Nutrition recommendations and interventions for diabetes--2006: a position statement of the American Diabetes Association

Difference in association of carbohydrate intake with all-cause mortality between middle-aged and older Korean adults with and without diabetes mellitus: A prospective study

BACKGROUND & AIMS

The relationship between diet and health, particularly the role of carbohydrates, has been extensively studied. However, carbohydrate intake based on individual health conditions remains unclear. Here, we aimed to investigate whether the association between carbohydrate intake and all-cause mortality varied between individuals with and without diabetes mellitus (DM).

METHODS

This prospective cohort study used data from the Korean Genome and Epidemiology Study (KoGES). Overall, 143,050 participants were included, with 10.1% having DM. Dietary intake was assessed using a semiquantitative food frequency questionnaire. Cox proportional hazards regression models were used to assess the association between carbohydrate intake and mortality after adjusting for confounders.

RESULTS

The study showed that 5436 deaths occurred during the median follow-up period of 10.1 years. A significant interaction between carbohydrate intake and DM was observed in the study population (interaction p = 0.061). Higher carbohydrate intake proportion was associated with an increased risk of all-cause mortality among individuals with DM (adjusted hazard ratio [HR], p-value = 1.10 [1.01-1.20], p = 0.032). Conversely, no association was observed between the proportion of carbohydrate intake and all-cause mortality in participants without DM. Additionally, both total sugar and added sugar intakes were associated with an increased risk of all-cause mortality in participants with DM (adjusted HR, p-value = 1.02 [1.01-1.04], p < 0.001 and 1.18 [1.13-1.24], p < 0.001).

CONCLUSIONS

High carbohydrate (%) and added sugar intake were associated with an increased mortality risk in individuals with DM. Reducing carbohydrate intake and opting for healthy carbohydrates to mitigate mortality risk may be beneficial for individuals with DM, particularly when compared with the general population.

Secular trends in dietary energy, carbohydrate, fat, and protein intake among Korean adults, 2010-2020 KHANES

OBJECTIVES

The composition and balance of macronutrient intake play key roles in promoting a longer lifespan. In this study, we aimed to investigate the secular trends in carbohydrate, fat, and protein intakes in South Koreans from 2010 to 2020.

METHODS

We examined the dietary nutritional intake of South Koreans using data from the Korean National Health and Nutrition Examination Survey. A total of 60,190 adults aged ≥19 y who completed the 24-h dietary recall interviews in a single day on all survey periods were included in this study. The outcomes included changes in macronutrient intake according to subgroups, such as age; sex; and the presence of diabetes, dyslipidemia, stroke, or heart disease, as well as energy intake from macronutrients.

RESULTS

The study population showed a significant decrease in total energy intake from 2010 to 2020, with a corresponding decrease in the percentage of energy intake from carbohydrates (p-values for trend < 0.001). Conversely, the proportions of energy intake from proteins and fats increased during the same period (p < 0.001). Subgroup analyses revealed variations in macronutrient intake trends according to age, sex, obesity status, and underlying diseases. The analysis of trends in energy intake from various fat subtypes, total sugar, and fiber revealed a decrease in the energy intake percentage of total sugar from 2016 to 2020 and an increase in the energy intake percentage of all fat subtypes and fiber from 2013 to 2020.

CONCLUSIONS

In the past 10 y, the dietary patterns in Korea have shifted toward the consumption of high-fat and high-protein diets with reduced carbohydrate intake.

Effectiveness of breath acetone monitoring in reducing body fat and improving body composition: a randomized controlled study

When attempts to lose body fat mass frequently fail, breath acetone (BA) monitoring may assist fat mass loss during a low-carbohydrate diet as it can provide real-time body fat oxidation levels. This randomized controlled study aimed to evaluate the effectiveness of monitoring BA levels and providing feedback on fat oxidation during a three-week low-carbohydrate diet intervention. Forty-seven participants (mean age = 27.8 ± 4.4 years, 53.3% females, body mass index = 24.1 ± 3.4 kg m-2) were randomly assigned to three groups (1:1:1 ratio): daily BA assessment with a low-carbohydrate diet, body weight assessment (body scale (BS)) with a low-carbohydrate diet, and low-carbohydrate diet only. Primary outcome was the change in fat mass and secondary outcomes were the changes in body weight and body composition. Forty-five participants completed the study (compliance rate: 95.7%). Fat mass was significantly reduced in all three groups (allP< 0.05); however, the greatest reduction in fat mass was observed in the BA group compared to the BS (differences in changes in fat mass, -1.1 kg; 95% confidence interval: -2.3, -0.2;P= 0.040) and control (differences in changes in fat mass, -1.3 kg; 95% confidence interval: -2.1, -0.4;P= 0.013) groups. The BA group showed significantly greater reductions in body weight and visceral fat mass than the BS and control groups (allP< 0.05). In addition, the percent body fat and skeletal muscle mass were significantly reduced in both BA and BS groups (allP< 0.05). However, no significant differences were found in changes in body fat percentage and skeletal muscle mass between the study groups. Monitoring BA levels, which could have motivated participants to adhere more closely to the low-carbohydrate diet, to assess body fat oxidation rates may be an effective intervention for reducing body fat mass (compared to body weight assessment or control conditions). This approach could be beneficial for individuals seeking to manage body fat and prevent obesity.

