1, P < 0.0001). VAT had no influence on the acute changes in CTX-1 or PTH with calcium or juice. A suppression of 44% in CTX-1 was seen with calcium carbonate and milk and a suppression of 18% with juice. PTH was suppressed more with calcium carbonate (47%) compared to milk (22%). Milk calcium reduced PTH and CTX-1 at 2-hour while calcium carbonate reduced PTH in 1 hour. The suppression in CTX-1 was slower with lowest levels at 4-5 hour.

CONCLUSIONS

1000 mg calcium obtained from milk or from calcium carbonate is effective in acutely suppressing bone resorption in postmenopausal women irrespective of visceral fat.This trial is registered with the Australian New Zealand Clinical Trials Registry http://www.ANZCTR.org.au/ACTRN12617000779370.aspx (ACTRN 12617000779370).

Weight Loss Barriers and Dietary Quality of Intermittent and Continuous Dieters in Women with a History of Gestational Diabetes

Weight-loss after gestational diabetes (GDM) lowers the risk of type-2 diabetes (T2DM). Intermittent energy restriction (IER) produces comparable weight-loss to continuous energy restriction (CER), but long-term adherence remains difficult in this population. This exploratory secondary analysis of a 12-month trial comparing IER to CER following GDM examined weight-loss and dietary quality associated with barriers to weight-loss or T2DM risk perception as assessed in a Likert scale questionnaire at baseline. The participants had a median (IQR) BMI of 32.6 (9.4) kg/m² and 3 (4) years postpartum (n = 121). Forty-five percent (n = 54) of the participants thought they were at a high risk of developing T2DM. Greater affordability of healthy food was related with greater weight-loss at 3 months (p = 0.044, n = 85). At 12 months, there was no significant relationship between weight-loss and the barriers to weight-loss (p > 0.05). CER had superior improvement in dietary quality at 12 months (CER 11 ± 10, IER 6 ± 5.6, n = 42, p = 0.05). Under the Theoretical Domains Framework, the barriers were predominantly related to behavioral regulation (n = 83, 69%; n = 76, 63%) and environmental context and resources (n = 67, 56%). Interventions for diabetes prevention in this population should include behavioral regulation strategies, consider the family home environment, and ensure that the risk of T2DM is conveyed. Women choosing IER may benefit from education to improve their dietary quality.

The effect of intermittent energy restriction on weight loss and diabetes risk markers in women with a history of gestational diabetes: a 12-month randomized control trial

BACKGROUND

Weight loss after gestational diabetes (GDM) can prevent or delay the onset of type 2 diabetes. Intermittent energy restriction (IER) may offer an alternative to continuous energy restriction (CER) for weight loss.

OBJECTIVES

We compared the effects of IER (2 days per week) to daily CER over 12 mo on weight loss and diabetes risk markers in overweight women with previous GDM.

METHODS

Overweight females (n = 121) ≥18 y were randomized 1:1 to either IER [2-d 500 kcal (2100 kJ); n = 61] or CER [1500 kcal (6000 kJ); n = 60] in this 12-mo noninferiority trial.

RESULTS

The trial was completed by 62 participants with a median age of 39.6 y [Quartile (Q) 1 to Quartile 3, 34.9 to 43.9 y] with a median BMI of 32.6 kg/m2 (Q1 to Q3, 28.5 to 37.9 kg/m2) at a median of 2.9 y after GDM (Q1 to Q3, 2.1 to 6.4 y; 49% attrition; IER n = 29; CER n = 30; P = 0.8). The mean ± SD weight loss was significant over time (P < 0.001) but not by diet group (IER -4.8 ± 5.0 kg; CER -3.2 ± 5.0; P = 0.2). The mean between-group difference was -1.6 kg (95% CI: -4.2 to 1.0 kg; P = 0.2). There were no significant between-group differences in change in HbA1c, fasting plasma glucose, fasting serum insulin, HOMA-IR or 2-h oral glucose tolerance at 12 mo (p>0.05). The trial was registered at https://www.anzctr.org.au/ (ACTRN12617001476325).

CONCLUSIONS

IER produces comparable weight loss to CER over 12 mo in overweight women with previous GDM. The high dropout rate in this study is a limitation in the interpretation of these results. Larger studies are needed to confirm noninferiority of IER compared to CER.

Iodine Excretion and Intake in Women of Reproductive Age in South Australia Eating Plant-Based and Omnivore Diets: A Pilot Study

Women consuming a strictly vegan/plant-based diet may be at increased risk of low iodine intake due to avoidance of animal products containing iodine. The aim of this pilot study was to determine the iodine excretion and intake in women consuming vegan/plant based diets compared with women consuming omnivore diets. Fifty-seven women (n = 31 plant-based, n = 26 omnivores), provided two spot urine samples to assess urinary iodine concentration (UIC). Two days of dietary intake were also recorded by participants. As the data were not normally distributed results are reported as median (IQR). UIC was significantly different between groups, 44 (26-66) µg/L in the vegan/plant-based group versus 64 (40-88) µg/L in omnivores (p < 0.05). UIC did not meet the >100 µg/L level recommended by the World Health Organization. Iodine intake was also significantly different, 78 (62-91) µg/day in the vegan/plant-based group and 125 (86-175) µg/day in the omnivores (p = 0.000). Iodine intake and bread intake were correlated with iodine excretion (CC 0.410-4.11, p = 0.003). These data indicate iodine insufficiency in both groups of women as the median values were below the minimum WHO recommendation. A larger study assessing iodine excretion in the Australian women of reproductive age who are not pregnant or breastfeeding is needed to confirm these findings.

Women's Barriers to Weight Loss, Perception of Future Diabetes Risk and Opinions of Diet Strategies Following Gestational Diabetes: An Online Survey

Weight loss after gestational diabetes (GDM) reduces the risk of type 2 diabetes (T2DM); however, weight loss remains challenging in this population. In order to explore perceptions of T2DM risk, barriers to weight loss, and views of diet strategies in women with previous GDM, a cross-sectional online survey of n = 429 women in Australia aged ≥18 years with previous GDM was conducted. Opinions of intermittent energy restriction (IER) were of interest. Seventy-five percent of responders (n = 322) had overweight or obesity, and 34% (n = 144) believed they had a high risk of developing T2DM. Within the Theoretical Domains Framework, barriers to weight loss were prominently related to Environmental Context and Resources, Beliefs about Capabilities, and Behavioural Regulation. Exercising was the most tried method of weight loss over other diet strategies (71%, n = 234) and weight loss support by a dietician was appealing as individual appointments (65%, n = 242) or an online program (54%, n = 200). Most women (73%, n = 284) had heard of IER (the "5:2 diet"), but only 12% (n = 34) had tried it. Open comments (n = 100) revealed mixed views of IER. Women in Australia with previous GDM were found to lack a self-perceived high risk of developing T2DM and expressed barriers to weight loss related to their family environment, beliefs about their capabilities and behavioural regulation. IER is appealing for some women with previous GDM; however, views vary.

Consumption of a Beverage Containing Aspartame and Acesulfame K for Two Weeks Does Not Adversely Influence Glucose Metabolism in Adult Males and Females: A Randomized Crossover Study

There is an association between the consumption of artificial sweeteners and Type 2 diabetes in cohort studies, but intervention studies do not show a clear elevation of blood glucose after the use of artificial sweeteners. The objective of this study was to examine whether two commonly used artificial sweeteners had an adverse effect on glucose control in normal-weight subjects, and in overweight and obese subjects when consumed for 2 weeks. In the study, 39 healthy subjects (body-mass index, kg/m²) (18–45) without Type 2 diabetes with an age of 18–75 years were randomly assigned to 0.6 L/day of an artificially sweetened soft drink containing acesulfame K (950) and aspartame (951) or 0.6 L/day of mineral water for 2 weeks each in a crossover study. There was a 4 week washout period with no drinks consumed. Glucose levels were read by a continuous glucose monitor (CGM) during each 2 week period. A 75 g oral glucose-tolerance test (OGTT) was performed at the beginning and end of each intervention period. Blood samples were collected at baseline, and 1 and 2 h for glucose and insulin. A 2 week intake of artificially sweetened beverage (ASB) did not alter concentrations of fasting glucose and fasting insulin, the area under the curve (AUC) for OGTT glucose and insulin, the incremental area under the curve (iAUC) for OGTT glucose and insulin, the homeostatic model assessment for insulin resistance (HOMA-IR), and the Matsuda index compared with the baseline and with the changes after a 2 week intake of mineral water. Continuous 2 week glucose concentrations were not significantly different after a 2 week intake of ASB compared with a 2 week intake of mineral water. This study found no harmful effect of the artificially sweetened soft drink containing acesulfame K (950) and aspartame (951) on glucose control when consumed for 2 weeks by people without Type 2 diabetes.