Omega-3 long-chain polyunsaturated fatty acids: Metabolism and health implications

Recently, omega-3 long-chain polyunsaturated fatty acids (n-3 LC-PUFAs) have gained substantial interest due to their specific structure and biological functions. Humans cannot naturally produce these fatty acids (FAs), making it crucial to obtain them from our diet. This comprehensive review details n-3 LC-PUFAs and their role in promoting and maintaining optimal health. The article thoroughly analyses several sources of n-3 LC-PUFAs and their respective bioavailability, covering marine, microbial and plant-based sources. Furthermore, we provide an in-depth analysis of the biological impacts of n-3 LC-PUFAs on health conditions, with particular emphasis on cardiovascular disease (CVD), gastrointestinal (GI) cancer, diabetes, depression, arthritis, and cognition. In addition, we highlight the significance of fortification and supplementation of n-3 LC-PUFAs in both functional foods and dietary supplements. Additionally, we conducted a detailed analysis of the several kinds of n-3 LC-PUFAs supplements currently available in the market, including an assessment of their recommended intake, safety, and effectiveness. The dietary guidelines associated with n-3 LC-PUFAs are also highlighted, focusing on the significance of maintaining a well-balanced intake of n-3 PUFAs to enhance health benefits. Lastly, we highlight future directions for further research in this area and their potential implications for public health.

Association between self-reported alcohol consumption and diastolic dysfunction: a cross-sectional study

BACKGROUND AND OBJECTIVES

While alcohol consumption is associated with common risk factors for diastolic dysfunction the independent impact of low levels of alcohol consumption on this condition in a community setting is still unclear.Thus, the aim of this study was to explore this association in a representative population sample employing optimal echocardiographic techniques.

DESIGN

Cross-sectional observational study in community-based population.

SETTINGS, PARTICIPANTS AND METHODS

Participants between 30 and 75 years of age were consecutively invited to a physical examination, interview, conventional echocardiography, including Tissue Velocity Imaging. Diastolic dysfunction was defined according to the European Society of Cardiology criteria, excluding subjects with ejection fraction <45%, self-reported history of heart failure or atrial fibrillation on ECG. Self-reported alcohol intake using a validated questionnaire was categorised as no intake, low and medium-high intake.

RESULTS

In total, 500 men and 538 women (mean age 55.4±13) were successfully examined. Diastolic dysfunction was identified in 16% (79/500) of the men and 13% (58/538) of the women. The multivariable adjusted model revealed a strong and independent association between alcohol intake and diastolic dysfunction. In fact, using no alcohol intake as reference, diastolic dysfunction was independently associated with alcohol consumption in a dose-dependent fashion; low consumption, OR 2.3 (95% CI 1.3 to 4.0) and medium-high consumption OR 3.1 (95% CI 1.6 to 6.2), respectively.

CONCLUSION

There was a significant association between alcohol consumption and diastolic dysfunction starting already at low levels that was supported by a dose-dependent pattern. These results need confirmatory studies and are important in public health policies.

The effect of cinnamon consumption on lipid profile, oxidative stress, and inflammation biomarkers in adults: An umbrella meta-analysis of randomized controlled trials

AIMS

Cinnamon is a polyphenol-rich spice that has beneficial effects on markers of cardio metabolic health such as lipid profile, oxidative stress, and inflammation. Despite the accumulating evidence from meta-analyses on the effects of cinnamon on these markers, their findings are controversial. Thus, this umbrella meta-analysis was performed to evaluate the present evidence and provide a conclusive clarification.

DATA SYNTHESIS

We searched the following international databases from inception to January 2022: PubMed, Scopus, Web of Science and Embase, and Google Scholar. Our findings of eleven meta-analyses showed that cinnamon consumption can significantly improve total cholesterol (TC) (WMD = -1.01 mg/dL; 95% CI: -2.02, -0.00, p = 0.049), low-density lipoprotein-cholesterol (LDL-C) (WMD = -0.82 mg/dL; 95% CI: -1.57, -0.07, p = 0.032), and high-density lipoprotein-cholesterol (HDL-C) (WMD = 0.47 mg/dL; 95% CI: 0.17, 0.77, p = 0.002) levels but not triglyceride (TG) levels (WMD = -0.13 mg/dL; 95% CI: -0.58, 0.32, p = 0.570). Our results did not show any significant effect of cinnamon on malondialdehyde (MDA) levels (WMD = -0.47; 95% CI: -0.99, 0.05, p = 0.078) and C-reactive protein (CRP) levels (WMD = -1.33; 95% CI: -2.66, 0.00, p = 0.051) but there was enhanced total antioxidant capacity (TAC) in patients with type 2 diabetes (T2DM) and polycystic ovary syndrome (PCOS) (WMD = 0.34; 95% CI: 0.04, 0.64, p = 0.026) and increased levels of interleukin-6 (WMD = -1.48; 95% CI: -2.96, -0.01, p = 0.049).

CONCLUSIONS

Our results support the usefulness of cinnamon intake in modulating an imbalanced lipid profile in some metabolic disorders, particularly PCOS, as well as in improving TAC and interleukin-6. The review protocol was registered on PROSPERO as CRD42022358827.

Structural and mechanical properties of gelatin composite films

The deformation properties, elastic modulus and strength of gelatin films with chitosan, citric acid and L-glutamic acid were studied. According to the results of the study, it was found that the addition of chitosan, citric and L-glutamic acid increases the strength and elasticity modulus of gelatin films. Assessment of the pH effect on the gelatin - chitosan, gelatin - citric acid and gelatin - L-glutamic acid systems provide a representation of their changes in these media. It is assumed that gelatin with L-glutamic acid forms a strong structure at low pH and withstands the conditions of the acidic environment of the stomach, while in an alkaline environment the structural and mechanical characteristics of this system decrease, creating favorable conditions for the release of encapsulated insulin in the intestinal phase. The changes of the physicochemical, structural and mechanical properties of the films under simulated gastrointestinal conditions (pH = 1.0; 4.01; 6.86; 9.18) were determined by IR spectroscopy. The observability of the bands of С-Н, С-ОН, С=O, C-N, N-H, СН(NH2), CH2OH groups in the infrared spectra of films in various pH media is associated with an increase of intermolecular hydrogen bonds and the formation of associative structures.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Zinc(II) - Syringic acid complexation synergistically exerts antioxidant action and modulates glucose uptake and utilization in L-6 myotubes and rat muscle tissue

Zinc and syringic acid have metabolic and antioxidant medicinal potentials. A novel zinc(II)-syringic acid complex with improved anti-hyperglycaemic and antioxidant potential was developed. Zinc(II) was complexed with syringic acid in a 1:2 molar ratio and characterized using FT-IR, ¹H NMR and LC-MS. Different experimental models were used to compare the anti-hyperglycaemic and antioxidant properties between the complex and precursors. A Zn(II)-bisyringate.2H₂O complex was formed. The in vitro radical scavenging and Fe³⁺ reducing antioxidant, antiglycation, and α-glucosidase inhibitory activities of the complex were 1.8-5.2 folds stronger than those of the syringic acid precursor and comparable to those of the positive controls. The complex possessed an increased ability to inhibit lipid peroxidation (by 1.6-1.7 folds) and glutathione depletion (2.8-3 folds) relative to syringic acid in Chang liver cells and liver tissues isolated from rats. The complex exhibited a higher glucose uptake effect (EC₅₀ = 20.4 and 386 µM) than its precursors (EC₅₀ = 71.1 and 6460 µM) in L6-myotubes and psoas muscle tissues isolated from rats, respectively, which may be linked to the observed increased cellular zinc uptake potentiated by complexation. Tissue glucose uptake activity was accompanied by increased hexokinase activity, suggesting increased glucose utilization. Moreover, treatment increased tissue phospho-Akt/pan-Akt ratio. The complex had strong molecular docking scores than syringic acid with target proteins linked to diabetes. The presence of two syringic acid moieties and Zn(II) in the complex influenced its potency. The complex was not hepatotoxic and myotoxic in vitro. Zinc-syringic acid complexation may be a novel promising therapeutic approach for diabetes and oxidative complications.

Covid 19 May Limit the Use of Anti-hyperglycemic Agents. Does it Call for the Development of New Anti-hyperglycemic Agents?

Diabetes mellitus has been identified as a major risk factor for developing severe COVID 19 complications. In this review article, the efforts were directed to provide insights and the possible extent to which some diabetic pharmacological interventions may exacerbate COVID 19 or may not be idyllic options for COVID 19 patients. Articles reviewed were identified using the Google scholar database, and search was done using the English language. Anti-hyperglycemic is associated with undesirable effects including episodes of hypoglycemia, diarrhea, lactic acidosis, and increased risks of cardiovascular and hepatic hazards. These undesirable effects associated with the anti-hyperglycemic agents possess a threat of developing severe COVID19 complications Therefore, this calls for more studies to understand the extent of the risks these agents possess in diabetic COVID 19 patients. Almost all the anti-hyperglycemic agents have the potential to worsen COVID 19, despite their class. COVID 19 may limit the options in terms of available anti-hyperglycemic agents which may not heighten the risk of developing severe COVID 19 complications. The research towards the discovery and development of new compounds and also new therapeutic targets for hyperglycemia should be encouraged and welcome.

Association between Health Literacy, Self-care Behavior, and Blood Sugar Level among Older Patients with Type 2 Diabetes in Rural Thai Communities

Background

Diabetes mellitus is a major problem worldwide. Moreover, older patients with significantly limited health literacy (HL) tend to have worse self-care behaviors and health outcomes. This study aimed to describe the associations of HL, self-care behavior, and blood sugar levels among older patients with type 2 diabetes in rural Thai communities.

Methods

This cross-sectional study included 415 patients with diabetes who were purposively selected from rural Thai communities. Data were collected using questionnaires and analyzed using descriptive statistics, Pearson correlation, Spearman rho, and stepwise multiple linear regression.

Results

The results revealed that most participants were women (66.50%). The respondents had moderate overall HL (2.68±0.64). On average, the respondents had fair overall self-care behavior (4.0±0.33). We discovered that HL was significantly positively correlated with self-care behavior (r=0.90) but not with blood sugar level. In addition, self-care behavior was significantly negatively correlated with blood sugar level (r=-0.50). Self-care behaviors and blood sugar levels were significant predictors of HL in patients with type 2 diabetes (total variance, 28.4%).

Conclusion

The results suggested increased HL in patients with diabetes would improve self-care behavior and, consequently, decrease their blood sugar level. Our findings indicate the need to involve nurses and multidisciplinary healthcare teams when developing health promotion programs to encourage blood sugar control.

Carbohydrate restriction for diabetes: rediscovering centuries-old wisdom

Carbohydrate restriction, used since the 1700s to prolong survival in people with diabetes, fell out of favor after the discovery of insulin. Despite costly pharmacological and technological developments in the last few decades, current therapies do not achieve optimal outcomes, and most people with diabetes remain at high risk for micro- and macrovascular complications. Recently, low-carbohydrate diets have regained popularity, with preliminary evidence of benefit for body weight, postprandial hyperglycemia, hyperinsulinemia, and other cardiometabolic risk factors in type 2 diabetes and, with more limited data, in type 1 diabetes. High-quality, long-term trials are needed to assess safety concerns and determine whether this old dietary approach might help people with diabetes attain clinical targets more effectively, and at a lower cost, than conventional treatment.