Practical Guidance for Food Consumption to Prevent Cardiovascular Disease

This dietary guidance, informed by best contemporary evidence, aims to assist medical practitioners and allied health professionals in advising patients for the primary and secondary prevention of cardiovascular disease (CVD). While differing in some details from other current guidelines, the core messages accord with those published in 2019 by the American College of Cardiology/American Heart Association and the European Society of Cardiology/European Atherosclerosis Society; the National Lipid Association in 2014 and the NH&MRC Australian Dietary Guidelines in 2013. These were assessed through the Appraisal of Guidelines for Research and Evaluation (AGREE II) and the levels of evidence and classes of a recommendation developed using the GRADE system. Recommendations with high levels of evidence include increased consumption of plant based foods comprising mainly complex, fibre enriched carbohydrates (wholegrains, fruits and vegetables) while limiting intake of refined starches; partial replacement of saturated fats with monounsaturated or polyunsaturated fats and oils; reduced salt intake; achievement and maintenance of healthy weight; and low-to-moderate consumption of alcohol. Additional guidance but with moderate levels of evidence includes increased consumption of fish (and fish oils where indicated); reduction in sugar-sweetened beverages and added sugars; avoidance of butter and cream especially in those at increased CVD risk but encouragement of yoghurt; allow moderate consumption of lean meat but limit intake of processed meats; and limit cholesterol-rich foods such as eggs and crustaceans for those at increased CVD risk. Guidance has been formulated qualitatively on food categories of commonly eaten foods while avoiding prescriptive quantitative measures that are less readily translatable. This approach accords with current guidelines such as the American College of Cardiology/American Heart Association 2019 guidelines and is understandable and readily implemented.

Correction to: Comparison of the effects of weight loss from a high-protein versus standard-protein energy-restricted diet on strength and aerobic capacity in overweight and obese men

The original version of this article unfortunately contained a mistake.

Gaps in the Care of Familial Hypercholesterolaemia in Australia: First Report From the National Registry

BACKGROUND

Familial hypercholesterolaemia (FH) is under-diagnosed and under-treated worldwide, including Australia. National registries play a key role in identifying patients with FH, understanding gaps in care and advancing the science of FH to improve care for these patients.

METHODS

The FH Australasia Network has established a national web-based registry to raise awareness of the condition, facilitate service planning and inform best practice and care services in Australia. We conducted a cross-sectional analysis of 1,528 FH adults enrolled in the registry from 28 lipid clinics.

RESULTS

The mean age at enrolment was 53.4±15.1 years, 50.5% were male and 54.3% had undergone FH genetic testing, of which 61.8% had a pathogenic FH-causing gene variant. Only 14.0% of the cohort were family members identified through cascade testing. Coronary artery disease (CAD) was reported in 28.0% of patients (age of onset 49.0±10.5 years) and 64.9% had at least one modifiable cardiovascular risk factor. The mean untreated LDL-cholesterol was 7.4±2.5 mmol/L. 80.8% of patients were on lipid-lowering therapy with a mean treated LDL-cholesterol of 3.3±1.7 mmol/L. Among patients receiving lipid-lowering therapies, 25.6% achieved an LDL-cholesterol target of <2.5 mmol/L without CAD or <1.8 mmol/L with CAD.

CONCLUSION

Patients in the national FH registry are detected later in life, have a high burden of CAD and risk factors, and do not achieve guideline-recommended LDL-cholesterol targets. Genetic and cascade testing are under-utilised. These deficiencies in care need to be addressed as a public health priority.

Energy Intake and Satiety Responses of Eggs for Breakfast in Overweight and Obese Adults-A Crossover Study

The type of food eaten for breakfast may determine the amount of food consumed at the next meal. This may be important when considering dietary advice for overweight and obese individuals who are trying to lose weight. The aim of the study was to investigate the energy intake and subjective sensations of hunger using a visual analogue scale (VAS) of a breakfast meal of eggs compared with a breakfast meal of cereal in overweight Australian adults. In a cross-over study, participants attended the University of South Australia's Clinical Trial Facility on two separate days, one week apart. On each day participants consumed one of two isoenergetic breakfasts (1800 kJ), either eggs and toast or cereal with milk and orange juice. Fifty overweight or obese participants, 44 ± 21 years, 86 ± 14 kg, with a body mass index (BMI) of 31 ± 4 kg/m² completed both study visits. Energy intake following the egg breakfast was significantly reduced compared with the cereal breakfast (4518 vs. 5283 kJ, p = 0.001). BMI and gender were unrelated to these effects. The sensation of hunger was less after the egg breakfast (p = 0.028 for diet by time interaction) and returned more quickly after the cereal breakfast. There were no effects of gender or age. Energy intake was reduced at an ad libitum lunch meal 4 hours after a breakfast meal containing eggs. The findings suggest that satiety responses of overweight and obese are not different to non-obese participants as our study confirms findings from studies conducted in different populations. Determining which foods may help overweight and obese individuals manage their food intake is important for diet planning.

Differential Effects of Dietary Patterns on Advanced Glycation end Products: A Randomized Crossover Study

Dietary advanced glycation end products (AGEs) are believed to contribute to pathogenesis of diabetes and cardiovascular disease. The objective of this study was to determine if a diet high in red and processed meat and refined grains (HMD) would elevate plasma concentrations of protein-bound AGEs compared with an energy-matched diet high in whole grain, dairy, nuts and legumes (HWD). We conducted a randomized crossover trial with two 4-week weight-stable dietary interventions in 51 participants without type 2 diabetes (15 men and 36 women aged 35.1 ± 15.6 y; body mass index (BMI), 27.7 ± 6.9 kg/m²). Plasma concentrations of protein-bound Nε-(carboxymethyl) lysine (CML), Nε-(1-carboxyethyl) lysine (CEL) and Nδ-(5-hydro-5-methyl-4-imidazolon-2-yl)-ornithine (MG-H1) were measured by liquid chromatography–tandem mass spectrometry (LC-MS/MS). The HMD significantly increased plasma concentrations (nmol/mL) of CEL (1.367, 0.78 vs. 1.096, 0.65; p < 0.01; n = 48) compared with the HWD. No differences in CML and MG-H1 between HMD and HWD were observed. HMD increased plasma CEL concentrations compared with HWD in individuals without type 2 diabetes.

Does Nut Consumption Reduce Mortality and/or Risk of Cardiometabolic Disease? An Updated Review Based on Meta-Analyses

Aim We aimed to determine if nut consumption decreases mortality and/or the risk of cardiometabolic diseases based on updated meta-analyses of epidemiological and intervention studies. Methods. An updated electronic search was conducted in PubMed/MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library databases for original meta-analyses to investigate the effects of nut consumption on cardiometabolic disease in humans. Results. Seven new meta-analyses were included in this updated review. Findings similar to our previous review were observed, showing that nut consumption significantly decreased cardiovascular disease (CVD) mortality (−19% to −25%; n = 4), coronary heart disease (CHD) mortality (−24% to −30%; n = 3), stroke mortality (−17% to −18%; n = 3), CVD incidence (−15% to −19 %; n = 4), CHD [or coronary artery disease (CAD)] incidence (−17% to −34%; n = 8), and stroke incidence (−10% to −11%; n = 6) comparing high with low categories of nut consumption. Fasting glucose levels (0.08 to 0.15 mmol/L; n = 6), total cholesterol (TC; 0.021 to 0.30 mmol/L; n = 10), and low-density lipoprotein cholesterol (LDL-C; 0.017 to 0.26 mmol/L; n = 10) were significantly decreased with nut consumption compared with control diets. Body weight and blood pressure were not significantly affected by nut consumption. Conclusion. Nut consumption appears to exert a protective effect on cardiometabolic disease, possibly through improved concentrations of fasting glucose, total cholesterol, and LDL-C.

Non-nutritive Sweeteners and Glycaemic Control

PURPOSE OF REVIEW

The consumption of foods and beverages containing non-nutritive sweeteners (NNS) has increased worldwide over the last three decades. Consumers' choice of NNS rather than sugar or other nutritive sweeteners may be attributable to their potential to reduce weight gain.

RECENT FINDINGS

It is not clear what the effects of NNS consumption are on glycaemic control and the incidence of type 2 diabetes. This review aims to examine this question in epidemiological, human intervention and animal studies. It is not clear that NNS consumption has an effect on the incidence of type 2 diabetes or on glycaemic control even though there is some evidence for the modification of the microbiome and for interaction with sweet taste receptors in the oral cavity and the intestines' modification of secretion of glucagon-like peptide-1 (GLP-1), peptide YY (PYY), ghrelin and glucose-dependent insulinotropic polypeptide (GIP), which may affect glycaemia following consumption of NNS. In conclusion, long-term studies of NNS consumption are required to draw a firm conclusion about the role of NNS consumption on glycaemic control.

Elevated Serum 25-Hydroxyvitamin D Levels Are Associated with Improved Bone Formation and Micro-Structural Measures in Elderly Hip Fracture Patients

Vitamin D, along with calcium, is generally considered necessary for bone health and reduction of fractures. However, he effects of improving vitamin D status have not always been observed to improve bone mineral density (BMD). We have investigated whether varying vitamin D status in humans, as measured by serum 25(OH)D levels, relate to micro-structural and histomorphetric measures of bone quality and quantity, rather than density. Intertrochanteric trabecular bone biopsies and serum samples were collected from patients undergoing hip arthroplasty (65 females, 38 males, mean age 84.8 ± 8.3 years) at Royal Adelaide Hospital. Estimated GFR, serum ionized calcium, alkaline phosphatase, albumin, supplement and medication intake prior to surgery were taken from patient case records. Serum 25(OH)D, 1,25(OH)2D, and parathyroid hormone (PTH) levels were measured by immunoassays. Trabecular bone structural indices were determined by high-resolution micro-CT. Mean wall thickness (MWT) was measured on toluidine blue-stained histological sections. Bone mRNA levels for vitamin D metabolising enzymes CYP27B1 and CYP24A1 were measured by qRT-PCR. While serum 25(OH)D levels did not associate with bone volume/tissue volume (BV/TV%), serum 25(OH)D levels were strongly and independently associated with MWT (r = 0.81 p < 0.0001) with values significantly greater in patients with higher serum 25(OH)D levels. Furthermore, serum 25(OH)D levels were negatively associated with Bone Surface/Bone Volume (BS/BV) (r = −0.206, p < 0.05) and together with bone CYP27B1 and CYP24A1 mRNA accounted for 10% of the variability of BS/BV (p = 0.001). These data demonstrate that serum 25(OH)D is an independent positive predictor of micro-structural and bone formation measures and may be dependent, in part, on its metabolism within the bone.