One Hundred Years of Insulin: Value Beyond Price in Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a chronic, progressive disease that frequently necessitates treatment with basal insulin to maintain adequate glycaemic control. In considering the value of different basal insulin therapies, although acquisition costs are of increasing importance to budget-constrained healthcare systems, value beyond simple price considerations should be taken into account. Whilst human basal insulins are of lower acquisition cost compared to long-acting insulin analogues, this difference in price has the potential to be offset in terms of total healthcare system value through the ultra-long duration of action and low variability in glucose-lowering activity which have been translated into real clinical benefits, in particular a reduced risk of hypoglycaemic events. The maintenance of glycaemic targets and avoidance of hypoglycaemia that have been associated with insulin analogues represent a significant value consideration, beyond price, for the use of basal insulin analogues to manage type 2 diabetes mellitus from the perspective of all stakeholders within the healthcare system, including payers, healthcare professionals, patients and society.

Adherence to Ketogenic and Mediterranean Study Diets in a Crossover Trial: The Keto-Med Randomized Trial

Adherence is a critical factor to consider when interpreting study results from randomized clinical trials (RCTs) comparing one diet to another, but it is frequently not reported by researchers. The purpose of this secondary analysis of the Keto–Med randomized trial was to provide a detailed examination and comparison of the adherence to the two study diets (Well Formulated Ketogenic Diet (WFKD) and Mediterranean Plus (Med-Plus)) under the two conditions: all food being provided (delivered) and all food being obtained by individual participants (self-provided). Diet was assessed at six time points including baseline (×1), week 4 of each phase when participants were receiving food deliveries (×2), week 12 of each phase when participants were preparing and providing food on their own (×2), and 12 weeks after participants completed both diet phases and were free to choose their own diet pattern (×1). The adherence scores for WFKD and Med-Plus were developed specifically for this study. Average adherence to the two diet patterns was very similar during both on-study time points of the intervention. Throughout the study, a wide range of adherence was observed among participants—for both diet types and during both the delivery phase and self-provided phase. Insight from this assessment of adherence may aid other researchers when answering the important question of how to improve behavioral adherence during dietary trials. This study is registered at clinicaltrials.gov NCT03810378.

Changes in Body Weight, Dysglycemia, and Dyslipidemia After Moderately Low-Carbohydrate Diet Education (LOCABO Challenge Program) Among Workers in Japan

PURPOSE

It is theorized that the prevalence of obesity has not decreased owing to poor adherence to implemented programs addressing metabolic syndrome, obesity, and diabetes in Japan. Therefore, we intended to evaluate the influence of a moderately low-carbohydrate diet on improving markers of metabolic syndrome among workers in Japan.

PATIENTS AND METHODS

Participants with metabolic syndrome or obesity were recruited based on the eligibility criteria for the Specific Health Guidance program and educated on a moderately low-carbohydrate diet between spring 2016 and fall 2018. The participants were then made to report their food intake and body weight once a week for the next 12 weeks and were counselled on maintaining a moderately low-carbohydrate diet. HbA1c levels, lipid profile, body weight, and sleep quality were evaluated. The normality of the data was evaluated using the Skewness/Kurtosis test. Each variable was compared before and after the intervention using the Wilcoxon signed-rank test. Further, a subgroup analysis of the data from the participants whose variables were abnormal at baseline was performed.

RESULTS

Among the 101 enrolled participants, a decrease in the median weight (from 82.5 to 79.7 kg, p<0.001, n=46), body mass index (from 27.3 to 26.9 kg/m², p<0.001, n=46), and apnea-hypopnea index (from 24.1 to 17.1, p<0.01, n=39) was observed. Subgroup analysis of participants with abnormal baseline values revealed changes in HbA1c (from 6.7% to 5.8%, p<0.001, n=34), total cholesterol (from 220 to 209 mg/dL, p<0.01, n=54), low-density lipoprotein cholesterol (from 133 to 120 mg/dL, p<0.001, n=31), high-density lipoprotein cholesterol (from 35 to 40 mg/dL, p<0.01, n=31), triglycerides (from 242 to 190 mg/dL, p<0.01, n=57), and deep sleep percentage (from 10.4% to 18.2%, p<0.05, n=7).

CONCLUSION

A moderately low-carbohydrate diet may be considered a potential intervention for improving the markers of metabolic syndrome, obesity, and diabetes.

Nutritional Therapy for Athletes with Diabetes

Diabetes is a worldwide disease also affecting the sports field. The two main forms of diabetes, namely type 1 diabetes (T1D) and type 2 diabetes (T2D), differ in both their pathological and pharmacological characteristics and thus require a distinct nutritional treatment. Diet plays an important role in the management of athletes with diabetes and is crucial to achieving their best performance. This review aims to investigate the objectives of nutritional therapy before, during and after training, in order to improve the best composition of macronutrients during meals. In this review, we provide a brief overview of recent studies about nutritional approaches to people with diabetes for performance optimization and for the control of diabetes-related complications. Thereafter, we discuss the differences between macronutrients and dietary intake before, during and after training. It can be concluded that each sport has particular characteristics in terms of endurance and power, hence demanding a specific energy expenditure and consequent nutritional adjustments. Therefore, the management of athletes with diabetes must be personalized and supported by medical professionals, including a diabetologist, physiologist and a nutritionist.

Nutrition habits of children and adolescents with type 1 diabetes changed in a 10 years span

BACKGROUND

Diet plays a key role in the treatment of type 1 diabetes (T1D). Dietary habits changed rapidly in the last decades and few data are available on recent dietary changes in children and adolescents with T1D.

OBJECTIVE

To test the hypothesis that diet composition changed in a 10-year period in children and adolescents with T1D.

METHODS

Two hundred and twenty-nine T1D subjects (M/F:121/108) aged 6 to 16 years were recruited: 114 (group A) enrolled in 2009, not using CGM and/or CSII, and 115 (group B) enrolled in 2019. Anthropometric biochemical (HbA1c, lipid profile), diet, and insulin therapy parameters were compared between the two groups. Multivariate logistic regression analysis was performed with HbA1c as dependent variable (HbA1c > 58 mmol/mol = 1) and nutritional variables and technology use as independent ones.

RESULTS

Energy intake of group A was not statistically different from that of group B. Group B had a significantly (P < 0.001) higher protein and lipids intake and lower total carbohydrate and fiber intake than group A. HbA1c was significantly (P < 0.01) lower in group B than in group A. Logistic regression analysis showed that MUFA (OR 0.83, 95%CI:0.693-0.998), fiber intake (OR 0.82, 95%CI:0.699-0.0969), and technology use (OR 0.15, 95%CI:0.031-0.685), adjusted for age, gender, BMI, energy intake and diabetes duration, were associated with a HbA1c higher than 58 mmol/mol) (R² = 0.27, P < 0.05).

CONCLUSIONS

In a 10-year period, diet composition of children and adolescents with T1D changed and glucometabolic control improved. Fiber and MUFA intake showed a positive effect on HbA1c, independent from technology use, supporting the importance of educating children with T1D and families to maintain healthy eating habits.

What Next After Metformin? Thinking Beyond Glycaemia: Are SGLT2 Inhibitors the Answer?

The prevalence of type 2 diabetes continues to increase, along with a proliferation of glucose-lowering treatment options. There is universal agreement in the clinical community for the use of metformin as the first-line glucose-lowering therapy for the majority of patients. However, controversy exists regarding the choice of second-line therapy once metformin is no longer effective. The most recent treatment consensus focuses on the presence of cardiovascular disease, heart failure or kidney disease as a determinant of therapy choice. The majority of patients in routine practice, however, do not fall into such categories. Heart failure and kidney disease represent significant clinical and cost considerations in patients with type 2 diabetes and have a close pathophysiological association. Recent data has illustrated that sodium-glucose transporter 2 (SGLT2) inhibitor therapy can reduce the burden of heart failure and the progression of renal disease across a wide range of patients including those with and without established disease, supported by an increased understanding of the mechanistic effects of these agents. Furthermore, there is growing evidence to illustrate the overall safety profile of this class of agents and support the benefit-risk profile of SGLT2 inhibitors as a preferred option following metformin monotherapy failure, with respect to both kidney disease progression and heart failure outcomes.

The impact of body size changes on recurrence risk depends on age and estrogen receptor status in primary breast cancer

PURPOSE

To investigate the prognostic impact of body size changes during the first postoperative year in breast cancer.

METHODS

A cohort of 1,317 primary breast cancer patients included in Sweden (2002-2014) underwent body size measurements at the preoperative and 1-year visits (n = 1,178). Landmark survival analyses were used to investigate how postoperative weight gain or loss (> 5%) or change in waist-hip ratio (WHR) categories (≤ 0.85 or > 0.85) impact prognosis.

RESULTS

Median age at inclusion was 61 years and body mass index 25.1 kg/m². After a median follow-up of 5.0 years from inclusion, 165 recurrences and 77 deaths occurred. Weight gain (17.0%) conferred over twofold recurrence risk only in patients < 50 years (P_interaction = 0.033). Weight loss (8.6%) was only associated with a poor prognosis in patients ≥ 70 years, but not after restriction analysis. Weight change did not impact prognosis in patients 50 to < 70 years. Changes between WHR categories were associated with differential recurrence risk depending on estrogen receptor (ER) status (P_interaction = 0.007), with higher recurrence risk in patients with ER+ tumors and lower recurrence risk with ER- tumors.

CONCLUSION

Both changes in terms of weight and WHR category yielded independent prognostic information. Further research is imperative before recommending weight loss for all overweight breast cancer patients.

Non-pharmacological Treatment Options in the Management of Diabetes Mellitus

The global prevalence of diabetes, especially type 2 diabetes mellitus, has reached epidemic proportions in the last few decades of the 20th century because of the obesity pandemic resulting from adverse lifestyles. Diabetes as a consequence of obesity (diabesity), continues to increase exponentially in the 21st century. Although there are a multitude of drugs for the effective management of diabesity with modest benefits, most patients will require insulin for control of diabetes at some stage that would worsen obesity, and thereby diabesity. Therefore, effective non-pharmacological therapy needs to be expedited in all patients with diabesity. These measures include medical nutrition interventions, change of lifestyles and bariatric surgery. Non-pharmacological interventions are also useful for the effective management of even type 1 diabetes mellitus when used along with insulin therapy especially in those with obesity. This review summarises the current evidence base for the non-pharmacological interventions in the management of diabetes.

A spatial analysis of race, local health-promoting resources and preventable hospitalizations

INTRODUCTION

Preventable hospitalizations (PHs) for chronic conditions could have been avoided if treated with primary healthcare. PH rates are higher among African Americans, and in areas with less healthcare. Little is known about the effects of non-healthcare local health-promoting resources (LHPRs). The objective of this study is to determine associations between LHPRs and chronic PH rates in Maryland, and to assess spatial clustering of areas with high PH rates.

METHODS

Hospitalizations in 2010 were obtained from the Maryland Health Services Cost Review Commission by zip code of residence. Negative binomial regressions were used to determine associations between PH rates and LHPRs by race. Clusters of zip codes with high PH rates were assessed using the spatial Scan Statistic.