Flash glucose monitoring for the safe use of a 2-day intermittent energy restriction in patients with type 2 diabetes at risk of hypoglycaemia: An exploratory study

AIMS

Two medication change protocols were tested, both based on haemoglobin A1c (HbA1c), with one protocol also accounting for hypoglycaemic events. The aim was to compare the two protocols during intermittent energy restriction (5:2 diet).

METHODS

Forty-two adults with type 2 diabetes (HbA1c ≥ 7% [53 mmol/mol], BMI of ≥27 kg/m²) treated with sulphonylureas and/or insulin were recruited and randomised 1:1 to fixed or adjusted medication protocols. Participants experiencing hypoglycaemia during a 2-week usual diet period then followed the 5:2 diet for 2 weeks (2 non-consecutive very-low-calorie days [500-600 kcal] and 5 habitual eating days/week), following the allocated medication protocol. The primary outcome was to determine if the adjusted protocol was superior to the fixed protocol at reducing hypoglycaemic events during the 5:2 diet. Flash glucose monitoring was used throughout to detect hypoglycaemia.

RESULTS

There was a significant difference in change in the number of hypoglycaemic events between fixed and adjusted protocols (-1.0 vs. -3.5; P = 0.04). Over 60% of participants on the adjusted protocol had no hypoglycaemic events.

CONCLUSIONS

This pilot study demonstrates the importance of assessing the risk of hypoglycaemia before starting a 5:2 diet and that the adjusted medication protocol is likely the best option for patients at risk.

CLINICAL TRIAL REGISTRY

This study has been registered with the Australia New Zealand Clinical Trial Registry (ANZCTR) www.anzctr.org.au and given the registration number ACTRN12617000512325.

The effect of intermittent compared with continuous energy restriction on glycaemic control in patients with type 2 diabetes: 24-month follow-up of a randomised noninferiority trial

AIMS

We investigated the effects of intermittent compared to continuous energy restriction on glycaemic control in patients with type 2 diabetes mellitus.

METHODS

Adults (N = 137) with type 2 diabetes (mean [SD] HbA1c level, 7.3% (56 mmol/mol) [1.3%] [14.2 mmol/mol]) were randomised to one of two diets for 12 months. The intermittent group (n = 70) followed a 2100-2500 kJ (500-600 kcal) diet 2 non-consecutive days/week and their usual diet for 5 days/week. The continuous group (n = 67) followed a 5000-6300 kJ (1200-1500 kcal) diet for 7 days/week. Follow-up occurred at 24 months, 12 months after the completed intervention. The primary outcome was change in HbA1c and the secondary outcome was weight loss.

RESULTS

Intention-to-treat analysis showed an increase in mean [SEM] HbA1c level at 24 months in both the continuous and intermittent groups (0.4% [0.3%] vs 0.1% [0.2%] respectively; P = 0.32) (4.4 [3.3 mmol/mol] vs 1.1 [2.2 mmol/mol]; P = 0.32), with a between-group difference of 0.3% (90% CI, -0.31 to 0.83%) (3.3 mmol/mol [90% CI, -3.2 to 9.1 mmol/mol]) outside the prespecified boundary of ± 0.5% (5.5 mmol/mol), so statistical equivalence was not shown. Weight loss was maintained (P < 0.001) at -3.9 kg [1.1 kg] in both groups at 24 months, with a between-group difference of 0.07 kg (90% CI, -2.5 to 2.6 kg) outside the prespecified boundary of ±2.5 kg. There were no significant differences between groups in body composition, fasting glucose levels, lipid levels, or total medication effect score at 24 months, which remained less than baseline.

CONCLUSIONS

In this prospective analysis weight loss was maintained but despite this HbA1c increased to above baseline levels in both groups.

A whey/guar "preload" improves postprandial glycaemia and glycated haemoglobin levels in type 2 diabetes: A 12-week, single-blind, randomized, placebo-controlled trial

AIMS

To evaluate the effects of 12 weeks of treatment with a whey/guar preload on gastric emptying, postprandial glycaemia and glycated haemoglobin (HbA1c) levels in people with type 2 diabetes (T2DM).

MATERIALS AND METHODS

A total of 79 people with T2DM, managed on diet or metformin (HbA1c 49 ± 0.7 mmol/mol [6.6 ± 0.1%]), were randomized, in single-blind fashion, to receive 150 mL flavoured preloads, containing either 17 g whey protein plus 5 g guar (n = 37) or flavoured placebo (n = 42), 15 minutes before two meals, each day for 12 weeks. Blood glucose and gastric emptying (breath test) were measured before and after a mashed potato meal at baseline (without preload), and after the preload at the beginning (week 1) and end (week 12) of treatment. HbA1c levels, energy intake, weight and body composition were also evaluated.

RESULTS

Gastric emptying was slower (P < 0.01) and postprandial blood glucose levels lower (P < 0.05) with the whey/guar preload compared to placebo preload, and the magnitude of reduction in glycaemia was related to the rate of gastric emptying at both week 1 (r = -0.54, P < 0.001) and week 12 (r = -0.54, P < 0.0001). At the end of treatment, there was a 1 mmol/mol [0.1%] reduction in HbA1c in the whey/guar group compared to the placebo group (49 ± 1.0 mmol/mol [6.6 ± 0.05%] vs. 50 ± 0.8 mmol/mol [6.7 ± 0.05%]; P < 0.05). There were no differences in energy intake, body weight, or lean or fat mass between the groups.

CONCLUSIONS

In patients with well-controlled T2DM, 12 weeks' treatment with a low-dose whey/guar preload, taken twice daily before meals, had sustained effects of slowing gastric emptying and reducing postprandial blood glucose, which were associated with a modest reduction in HbA1c, without causing weight gain.

Diet, exercise and weight loss and dyslipidaemia

There is a large amount of controversy relating dietary fat intake and coronary artery disease. It has been strongly suggested that saturated fat is not harmful and that polyunsaturated fat is either not beneficial or even harmful. Given that dietary lipids and fibre can influence serum lipids which are strongly linked to the risk of coronary artery disease I have reviewed recent evidence linking diet and serum lipids to confirm a diet-heart disease link. Over 84 studies have been included in a recent meta-analysis and meta-regression which examined the effects of changes in fat type on lipid levels. An absolute 1% reduction in saturated fat or trans fat intake as a percentage of energy with replacement by n-6 polyunsaturated fat would lead to a reduction in low density lipoprotein (LDL) cholesterol of 0.05 mmol/L. In most Western countries the difference in intake between the highest quintile and the lowest quintile of saturated fat is about 7%, so moving from the highest to the lowest quintile should lower LDL cholesterol by 0.35 mmol/L or about 10%. This change should lower cardiovascular disease rates by at least 10%. Replacing this amount of saturated fat with carbohydrate of average quality would lower LDL cholesterol by 0.21 mmol/L and increase fasting triglyceride by 0.17 mmol/L. This combination of effects would have a neutral effect on cardiovascular disease rates. However, replacement of trans fat appears to reduce disease rates and total mortality. Substituting low glycaemic index carbohydrates for high glycaemic index carbohydrates will lower triglyceride by 15-25% and reduce cardiovascular risk. Large doses of fish oil will lower triglyceride with a mean lowering of 0.45 mmol/L for a 3.5 g/day amount. Large doses of soluble fibre (3.5-7.0 g/day) lower LDL cholesterol by 0.2-0.35 mmol/L with Konjac glucomannan being the most effective per gram. Plant sterols or stanols lower LDL cholesterol by about 10% for a 2 g/day dose, while exercise and weight loss lower cardiovascular risk predominantly by lowering fasting triglyceride. In conclusion, diet lowers LDL cholesterol and triglyceride and dietary changes should be ultimately linked to a reduced risk of heart disease.

Nuts and Cardio-Metabolic Disease: A Review of Meta-Analyses

OBJECTIVES

Accumulating epidemiological and intervention evidence suggest that nut consumption is associated with reduced incidence of some cardiometabolic diseases. However, to date no review of meta-analyses of epidemiological and intervention studies has evaluated the effects of nut consumption on cardiometabolic disease. Design/Results: Electronic searches for meta-analyses of epidemiological and intervention studies were undertaken in PubMed®/MEDLINE®. Meta-analyses of prospective studies show that nut consumption appears to be associated with reduced all-cause mortality by 19⁻20% (n = 6), cardiovascular disease (CVD) incidence (19%; n = 3) and mortality (25%; n = 3), coronary heart disease (CHD) incidence (20⁻34%; n = 2) and mortality (27⁻30%; n = 2) and stroke incidence (10⁻11%; n = 7) and mortality (18%; n = 2). No association between nut consumption and the risk of type 2 diabetes mellitus (T2DM) was observed in meta-analyses of prospective studies, whereas a decrease in fasting blood glucose ranging from 0.08 to 0.15 mmol/L was observed in 3 meta-analyses of intervention studies. In the interventions, nut consumption also had favorable effects on total cholesterol (0.021 to 0.28 mmol/L reduction from 8 meta-analyses of interventions) and low-density lipoprotein cholesterol (0.017 to 0.26 mmol/L reduction from 8 meta-analyses of interventions) and endothelial function (0.79 to 1.03% increase in flow-mediated dilation from 4 meta-analyses of interventions). Nut consumption did not significantly affect body weight. Nut consumption had no effect on inflammatory markers in intervention studies. The effect on blood pressure was inconsistent. A higher nut consumption was associated with a lower incidence of hypertension in prospective studies, while nut consumption did not improve blood pressure in intervention studies.