RESULTS

PH rates were associated with family practitioners (IRR=0.98, 95% CI=0.97-0.99), physicians' assistants (IRR=0.98, 95% CI=0.96-0.99), internists (IRR=1.02, 95% CI=1.01-1.03), teaching hospitals (IRR=1.21, 95% CI=1.04-1.40), and local health departments (IRR=1.19, 95% CI=1.03-1.37). No LHPRs were associated with PHs among whites, but African American PH rates were associated with family practitioners (IRR=0.97, 95% CI=0.94-0.99), nurse practitioners (IRR=1.03, 95% CI=1.01-1.06), teaching hospitals (IRR=1.37, 95% CI=1.08-1.75) and gyms/recreational centers (IRR=0.85, 95% CI=0.73-0.99). Clusters of areas with high PH rates varied by race. African American PH clusters had fewer family practitioners and more federally qualified health centers and teaching hospitals.

CONCLUSIONS

Public health practitioners should look to LHPRs beyond physician supply or public clinics to address PHs, particularly among African Americans. Specific LHPRs could be used to target African American PH rates and clusters.

Glycaemic response after intake of a high energy, high protein, diabetes-specific formula in older malnourished or at risk of malnutrition type 2 diabetes patients

BACKGROUND & AIMS

Several studies with diabetes-specific formulas (DSFs) for hyperglycaemic patients in need of nutritional support have been conducted in non-malnourished patients, mainly comparing products with varying macronutrient compositions. Here, the effect of a high energy, high protein DSF on postprandial responses was compared to a product with a similar macronutrient composition in malnourished or at risk of malnutrition patients with type 2 diabetes.

METHODS

In this randomised, double-blind cross-over study, 20 patients were included. After overnight fasting, patients consumed 200 mL of a DSF or standard supplement (control) (19.6 g protein, 31.2 g carbohydrates and 10.6 g fat), while continuing their anti-diabetic medication. The formulas differed in type of carbohydrates and presence of fibre. The postprandial glucose, insulin and glucagon responses were monitored over 4 h. Data were analysed with a Linear Mixed Model, and results of the modified ITT population (n = 19) are shown.

RESULTS

Postprandial glucose response as incremental area under the curve (iAUC), was lower after consumption of DSF compared with control (489.7 ± 268.5 (mean ± SD) vs 581.3 ± 273.9 mmol/L min, respectively; p = 0.008). Also, the incremental maximum concentration of glucose (iCmax) was lower for DSF vs control (3.5 ± 1.4 vs 4.0 ± 1.4 mmol/L; p = 0.007). Postprandial insulin and glucagon levels, expressed as iAUC or iCmax, were not significantly different between groups.

CONCLUSIONS

Consumption of a high energy, high protein DSF by older malnourished or at risk of malnutrition type 2 diabetes patients resulted in a significantly lower glucose response compared to control. These data suggest that the use of a DSF is preferred for patients with diabetes in need of nutritional support.

Influence of Socioeconomic Status on Knowledge of Obesity and Diabetes among Adolescents in Chennai, South India

The Obesity Reduction and Awareness of Non-communicable disease through Group Education (ORANGE) Phase II program, is a school-based intervention aimed at healthy lifestyle practices for sixth and seventh grade adolescents (n = 2345) attending private (n = 1811) and government (n = 534) schools in Chennai. The objectives of this paper are (a) to describe the intervention activities and their outcomes qualitatively and (b) to report changes in body mass index (BMI) of the intervention group participants. This intervention strategy used a teacher-peer-training model in each school for long-term sustainability of the lessons learned from this program. During each intervention session, teachers led a classroom discussion on the health topic of interest, and peers facilitated small-group learning activities. Anthropometric measurements of participants were assessed pre- and post-intervention. We found government school students perceived hygienic actions (e.g., drinking clean water, taking baths daily) as healthy habits for preventing diabetes, whereas private school students associated an expensive lifestyle (e.g., eating at restaurants, riding a car) with diabetes prevention. Overall, the mean post-intervention BMI (18.3 kg/m²) was in the normal range compared to the pre-intervention BMI (17.7 kg/m²) (p < 0.0001). These results suggest that future interventions should be tailored for adolescents from different socio-economic groups while acknowledging their varied perceptions.

Themed Review: Lifestyle Interventions Across the Continuum of Type 2 Diabetes: Reducing the Risks of Diabetes

Type 2 diabetes is a progressive disease that results from defects in insulin action (insulin resistance), insulin secretion (insulin deficiency), or both. The progressive decline in β-c ell function requires that medical therapy progress from lifestyle interventions for prevention of diabetes to medical nutrition therapy (MNT) alone for diabetes management to MNT in combination with glucose-lowering medications that target the multiple pathophysiologic aspects of diabetes to MNT with insulin. MNT also progresses from prevention of obesity or weight gain to improving insulin resistance to contributing to improved metabolic control of glucose, lipids, and blood pressure; however, MNT is important throughout the continuum of diabetes and its medical management. Early diagnosis and aggressive therapy decrease the risk of diabetes-related complications.