CONCLUSIONS

Nut consumption appeared to be associated with lower all-cause mortality and CVD and CHD mortality. There was no association between nut consumption and the incidence of T2DM although fasting blood glucose is decreased in intervention studies. In intervention studies nuts lower total cholesterol and low-density lipoprotein cholesterol (LDL-C).

The Role of Choice in Weight Loss Strategies: A Systematic Review and Meta-Analysis

Effective strategies to achieve weight loss and long-term weight loss maintenance have proved to be elusive. This systematic review and meta-analysis aims to explore whether the choice of weight loss strategy is associated with greater weight loss. An electronic search was conducted using the MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online), EMBASE (Excerpta Medica database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO (Database of Abstracts of Literature in the Field of Psychology, produced by the American Psychological Association and distributed on the association's APA PsycNET) databases for clinical trials and randomized controlled trials, investigating the role of choice in weight loss strategies. A total of nine studies were identified as meeting the pre-specified criteria. All of the studies included a 'Choice' or preference arm and a 'No Choice' arm or group who did not receive their preference as a control. A total of 1804 subjects were enrolled in these studies, with weight loss observed in both experimental and control groups of all studies, irrespective of dietary intervention, study duration, or follow-up length. Twelve interventions in nine trials were used for the meta-analysis, with results indicating a greater weight loss in the control groups, 1.09 ± 0.28 (overall mean difference in weight loss between groups ± standard error; p = 0). There was no significant effect of duration or attrition. In this meta-analysis, the choice of weight loss strategy did not confer a weight loss benefit.

Dietary quality and carotid intima media thickness in type 1 and type 2 diabetes: Follow-up of a randomised controlled trial

BACKGROUND AND AIMS

The relationship between dietary intake and carotid intima media thickness (IMT) and pulse wave velocity (PWV) in individuals with type 1 and type 2 diabetes has not been well studied. We investigated the association between dietary intake and common carotid artery intima media thickness (CCA IMT) and PWV in a cohort with type 1 and type 2 diabetes.

METHODS AND RESULTS

A one-year randomised controlled trial was conducted to investigate the effect of improving dietary quality on CCA IMT. These subjects were followed up again approximately 12 months after the completion of the trial (i.e. approximately 24 month since baseline). The study cohort included 87 subjects that had dietary intake and CCA IMT measured at baseline and after a mean of 2.3 years' follow-up. PWV was measured in a subsample of this cohort. Age and baseline mean CCA IMT were strongly associated with mean CCA IMT at 24 months. After adjustment for age and baseline mean CCA IMT, baseline consumption of carbohydrate (r = -0.28; p = 0.01), sugars (r = -0.27; p = 0.01), fibre (r = -0.26; p = 0.02), magnesium (r = -0.25; p = 0.02) and the Alternate Health Eating Index (AHEI) score (r = -0.23; p = 0.03) were inversely associated with mean CCA IMT at 24 months. Mixed linear modelling showed an interaction between mean CCA IMT and AHEI at baseline (p = 0.024). Those who were in the highest AHEI tertile at baseline had greater CCA IMT regression at 24 months compared to those in the lowest tertile, after adjustment for baseline age, BMI, smoking pack years, time since diabetes diagnosis, and mean arterial pressure at baseline (mean -0.043 mm; 95% CI -0.084, -0.003; p = 0.029).

CONCLUSIONS

In this prospective analysis greater diet quality at baseline, as measured by the AHEI, was associated with greater CCA IMT regression after approximately two years. This suggests that greater diet quality is associated with better longer term vascular health in individuals with type 1 and type 2 diabetes.

Effect of Intermittent Compared With Continuous Energy Restricted Diet on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Noninferiority Trial

IMPORTANCE

Intermittent energy restriction is an alternative weight loss method that is becoming popular; however, to date, there are no long-term clinical trials of intermittent energy restriction in patients with type 2 diabetes.

OBJECTIVE

To compare the effects of intermittent energy restriction (2 days per week) with those of continuous energy restriction on glycemic control and weight loss in patients with type 2 diabetes during a 12-month period.

DESIGN, SETTING, AND PARTICIPANTS

Adult participants (N = 137) with type 2 diabetes were randomized 1:1 to parallel diet groups (intermittent energy restriction [n = 70] or continuous energy restriction [n = 67]) between April 7, 2015, and September 7, 2017, at the University of South Australia. Medications likely to cause hypoglycemia were reduced at baseline according to the medication management protocol.

INTERVENTIONS

An intermittent energy restriction diet (500-600 kcal/d) followed for 2 nonconsecutive days per week (participants followed their usual diet for the other 5 days) or a continuous energy restriction diet (1200-1500 kcal/d) followed for 7 days per week for 12 months.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in hemoglobin A1c (HbA1c) level, with equivalence prespecified by a 90% CI margin of ±0.5%. The secondary outcome was weight loss with equivalence set at ±2.5 kg (±1.75 kg for fat mass loss and ±0.75 kg for fat-free mass loss). All other outcomes were tested for superiority.

RESULTS

Of the 137 randomized participants (77 women and 60 men; mean [SD] age, 61.0 [9.1] years; mean [SD] body mass index, 36.0 [5.8] [calculated as weight in kilograms divided by height in meters squared]; and mean [SD] HbA1c level, 7.3% [1.3%]), 97 completed the trial. Intention-to-treat analysis showed similar reductions in mean (SEM) HbA1c level between the continuous and intermittent energy restriction groups (-0.5% [0.2%] vs -0.3% [0.1%]; P = .65), with a between-group difference of 0.2% (90% CI, -0.2% to 0.5%) meeting the criteria for equivalence. Mean (SEM) weight change was similar between the continuous and intermittent energy restriction groups (-5.0 [0.8] kg vs -6.8 [0.8] kg; P = .25), but the between-group difference did not meet the criteria for equivalence (-1.8 kg; 90% CI, -3.7 to 0.07 kg), nor did the between-group difference in fat mass (-1.3 kg; 90% CI, -2.8 to 0.2 kg) or fat-free mass (-0.5 kg; 90% CI, -1.4 to 0.4 kg). There were no significant differences between groups in final step count, fasting glucose levels, lipid levels, or total medication effect score at 12 months. Effects did not differ using completers analysis. Hypoglycemic or hyperglycemic events in the first 2 weeks of treatment were similar between the continuous and intermittent energy restriction groups (mean number [SEM] of events, 3.2 [0.7] vs 4.9 [1.4]; P = .28), affecting 35% of participants (16 of 46) using sulfonylureas and/or insulin.

CONCLUSIONS AND RELEVANCE

Intermittent energy restriction is an effective alternative diet strategy for the reduction of HbA1c and is comparable with continuous energy restriction in patients with type 2 diabetes.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12615000383561.

Relationship Between Changes in Fat and Lean Depots Following Weight Loss and Changes in Cardiovascular Disease Risk Markers

Background

Gluteofemoral fat mass has been associated with improved cardiovascular disease risk factors. It is not clear if loss of this protective fat during weight loss partially negates the effect of loss of visceral fat. The aim of this study was to examine regional fat loss in a large weight‐loss cohort from one center and to determine if fat loss in the leg and total lean tissue loss is harmful.

Methods and Results

We combined the data from 7 of our previously published 3‐month weight‐loss studies and examined the relationship between regional fat and lean tissue loss and changes in cardiovascular disease risk factors in 399 participants. At baseline, leg fat was positively associated with high‐density lipoprotein cholesterol in women and inversely with fasting triglyceride level in both sexes. Abdominal lean tissue was also related to systolic blood pressure in men. Changes in regional fat and lean tissue were positively associated with changes in glucose, insulin, total cholesterol, triglycerides, low‐density lipoprotein cholesterol and systolic and diastolic blood pressure (r=0.11–0.22, P<0.05) with leg fat and arm lean tissue dominating in multivariate regression. After adjustment for total weight or total fat change, these relationships disappeared except for a positive relationship between arm and lean leg mass loss and changes in triglycerides and systolic blood pressure.

Conclusions

Loss of leg fat and leg lean tissue was directly associated with beneficial changes in cardiovascular disease risk markers. Loss of lean tissue may not have an adverse effect on cardiovascular disease risk, and measures to retain lean tissue during weight loss may not be necessary.

A systematic review of the effect of dietary saturated and polyunsaturated fat on heart disease

AIMS

Over the last 7 years there has been intense debate about the advice to reduce saturated fat and increase polyunsaturated fat to reduce CVD risk. The aim of this review was to examine systematic reviews and meta-analyses since 2010 on this topic plus additional cohort studies and interventions not included in these reviews.

DATA SYNTHESIS

High saturated and trans fat intake (which elevates LDL like saturated fat) in the Nurses and Health Professional Follow-Up Studies combined is associated with an 8-13% higher mortality and replacement of saturated fat with any carbohydrate, PUFA and MUFA is associated with lower mortality with PUFA being more effective than MUFA (19% reduction versus 11%). With CVD mortality only PUFA and fish oil replacement of saturated fat lowers risk with a 28% reduction in CVD mortality per 5% of energy. Replacing saturated fat with PUFA or MUFA is equally effective at reducing CHD events and replacement with whole grains will lower events while replacement with sugar and starch increases events. Replacement of saturated fat with carbohydrate has no effect on CHD events or death. Only PUFA replacement of saturated fat lowers CHD events and CVD and total mortality. Replacing saturated fat with linoleic acid appears to be beneficial based on the Hooper Cochrane meta-analysis of interventions although other analyses with fewer studies have shown no effect.