Nutrition Review: Diet and Nutrients in the Prevention and Treatment of Type 2 Diabetes

Lifestyle factors, including diet, are critical in the prevention and treatment of type 2 diabetes. Because weight gain increases diabetes risk, and even modest weight reduction reduces risk, weight management is paramount in lessening the occurrence and effects of diabetes. Weight loss interventions should include patient education, behavioral strategies, physical activity, energy intake deficits of 500 to 1000 kcal/day, and prevention of recidivism. Macronutrient distribution ranges of diets for diabetic patients follow those of the Dietary Reference Intakes, allowing for individualization according to a patient's metabolic responses, needs, and preferences. Nutrients to be limited include saturated fats, artificial trans fats, cholesterol, and sodium, whereas nutrients to be emphasized include monounsaturated fatty acids, omega-3 polyunsaturated fatty acids, fibers, antioxidants, and minerals, including potassium, magnesium, calcium, and chromium. Food sources are advised rather than supplements. Sugars can be isocalorically substituted for starches without detriments to glycemic control. Diets with low glycemic index or load may have modest benefits in managing type 2 diabetes. If a diabetic patient chooses to consume alcohol, he or she should do so in moderation. Foods advocated in type 2 diabetes are similar to those that are also beneficial in reducing risk for other chronic diseases.

The Evidence Is In: Lifestyle Interventions Can Prevent Diabetes

Early epidemiological and clinical trials suggested that type 2 diabetes could be prevented or delayed by lifestyle modifications. The Finnish Diabetes Prevention Study and the Diabetes Prevention Programs provided conclusive evidence that type 2 diabetes could be prevented or delayed with modest lifestyle changes—5% to 7% loss of body weight and 150 min/week of physical activity. Both used intensive intervention strategies and continued support and follow-up to achieve study goals. Other smaller studies made similar observations. Various medications—metformin, acarbose, troglitazone and pioglitazone, orlistat, and rosiglitazone—and bariatric surgery have also been effective for the prevention or delay of diabetes. Nutrient factors studied include the contribution of a high dietary fat intake, especially saturated fat, to the development of diabetes and increased intake of fiber, whole grains, and alcohol to decreased risk. A review of the evidence led the American Diabetes Association to conclude that lifestyle interventions should be the first choice for prevention or delay of diabetes and that drug therapy should not be a substitute for lifestyle interventions—healthy and appropriate food choices and physical activity.

The concept of low glycemic index and glycemic load foods as panacea for type 2 diabetes mellitus; prospects, challenges and solutions

BACKGROUND

This article examines the concepts of low glycemic indices (GIs) and glycemic load (GL) foods as key drivers in the dietary management of type 2 diabetes as well as their shortcomings. The controversies arising from the analysis of glycemic index (GI) and GL of foods such as their reproducibility as well as their relevance to the dietary management of type 2 diabetes are also discussed.

METHODS

Search was conducted in relevant electronic databases such as: Pubmed, Google Scholar, HINARI, the Cochrane library, Popline, LILACS, CINAHL, EMBASE, etc to identify the current status of knowledge regarding the controversies surrounding management of diabetes with low GI and GL foods.

CONCLUSION

This article suggests that in view of discrepancies that surround the results of GI versus GL of foods, any assay on the GI and GL of a food with the aim of recommending the food for the dietary management of type 2 diabetes, could be balanced with glycated hemoglobin assays before they are adopted as useful antidiabetic foods.

Effect of Cichorium intybus L. on the expression of hepatic NF-κB and IKKβ and serum TNF-α in STZ- and STZ+ niacinamide-induced diabetes in rats

BACKGROUND

Inflammation is an early event in the development of diabetes type 2 (T2D). Cichorium intybus L. (chicory) possesses anti-inflammatory action. We compared the anti-inflammatory aspect of aqueous chicory seed extract (CSE) in early and late stage T2D in rats.

METHODS

Wistar albino rats were divided into nine final groups (n = 6). Three main groups consisted of non-diabetic (Control), early stage diabetes (ET2D; niacinamide/streptozotocin, i.e., NIA/STZ), and late stage diabetes (LT2D; STZ). Within each main group, a subgroup was treated with CSE (125 mg/kg; i.p.); within each diabetic group (STZ and NIA/STZ) a subgroup received metformin (100 mg/kg; i.p.); another subgroup in STZ group received aspirin (120 mg/kg; oral). After 21 days, fasting blood glucose (FBS), insulin, and TNF-α level were measured in serum; IKKβ and NF-κB (p65) mRNA and protein expression were evaluated by real time PCR and Western blotting; p65 DNA binding activity was determined by ELISA, in liver tissue.

RESULTS

The mRNA and protein expression levels of IKKβ, and P65 genes increased in both stages of T2D (p < 0.01); CSE decreased their expression (p < 0.001, mRNAs; p < 0.05, proteins). The increased DNA-binding capacity of NF-κB (p < 0.0001) in diabetes was lowered by CSE (p < 0.001). The effect of CSE was limited to ET2D requiring insulin.

CONCLUSIONS

The anti-inflammatory action of CSE is due to a direct modulation of cytokine expression. The dependency of chicory action on the presence of insulin indicates its usefulness in the early stages of diabetes and for the purpose of preventing and delaying diabetes onset.

Lost in translation: dietary management of cardiovascular risk factors is seldom implemented

OBJECTIVE

To assess dietary management of cardiovascular risk factors (CVRFs) in the general population.

METHOD

Cross-sectional study conducted between 2009 and 2012 on 4811 participants (2567 women, 58±11years) living in Lausanne, Switzerland.