CONCLUSIONS

Reducing saturated fat and replacing it with carbohydrate will not lower CHD events or CVD mortality although it will reduce total mortality. Replacing saturated fat with PUFA, MUFA or high-quality carbohydrate will lower CHD events.

Benefits of Nut Consumption on Insulin Resistance and Cardiovascular Risk Factors: Multiple Potential Mechanisms of Actions

Epidemiological and clinical studies have indicated that nut consumption could be a healthy dietary strategy to prevent and treat type 2 diabetes (T2DM) and related cardiovascular disease (CVD). The objective of this review is to examine the potential mechanisms of action of nuts addressing effects on glycemic control, weight management, energy balance, appetite, gut microbiota modification, lipid metabolism, oxidative stress, inflammation, endothelial function and blood pressure with a focus on data from both animal and human studies. The favourable effects of nuts could be explained by the unique nutrient composition and bioactive compounds in nuts. Unsaturated fatty acids (monounsaturated fatty acids and polyunsaturated fatty acids) present in nuts may play a role in glucose control and appetite suppression. Fiber and polyphenols in nuts may also have an anti-diabetic effect by altering gut microbiota. Nuts lower serum cholesterol by reduced cholesterol absorption, inhibition of HMG-CoA reductase and increased bile acid production by stimulation of 7-α hydroxylase. Arginine and magnesium improve inflammation, oxidative stress, endothelial function and blood pressure. In conclusion, nuts contain compounds that favourably influence glucose homeostasis, weight control and vascular health. Further investigations are required to identify the most important mechanisms by which nuts decrease the risk of T2DM and CVD.

Changes in Lipids and Inflammatory Markers after Consuming Diets High in Red Meat or Dairy for Four Weeks

There is a body of evidence linking inflammation, altered lipid metabolism, and insulin resistance. Our previous research found that insulin sensitivity decreased after a four-week diet high in dairy compared to a control diet and to one high in red meat. Our aim was to determine whether a relationship exists between changes in insulin sensitivity and inflammatory biomarkers, or with lipid species. Fasting Tumor Necrosis Factor alpha (TNF-α), Tumor Necrosis Factor Receptor II (sTNF-RII), C-reactive protein (CRP), and lipids were measured at the end of each diet. TNF-α and the ratio TNF-α/sTNF-RII were not different between diets and TNF-α, sTNF-RII, or the ratio TNF-α/sTNF-RII showed no association with homeostasis model assessment-estimated insulin resistance (HOMA-IR). A number of phosphatidylethanolamine (PE) and phosphatidylinositol (PI) species differed between dairy and red meat and dairy and control diets, as did many phosphatidylcholine (PC) species and cholesteryl ester (CE) 14:0, CE15:0, lysophosphatidylcholine (LPC) 14:0, and LPC15:0. None had a significant relationship (p = 0.001 or better) with log homeostasis model assessment-estimated insulin resistance (HOMA-IR), although LPC14:0 had the strongest relationship (p = 0.004) and may be the main mediator of the effect of dairy on insulin sensitivity. LPC14:0 and the whole LPC class were correlated with CRP. The correlations between dietary change and the minor plasma phospholipids PI32:1 and PE32:1 are novel and may reflect significant changes in membrane composition. Inflammatory markers were not altered by changes in protein source while the correlation of LPC with CRP confirms a relationship between changes in lipid profile and inflammation.

Association between dairy intake, lipids and vascular structure and function in diabetes

AIM

To determine lipid species that change in response to a change in dairy consumption. In addition, to investigate whether dairy associated lipid species are correlated with changes in measures of vascular structure and function.

METHODS

A 12-mo randomised controlled trial was conducted to determine the effect of increased consumption of fruit, vegetables and dairy, compared to usual diet, on measures of vascular structure and function in adults with type 1 and type 2 diabetes (n = 108). This paper comprises post-hoc analyses investigating the relationship between dairy intake, serum lipid species and vascular health. Central and peripheral blood pressure, carotid femoral pulse wave velocity, augmentation index, serum lipid species and dietary intake were measured at baseline and 3-mo. Common carotid artery intima media thickness was measured at baseline and 12-mo.

RESULTS

Serum lipid species [lysophosphatidylcholine (LPC) 14:0, LPC 15:0, LPC 16:1, phosphatidylcholine (PC) 29:0 PC 30:0, PC 31:0 and cholesterol ester (CE) 14:0] were associated with the change in full fat dairy consumption (rho 0.19-0.25; P < 0.05). The 3-mo change in some lipids was positively associated with the 3-mo change in central systolic [LPC 14:0 (rho 0.30; P = 0.007), PC 30:0 (rho 0.28; P = 0.010)] and diastolic blood pressure [LPC 14:0 (rho 0.32; P = 0.004), LPC 15:0 (rho 0.23; P = 0.04), LPC 16:1 (rho 0.23; P = 0.035), PC 29:0 (rho 0.28; P = 0.01), PC 30:0 (rho 0.36; P = 0.001), PC 31:0 (rho 0.30; P = 0.007)] and 12-mo change in common carotid artery intimal medial thickness [CE 14:0 (rho 0.22; P = 0.02)]. Pulse wave velocity and augmentation index were unrelated to dairy and lipid species.

CONCLUSION

An increase in dairy associated lipids appears to be associated with an increase in blood pressure and common carotid intimal medial thickness.

Effects of Two Different Dietary Patterns on Inflammatory Markers, Advanced Glycation End Products and Lipids in Subjects without Type 2 Diabetes: A Randomised Crossover Study

Epidemiological studies suggest that consumption of red and processed meat and refined grains are associated with type 2 diabetes and metabolic syndrome and increased inflammatory and fibrinolytic markers. We hypothesised that a diet high in red and processed meat and refined grains (HMD) would increase inflammatory markers and advanced glycation end products (AGEs) compared with a diet high in dairy, whole grains, nuts and legumes (HWD). We performed a randomised crossover study of two four-week interventions in 51 participants without type 2 diabetes (15 men and 36 women aged 35.1 ± 15.6 years; body mass index: 27.7 ± 6.9 kg/m²). No baseline measurements were performed. Plasma fluorescent AGEs, carboxymethyllysine, glucose, insulin, lipids, hs-CRP, interleukin 6 (IL-6) and plasminogen activator inhibitor-1 (PAI-1) were analysed after four weeks on each diet. IL-6, hs-CRP, AGEs and carboxymethyllysine were not different between diets but PAI-1 was higher after the HMD than after HWD ((median and interquartile range) 158, 81 vs. 121, 53 ng/mL p < 0.001). PAI-1 on the HWD diet was inversely correlated with whole grains intake (p = 0.007). PAI-1 was inversely correlated with insulin sensitivity index (r = −0.45; p = 0.001) and positively correlated with serum total cholesterol (r = 0.35; p = 0.012) and serum triglyceride (r = 0.32; p = 0.021) on HMD. This trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000519651).

Design of the Familial Hypercholesterolaemia Australasia Network Registry: Creating Opportunities for Greater International Collaboration

Familial Hypercholesterolemia (FH) is the most common and serious monogenic disorder of lipoprotein metabolism that leads to premature coronary heart disease. There are over 65,000 people estimated to have FH in Australia, but many remain undiagnosed. Patients with FH are often undertreated, but with early detection, cascade family testing and adequate treatment, patient outcomes can improve. Patient registries are key tools for providing new information on FH and enhancing care worldwide. The development and design of the FH Australasia Network Registry is a crucial component in the comprehensive model of care for FH, which aims to provide a standardized, high-quality and cost-effective system of care that is likely to have the highest impact on patient outcomes. Informed by stakeholder engagement, the FH Australasia Network Registry was collaboratively developed by government, patient and clinical networks and research groups. The open-source, webbased Rare Disease Registry Framework was the architecture chosen for this registry owing to its open-source standards, modular design, interoperability, scalability and security features; all these are key components required to meet the ever changing clinical demands across regions. This paper provides a high level blueprint for other countries and jurisdictions to help inform and map out the critical features of an FH registry to meet their particular health system needs.

Consumption of red and processed meat and refined grains for 4weeks decreases insulin sensitivity in insulin-resistant adults: A randomized crossover study

BACKGROUND

Red and processed meat and refined grains are associated with an increased risk of type 2 diabetes. Interventions are limited. We hypothesized that a diet high in red and processed meat and refined grains (HMD) would decrease insulin sensitivity compared to a diet high in whole grains, nuts, dairy and legumes with no red meat (HWD).

METHODS

Forty-nine subjects without diabetes [15 men and 34 women, age, 35.6±15.7 years, body mass index (BMI), 27±5.9kg/m²] underwent two 4-week weight-stable dietary interventions in a randomized crossover design. The insulin sensitivity index (ISI) was calculated from the last 30min of a continuous low-dose insulin (25mU/kg·h) and glucose (4mg/kg·min) infusion test (LDIGIT _120-150min) at the end of each diet.

RESULTS

The population fell into two very discrete groups: those with a very low insulin response in the LDIGIT _120-150min on HMD (Group 1<56pmol/L, n=24), and those with relatively normal insulin responses (Group 2>56pmol/L, n=25). Group 2 had significantly higher insulin concentrations [(median and interquartile range) 153, 180 for HMD vs. 123, 149pmol/L for HWD; P=0.019] and glucose concentrations [(mean±standard deviation) 7.4±1.3 for HMD vs.6.7±1.2mmol/L for HWD; P=0.05], resulting in a significantly decreased ISI [(median and interquartile range) 21.1, 34.2 for HMD vs. 31.6, 39.4 for HWD; P=0.014] compared to HWD. Log ISI after HMD was significantly correlated with BMI (r=-0.5; P=0.009), fat mass (r=-0.55; P=0.004) and self-reported activity levels (r=-0.45; P=0.024).

CONCLUSIONS

A dietary pattern high in red and processed meat and refined grains decreased insulin sensitivity compared to a dietary pattern high in whole grains, nuts, dairy products and legumes only in relatively insulin-resistant adults.

Clinical and dietary predictors of common carotid artery intima media thickness in a population with type 1 and type 2 diabetes: A cross-sectional study

AIM

To determine the clinical and dietary predictors of common carotid artery intima media thickness (CCA IMT) in a cohort of subjects with type 1 and type 2 diabetes.

METHODS

Participants with type 1 (n = 23) and type 2 diabetes (n = 127) had mean and mean maximum CCA IMT measured using B mode ultrasound. Dietary intake was measured using a food frequency questionnaire. Clinical and dietary predictors of mean and mean maximum CCA IMT were determined using linear regression analysis adjusted for potential confounders.

RESULTS

The main predictors of mean and mean maximum CCA IMT were age and weight. After multivariate adjustment there were no dietary predictors of CCA IMT. However, in subjects that were not prescribed a lipid lowering medication alcohol consumption was positively associated with CCA IMT after multivariate adjustment. No difference existed in CCA IMT between subjects with type 1 or type 2 diabetes once age was adjusted for.

CONCLUSION

CCA IMT was predominantly predicted by age and weight in these subjects with diabetes. The finding that CCA IMT was not different between people with type 1 and type 2 diabetes warrants further investigation in a larger cohort.

Intermittent energy restriction in type 2 diabetes: A short discussion of medication management

AIM

To discuss type 2 diabetes mellitus (T2DM) medication changes required during the popular 5:2 intermittent energy restriction (IER) diet.

METHODS

A search was conducted in MEDLINE, EMBASE, AMED, CINAHL and Cochrane library for original research articles investigating the use of very low calorie diets (VLCD) in people with T2DM. The search terms used included “VLCD” or “very low energy diet” or “very low energy restriction” or “IER” or “intermittent fasting” or “calorie restriction” or “diabetes mellitus type 2” and “type 2 diabetes”. Reference lists of selected articles were also screened for relevant publications. Only research articles written in English, which also included an explanation of medication changes were included. A recent pilot trial using the 5:2 IER method, conducted by our research group, will also be summarized.

RESULTS

A total of 8 studies were found that investigated the use of VLCD in T2DM and discussed medication management. Overall these studies indicate that the use of a VLCD for people with T2DM usually require the cessation of medication to prevent hypoglycemia. Therefore, the 5:2 IER method will also require medication changes, but as seen in our pilot trial, may not require total cessation of medication, rather a cessation on the 2 IER days only.

CONCLUSION

Guidelines outlined here can be used in the initial stages of a 2-d IER diet, but extensive blood glucose monitoring is still required to make the necessary individual reductions to medications in response to weight loss.

The effects of intermittent compared to continuous energy restriction on glycaemic control in type 2 diabetes; a pragmatic pilot trial

AIMS

Weight loss improves glycaemic control in type 2 diabetes mellitus (T2DM). However, as achieving and maintaining weight loss is difficult, alternative strategies are needed. Our primary aim was to investigate the effects of intermittent energy restriction (IER) compared to continuous energy restriction (CER) on glycated haemoglobin A1c (HbA1c). Secondary aims were to assess effects on weight loss, body composition, medication changes and subjective measures of appetite. Using a 2-day IER method, we expected equal improvements to HbA1c and weight in both groups.

METHOD

Sixty-three overweight or obese participants (BMI 35.2±5kg/m²) with T2DM (HbA1c 7.4±1.3%) (57mmol/mol) were randomised to a 2-day severe energy restriction (1670-2500kJ/day) with 5days of habitual eating, compared to a moderate CER diet (5000-6500kJ/day) for 12weeks.

RESULTS

At 12weeks HbA1c (-0.7±0.9% P<0.001) and percent body weight reduction (-5.9±4% P<0.001) was similar in both groups with no group by time interaction. Similar reductions were also seen for medication dosages, all measures of body composition and subjective reports of appetite.

CONCLUSIONS

In this pilot trial, 2days of IER compared with CER resulted in similar improvements in glycaemic control and weight reduction offering a suitable alternative treatment strategy.

Differential Effects of Red Meat/Refined Grain Diet and Dairy/Chicken/Nuts/Whole Grain Diet on Glucose, Insulin and Triglyceride in a Randomized Crossover Study

Epidemiological studies suggest that a diet high in processed meat, with a high glycemic index is associated with an increased risk of type 2 diabetes. It is not clear if this is due to altered insulin sensitivity or an enhanced postprandial glucose. We aimed to compare the acute metabolic response of two different types of meals after ingestion of the matching diet for four weeks. The study was a randomized, crossover acute meal study. Volunteers consumed either a red meat/refined grain meal or a dairy/chicken/nuts/wholegrain meal after four weeks of the matching diet. After a three-week washout period and four weeks of the alternate diet, they consumed the matching meal. The diets differed with respect to both protein and carbohydrate sources. Blood samples were taken for 180 min for the measurement of glucose, insulin, C-peptide and triglyceride. Fifty-one participants (age: 35.1 ± 15.6 years; body mass index: 27.7 ± 6.9 kg/m², 17 with normal and 34 with impaired glucose tolerance) completed two meal tests. The area under the curve (p < 0.001) and incremental area under the curve (p = 0.001) for insulin was significantly higher after the red meat/refined grain diet than after the dairy/chicken/nuts/whole grain diet. There was an interaction between meal and glucose tolerance group (p < 0.05) in the area under the curve (AUC) and the incremental area under the curve (iAUC) of glucose; the red meat/refined grain diet increased glucose relative to the dairy/chicken/nuts/whole grain diet only in the normal group (+2.5 mmol/L/3 h). The red meat/refined grain diet increased glucose and insulin responses compared with the dairy/chicken/nuts/whole grain diet. This meal pattern would increase pancreatic stress long term and may account for the increased risk of type 2 diabetes with this diet.

Long-Term Effects of a Randomised Controlled Trial Comparing High Protein or High Carbohydrate Weight Loss Diets on Testosterone, SHBG, Erectile and Urinary Function in Overweight and Obese Men

Introduction

Obesity is associated with reduced testosterone and worsened erectile and sexual function in men. Weight loss improves these outcomes. High protein diets potentially offer anthropometric and metabolic benefits, but their effects on reproductive and sexual outcomes is not known.

Aim

To examine the long-term effects of weight loss with a higher protein or carbohydrate diet on testosterone, sex hormone binding globulin, erectile dysfunction, lower urinary tract symptoms and sexual desire in overweight and obese men.

Methods

One-hundred and eighteen overweight or obese men (body mass index 27–40 kg/m², age 20–65 years) were randomly assigned to an energy restricted higher protein low fat (35% protein, 40% carbohydrate, 25% fat; n = 57) or higher carbohydrate low fat diet (17% protein, 58% carbohydrate, 25% fat, n = 61) diet for 52 weeks (12 weeks weight loss, 40 weeks weight maintenance). Primary outcomes were serum total testosterone, sex hormone binding globulin and calculated free testosterone. Secondary outcomes were erectile function as assessed by the International Index of Erectile Function (IIEF) (total score and erectile function domain), lower urinary tract symptoms and sexual desire.

Results

Total testosterone, sex hormone binding globulin and free testosterone increased (P<0.001) and the total IIEF increased (P = 0.017) with no differences between diets (P≥0.244). Increases in testosterone (P = 0.037) and sex hormone binding globulin (P<0.001) and improvements in the total IIEF (P = 0.041) occurred from weeks 0–12 with a further increase in testosterone from week 12–52 (P = 0.002). Increases in free testosterone occurred from week 12–52 (p = 0.002). The IIEF erectile functon domain, lower urinary tract symptoms and sexual desire did not change in either group (P≥0.126).

Conclusions

In overweight and obese men, weight loss with both high protein and carbohydrate diets improve testosterone, sex hormone binding globulin and overall sexual function.

Trial Registration

Anzctr.org.au ACTRN12606000002583

Effect of Improving Dietary Quality on Arterial Stiffness in Subjects with Type 1 and Type 2 Diabetes: A 12 Months Randomised Controlled Trial

People with diabetes have accelerated arterial stiffening. The aim of this study was to determine the effect of increasing fruit, vegetable and dairy intake for 12 months on carotid femoral pulse wave velocity (cfPWV), augmentation index (AIx), and central blood pressure (cBP), compared to a usual diet control, in people with type 1 and type 2 diabetes. In a 12 months randomised controlled trial, cfPWV, AIx and cBP were measured every 3 months. The intervention group received dietary counselling to increase consumption of fruit (+1 serving/day; 150 g/day), vegetables (+2 servings/day; 150 g/day) and dairy (+1 serving/day; 200–250 g/day) at baseline, 1, 3, 6 and 9 months. The control group continued on their usual diet. One hundred and nine participants were randomised and 92 (intervention n = 45; control n = 47) completed. At 3 months, fruit (184 g/day; p = 0.001) and dairy (83 g/day; p = 0.037) intake increased in the intervention group compared with the control group but this increase was not maintained at 12 months. After adjustment for baseline measurements there was no time by treatment effect for central systolic or diastolic BP, AIx or cfPWV. A time effect existed for AIx which modestly increased over time. Peripheral diastolic BP and central pulse pressure were improved in the intervention group compared with the control group at 12 months. In the cohort with type 1 and type 2 diabetes, improving dietary quality by increasing consumption of fruit, vegetables and dairy did not improve cBP, AIx or cfPWV, compared with a control group continuing on their usual diet, after 12 months.

Fructose acute effects on glucose, insulin, and triglyceride after a solid meal compared with sucralose and sucrose in a randomized crossover study

BACKGROUND

Fructose, which is a sweetener with a low glycemic index, has been shown to elevate postprandial triglyceride compared with glucose. There are limited data on the effect of fructose in a solid mixed meal containing starch and protein.

OBJECTIVE

We determined the effects of sucrose, fructose, and sucralose on triglyceride, glucose, and insulin in an acute study in healthy, overweight, and obese individuals.

DESIGN

The study had a randomized crossover design. Twenty-seven participants with a mean age of 44 y and a mean body mass index (in kg/m(2)) of 26 completed the study. Fructose (52 g), sucrose (65 g), and sucralose (0.1 g) were delivered as sweet-taste-balanced muffins with a total fat load (66 g). Blood samples were taken at baseline and every 30 min for 4-h glucose, triglyceride, and insulin concentrations, and the area under the curve (AUC) and the incremental area under the curve (iAUC) were analyzed.

RESULTS

No significant difference was shown between the 3 sweeteners for triglyceride and glucose concentrations and the AUC. The glucose iAUC was lower for fructose than for sucrose and sucralose (P < 0.05). Insulin concentrations differed significantly by the type of muffin (P = 0.001), the interaction of time by type of muffin (P = 0.035), the AUC (P < 0.001), and the iAUC (P < 0.001). Fructose had a significantly lower insulin response than that of either sucrose (P-treatment = 0.006) or sucralose (P-treatment = 0.041).

CONCLUSIONS

Fructose, at a moderate dose, did not significantly elevate triglyceride compared with sucrose or sucralose and lowered the glucose iAUC. These results indicate that these sweeteners, at an equivalent sweetness, can be used in normal solid meals. Fructose showed a lower insulin response, which may be beneficial in the long term in individuals at risk of type 2 diabetes. This trial was registered at the Australian New Zealand Clinical Trials Registry as ACTRN12615000279527.

Long-term effects of a very-low-carbohydrate weight-loss diet and an isocaloric low-fat diet on bone health in obese adults

OBJECTIVE

Compromised bone health is a frequently cited concern of very-low-carbohydrate (LC) diets, although limited data are available from long-term, well-controlled, randomized studies. This study compared the effects of an energy-restricted LC diet and traditional, higher-carbohydrate, low-fat (LF) diet on bone health after 12 mo.

METHODS

One hundred eighteen abdominally obese adults were randomized to consume either an energy-restricted (∼6-7 MJ/d [∼1450-1650 kcal/d]), planned isocaloric LC, or LF diet for 12 mo. Body weight, total body bone mineral content and bone mineral density (BMD), and serum bone crosslaps were assessed pre- and postintervention.

RESULTS

Sixty-five participants completed the study (LC = 32, LF = 33; age: 51.3 ± 7.1 y; BMI: 33.4 ± 4.0 kg/m(2)). Weight loss was similar in both groups (LC: -14.5 ± 9.8 kg, LF: -11.7 ± 7.3 kg; P = 0.26). By 1 y, total body bone mineral content had not changed in either group (LC: 2.84 ± 0.47 to 2.88 ± 0.49 kg, LF: 3.00 ± 0.52 to 3.00 ± 0.51 kg; P = 0.07 time × diet effect). In both groups, total body BMD decreased (LC: 1.26 ± 0.10 to 1.22 ± 0.09 g/cm(2), LF: 1.26 ± 0.09 to 1.23 ± 0.08 g/m(2); P < 0.001 time) and bone serum crosslaps increased (LC: 319.3 ± 142.6 to 396.5 ± 172.0 ng/L, LF: 276.3 ± 100.6 to 365.9 ± 154.2 ng/L; P < 0.001 time) independent of diet composition (P ≥ 0.25 time × diet effect). Future studies would be strengthened by the assessment of regional BMD at clinically relevant sites (i.e., hip and spine) and multiple markers of bone turnover.

CONCLUSIONS

Weight loss following a hypocaloric LC diet compared with an LF diet does not differentially affect markers of bone health over 12 mo in overweight and obese adults.

Plasma Free Amino Acid Responses to Intraduodenal Whey Protein, and Relationships with Insulin, Glucagon-Like Peptide-1 and Energy Intake in Lean Healthy Men

This study determined the effects of increasing loads of intraduodenal (ID) dairy protein on plasma amino acid (AA) concentrations, and their relationships with serum insulin, plasma glucagon-like peptide-1 (GLP-1) and energy intake. Sixteen healthy men had concentrations of AAs, GLP-1 and insulin measured in response to 60-min ID infusions of hydrolysed whey protein administered, in double-blinded and randomised order, at 2.1 (P2.1), 6.3 (P6.3) or 12.5 (P12.5) kJ/min (encompassing the range of nutrient emptying from the stomach), or saline control (C). Energy intake was quantified immediately afterwards. Compared with C, the concentrations of 19/20 AAs, the exception being cysteine, were increased, and this was dependent on the protein load. The relationship between AA concentrations in the infusions and the area under the curve from 0 to 60 min (AUC0-60 min) of each AA profile was strong for essential AAs (R² range, 0.61-0.67), but more variable for non-essential (0.02-0.54) and conditional (0.006-0.64) AAs. The AUC0-60 min for each AA was correlated directly with the AUC0-60 min of insulin (R² range 0.3-0.6), GLP-1 (0.2-0.6) and energy intake (0.09-0.3) (p < 0.05, for all), with the strongest correlations being for branched-chain AAs, lysine, methionine and tyrosine. These findings indicate that ID whey protein infused at loads encompassing the normal range of gastric emptying increases plasma concentrations of 19/20 AAs in a load-dependent manner, and provide novel information on the close relationships between the essential AAs, leucine, valine, isoleucine, lysine, methionine, and the conditionally-essential AA, tyrosine, with energy intake, insulin and GLP-1.

Acute effect of red meat and dairy on glucose and insulin: a randomized crossover study

BACKGROUND

In contrast with some epidemiologic evidence, our previous research showed that a 4-wk diet that was high in low-fat dairy reduced insulin sensitivity compared with the effect of a diet that was high in red meat.

OBJECTIVE

We investigated whether a dairy meal would produce a greater insulin response than a carbohydrate-matched red meat meal would, which might account for the change in insulin sensitivity.

DESIGN

One meal contained lean red meat, bread, and orange juice, and the other meal contained skim milk, low-fat yogurt, cheese, and bread. Meals were isoenergetic, equal in macronutrient profile, and consumed 1 wk apart. Glucose, insulin, and triglycerides were measured before and 30, 60, 90, 120, 150, and 180 min after meal consumption. Differences between meals were tested with the use of a repeated-measures ANOVA and paired sample t tests.

RESULTS

Nineteen men and 24 women [mean ± SD age: 50.8 ± 16.0 y; body mass index (in kg/m(2)): 30.0 ± 3.5] completed the study. Twenty-two participants had normal glucose tolerance, and 21 participants had impaired fasting glucose or impaired glucose tolerance. The red meat meal resulted in a higher glucose response at 30 min after consumption (P < 0.001); however, the glucose total AUC was not different between meals (P = NS). The mean ± SEM incremental AUC (iAUC) for glucose was significantly higher after the dairy meal than after the red meat meal (2.23 ± 0.49 compared with 0.88 ± 0.57 mmol/L · 3 h, respectively; P = 0.004). The insulin total AUC and iAUC were not different between meals (iAUC: 159.65 ± 20.0 mU/L · 3 h for red meat compared with 167.49 ± 24.1 mU/L · 3 h for dairy; P = NS).

CONCLUSIONS

Lean red meat and low-fat dairy produced a similar glycemic response. The higher glucose response 30 min after consumption of the red meat meal was likely attributable to differences in the glycemic load between orange juice and milk and yogurt. An insulinotropic effect of dairy was not observed. This trial was registered at www.anzctr.org.au as ACTRN12615000164594.

Acute load-dependent effects of oral whey protein on gastric emptying, gut hormone release, glycemia, appetite, and energy intake in healthy men

BACKGROUND

In healthy individuals, intraduodenal whey protein load-dependently modulates gastrointestinal motor and hormonal functions and suppresses energy intake. The effect of oral whey, particularly the impact of load, has not been evaluated.

OBJECTIVE

The purpose of this study was to quantify gastric emptying of 30 and 70 g of oral whey protein loads and their relation to gastrointestinal hormone, glycemic, and appetitive responses.

DESIGN

On 3 separate occasions in a randomized, double-blind order, 18 lean men [mean ± SEM age: 24.8 ± 1.4 y; body mass index (in kg/m(2)): 21.6 ± 0.5] received iso-osmolar, equally palatable drinks (∼450 mL) containing 30 g pure whey protein isolate (L), 70 g pure whey protein isolate (H), or saline (control). Gastric emptying (with the use of 3-dimensional ultrasound), plasma cholecystokinin, glucagon-like peptide 1, glucose-dependent insulinotropic peptide, insulin, glucagon, total amino acids, and blood glucose were measured for 180 min after consumption of the drinks, and energy intake at a buffet-style lunch was quantified.

RESULTS

Gastric emptying of the L and H drinks was comparable when expressed in kilocalories per minute (L: 2.6 ± 0.2 kcal/min; H: 2.9 ± 0.3 kcal/min) and related between individuals (r = 0.54, P < 0.01). Gastrointestinal hormone, insulin, and glucagon responses to the L and H drinks were comparable until ∼45-60 min after ingestion, after which time the responses became more differentiated. Blood glucose was modestly reduced after the H drink between t = 45 and 150 min when compared with the L drink (all P < 0.05). Energy intake was suppressed by both L and H drinks compared with control (P < 0.05) (control: 1174 ± 91 kcal; L: 1027 ± 81 kcal; and H: 997 ± 71 kcal).

CONCLUSION

These findings indicate that, in healthy lean men, the rate of gastric emptying of whey protein is independent of load and determines the initial gastrointestinal hormone response. This study was registered at www.anzctr.org.au as 12611000706976.

Steroidal contraceptive use is associated with lower bone mineral density in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common condition affecting reproductive-aged women with features including hyperandrogenism and menstrual irregularity frequently treated with hormonal steroidal contraceptives. Women with PCOS appear to have lower bone mineral density (BMD). While steroidal contraceptives may positively affect bone health, their effect on BMD in PCOS is not known. The aim of this study was to assess BMD in women with PCOS according to recent contraceptive use. A cross-sectional analysis of 95 pre-menopausal overweight or obese sedentary women with PCOS [age 29.4 ± 6.4 years, body mass index (BMI) 36.1 ± 5.3 kg/m(2)] who either recently took steroidal contraceptives (ceased 3 months prior) or were not taking steroidal contraceptives was conducted. Clinical outcomes included BMD, anthropometry, insulin, glucose, reproductive hormones, dietary intake and vitamin use. BMD was significantly lower for women who used contraceptives compared to those who did not (mean difference 0.06 g/cm(2) 95 % confidence interval -0.11, -0.02, p = 0.005). In regression models, lower BMD was independently associated with contraceptive use (β = -0.05, 95 % CI -0.094, -0.002, p = 0.042), higher testosterone (β = -0.03, 95 % CI -0.05, -0.0008, p = 0.043) and lower BMI (β = 0.006, 95 % CI 0.002, 0.01, p = 0.007) (r (2) = 0.22, p = 0.001 for entire model). We report for the first time that overweight and obese women with PCOS with recent steroidal contraceptive use had lower BMD in comparison to non-users independent of factors known to contribute to BMD. Whether this observation is directly related to steroidal contraceptive use or other factors requires further investigation.

Comparative effects of intraduodenal whey protein hydrolysate on antropyloroduodenal motility, gut hormones, glycemia, appetite, and energy intake in lean and obese men

BACKGROUND

In lean individuals, intraduodenal protein and lipid modulate gastrointestinal motor and hormone functions and reduce energy intake in a load-dependent manner; protein also stimulates insulin, with modest effects on reducing blood glucose. The effect of intraduodenal lipid on gastrointestinal motor and hormone responses is diminished in obesity; whether the effects of protein are also attenuated remains unclear.

OBJECTIVES

The objectives of this study were to characterize the load-dependent effects of intraduodenal whey protein hydrolysate on antropyloroduodenal pressures, gut hormones, glycemia, appetite, and energy intake in obese subjects and to compare the responses to the higher protein load with those in lean subjects.

DESIGN

We measured antropyloroduodenal pressures, plasma cholecystokinin (CCK), glucagon-like peptide 1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), glucagon, insulin, blood glucose, appetite, and energy intake in 12 nondiabetic obese men on 3 separate occasions, in a double-blind, randomized order, during 60-min intraduodenal infusions of hydrolyzed whey protein at either 0 (saline control), 1.5, or 3 kcal/min. Twelve age-matched lean individuals received a 3-kcal/min infusion only. Immediately after the infusions, energy intake from a buffet lunch was quantified.

RESULTS

In obese subjects, protein suppressed antral and duodenal pressures; stimulated plasma CCK, GLP-1, GIP, insulin, and glucagon (all r > 0.57, P < 0.01); and tended to reduce energy intake (r = -10.38, P = 0.057) in a dose-dependent manner. In response to the 3-kcal/min protein load, antropyloroduodenal pressures, CCK, GLP-1, and glucagon did not differ between lean and obese subjects. Insulin release was greater, and GIP release less, in obese than in lean subjects (both P < 0.05), whereas the reduction in glucose was comparable. Energy intake tended to be higher in obese subjects (P = 0.08).

CONCLUSIONS

The gastrointestinal effects of hydrolyzed whey protein remain relatively intact in obesity; however, the observed changes in insulin and GIP suggest early disturbances in the insulin-incretin axis. This study was registered at www.anzctr.org.au as ACTRN 12612000203853.

Recurrent nocturnal hypoglycaemia as a cause of morning fatigue in treated Addison's disease--favourable response to dietary management: a case report

BACKGROUND

Addison's disease, or primary adrenal insufficiency, is often associated with reduced well-being and fatigue despite use of currently recommended adrenal hormone replacement. Hypoglycaemia is a known manifestation of glucocorticoid deficiency, but is generally considered rare in adults and not relevant to troubling ongoing symptoms in patients with Addison's disease.

CASE PRESENTATION

A 43 year old woman with a three year history of Addison's disease complained of severe morning fatigue and headaches, despite standard glucocorticoid replacement therapy in the form of thrice daily hydrocortisone and mineralocorticoid replacement with fludrocortisone. Alternative glucocorticoid replacement regimens and the addition of dehydroepiandrosterone replacement therapy had no effect. Nocturnal hypoglycaemia was suspected and a 4-day continuous glucose monitor system (CGMS) revealed hypoglycaemia (interstitial glucose < 2.2 mmol/L) between 0200-0400 h on 3 of 4 days. The patient was counselled to take an evening snack designed to ensure slow absorption of ingested carbohydrates. Nocturnal hypoglycaemia was then absent on follow up CGMS assessment. The patient noted a marked symptomatic improvement in morning symptoms, but with persistent fatigue during the day.

CONCLUSION

Currently, the best strategy for control of non-specific symptoms in treated Addison's disease is unknown, but it may be that investigation for hypoglycaemia and treatment, where necessary, could assist some sufferers to achieve improved wellbeing. A systematic study of this phenomenon in Addison's disease is required.

Effect of improving dietary quality on carotid intima media thickness in subjects with type 1 and type 2 diabetes: a 12-mo randomized controlled trial

BACKGROUND

People with diabetes are at a heightened risk of cardiovascular disease compared with the general population. To our knowledge, randomized controlled trials investigating the effect of improving dietary quality on carotid intima media thickness, a marker of subclinical atherosclerosis and predictor of cardiovascular disease, have not been conducted in populations with diabetes.

OBJECTIVE

We aimed to determine whether increasing fruit (+1 serving; 150 g/d), vegetable (+2 servings; 150 g/d), and dairy (+1 serving; 200-250 g/d) intakes slows 12-mo common carotid artery intima media thickness (CCA IMT) progression, compared with a control group continuing to consume their usual diet, in people with type 1 and type 2 diabetes.

DESIGN

A 12-mo randomized controlled trial was conducted. The primary outcome was mean CCA IMT, measured at baseline and 12 mo, with B-mode ultrasound. Participants in the intervention group received counseling from a dietitian at baseline and 1, 3, 6, and 9 mo, and compliance was measured with a food-frequency questionnaire at baseline, 3 mo, and 12 mo. The control group continued consuming their usual diet.

RESULTS

In total, 118 participants completed the study. Vegetable (46 g/d; 95% CI: 14, 77 g/d; P < 0.001) and fruit (179 g/d; 95% CI: 119, 239 g/d; P < 0.001) intakes were increased at 3 mo in the intervention group compared with the control group. This increase was not maintained at 12 mo, but intake increased overall in the cohort (fruit, 48 g/d; vegetables, 14 g/d). An increase in dairy consumption was not achieved, but yogurt intake was higher in the intervention group at 3 mo (38 g; 95% CI: 12, 65 g; P < 0.001); this was not maintained at 12 mo. At 12 mo, CCA IMT regressed (mean ± SD: -0.01 ± 0.04 mm; P < 0.001), with a greater effect in the treatment group (mean ± SD: -0.02 ± 0.04 mm compared with -0.004 ± 0.04 mm; P = 0.009).

CONCLUSION

Improving dietary quality in people with well-controlled type 1 and type 2 diabetes may slow CCA IMT progression. This trial was registered at https://www.anzctr.org.au as ACTRN12613000251729.

Salt Restriction in Diabetes

There are no long-term interventions examining the effects of salt reduction in people with diabetes, and these are urgently required. Sodium reduction is controversial as it appears that an intake below 2.5 g and above 6 g/day of salt is associated with increased cardiovascular disease risk. However, pre-existing illness leading to a lower salt intake may confound the findings. Only a few studies have prospectively collected data on the sodium intake and excretion of people with diabetes and examined hard end points. In addition, future studies need to collect more data on food intake as well as coexistent illnesses to address potential confounding. The World Health Organization recommends a reduction to less than 5 g/day salt in adults. Given that the available evidence suggests that the salt intake of people with type 2 diabetes is generally well above 6 g/day it seems reasonable to ensure individuals with diabetes have an intake below 6 g/day. However, such recommendations need to be individualized.