RESULTS

Sixteen percent of participants diagnosed with overweight/obesity reported a slimming diet. Slimming diet was associated with diagnosis of hypertension: Odds ratio and (95% confidence interval): 0.61 (0.40-0.93); older age [0.84 (0.58-1.21), 0.79 (0.53-1.18) and 0.47 (0.27-0.81) for [50-60[, [60-70[ and [70+ years, respectively]; female gender [1.84 (1.36-2.48)] and diagnosis of diabetes [2.16 (1.13-4.12)]. Only 8% of participants diagnosed with hypertension reported a low-salt diet. Low-salt diet was associated with antihypertensive drug treatment [2.17 (1.28-3.68)] and diagnosis of diabetes [2.72 (1.26-5.86)]. One-third of participants diagnosed with dyslipidemia reported a low-fat diet. Low-fat diet was associated with female gender [1.47 (1.17-1.86)]; older age [1.29 (0.89-1.87), 1.71 (1.18-2.48) and 2.01 (1.33-3.03) for [50-60[, [60-70[ and [70+ years, respectively]; hypolipidemic drug treatment [OR=1.68 (1.29-2.18)]; current smoking [0.70 (0.51-0.96)] and obesity [0.67 (0.45-1.00)]. Approximately half of participants diagnosed with diabetes reported an antidiabetic diet. Antidiabetic diet was associated with current smoking [0.44 (0.22-0.88)] and antidiabetic drug treatment [OR=3.26 (1.81-5.86)].

CONCLUSION

Dietary management of CVRFs is seldom implemented in Switzerland.

Eat Smart, Live Strong intervention increases fruit and vegetable consumption among low-income older adults

This study evaluated the impact of a four-session interactive nutrition education program-Eat Smart, Live Strong (ESLS)-on the consumption of fruit and vegetables by low-income older adults. A pre-post quasi-experimental design study was conducted with a longitudinal sample of 614 low-income Supplemental Nutrition Assistance Program (SNAP) participants and those eligible for SNAP, aged 60 to 80 years, in 17 intervention and 16 comparison senior centers in Michigan. The study compared participants' self-reports of their consumption of fruit and vegetables using a modified version of the University of California Cooperative Extension Food Behavior Checklist. ESLS increased participants' average daily consumption of fruit by 0.2 cups (P < 0.05) and vegetables by 0.31 cups (P < 0.01). ESLS, a four-session, cognitive-behavioral nutrition education program is an effective curriculum for helping low-income older adults eat more fruit and vegetables.

The hypertriglyceridemia is associated with isolated impaired glucose tolerance in subjects without insulin resistance

AIM OF THE STUDY

The objective of this study was to determine if hypertriglyceridemia is associated with isolated impaired glucose tolerance in subjects without insulin resistance.

MATERIALS AND METHODS

A total of 365 apparently healthy individuals aged 20-65 years were enrolled in a population-based cross-sectional study. Subjects were allocated into the groups with and without hypertriglyceridemia. Age, gender, body mass index, and waist circumference were matched criteria. Individuals with impaired fasting glucose, impaired fasting glucose+impaired glucose tolerance, diabetes, homeostasis model assessment of insulin resistance index ≥ 2.5, and/or chronic illnesses such as renal disease or malignancy were excluded. Hypertriglyceridemia was defined by triglycerides levels ≥ 150 mg/dL. Impaired glucose tolerance was defined by plasma glucose concentration 2-h post-load glucose ≥ 140 mg/dL <200 mg/dL. Subjects with impaired glucose tolerance were required to have fasting plasma glucose levels <100 mg/dL. Logistic regression analysis was used to compute the odds ratio between hypertriglyceridemia (independent variable) and impaired glucose tolerance (dependent variable).

RESULTS

A total of 132 and 233 subjects were allocated into the groups with and without hypertriglyceridemia, respectively. The frequency of impaired glucose tolerance was 13.6% and 5.6% in the individuals with and without hypertriglyceridemia, p = 0.01. The logistic regression analysis adjusted by gender, blood pressure, and high-density lipoprotein cholesterol showed that hypertriglyceridemia is significantly associated with impaired glucose tolerance (OR 2.34; 95% CI: 1.02-5.32, p = 0.04).

CONCLUSION

Results of this study indicate that hypertriglyceridemia is independently associated with isolated impaired glucose tolerance in subjects without insulin resistance.

Preoperative 4-week supplementation with omega-3 polyunsaturated fatty acids reduces liver volume and facilitates bariatric surgery in morbidly obese patients

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a very common condition among obese patients that may lead to the enlargement of the liver, that in turn impairs the access to the gastro-esophageal junction during laparoscopic bariatric surgery. Omega-3 polyunsaturated fatty acids (Ω-3 PUFAs) supplementation has been shown to reduce nutritional hepatic steatosis. The aim of this study was to assess the effects of a 4-week course of oral Ω-3 PUFAs supplementation on the volume of the liver.

METHODS

20 morbidly obese patients were administered oral Ω-3 PUFAs (1,500 mg daily) for 4 weeks before undergoing the laparoscopic Roux-en-Y gastric bypass (LRYGBP) without any dietary restriction. The volume of the left hepatic lobe was estimated by liver ultrasonography at baseline and at the end of treatment. The degree of difficulty to access the gastro-esophageal junction was appreciated subjectively by the operating surgeon.

RESULTS

All patients completed the study and no side effect was reported. The mean volume of the left hepatic lobe decreased by 20% from 598 ± 97 to 484 ± 118 cm(3) after the treatment (p = 0.002). The access to the gastro-esophageal junction was reported as simple, with easy retraction of the left hepatic lobe by the operating surgeon in all cases.

CONCLUSIONS

This study demonstrates that a 4-week course of oral Ω-3 PUFAs supplementation results in a significant reduction in liver size that facilitates the LRYGBP.

Are statin trials in diabetes representative of real-world diabetes care: a population-based study on statin initiators in Finland

OBJECTIVE

To assess the representativeness of the Heart Protection Study (HPS) and the Collaborative Atorvastatin Diabetes Study (CARDS) for incident statin users.

DESIGN

A population-based analysis with linked register data.

SETTING

Finland.

POPULATION

56 963 patients with diabetes initiating statin use from 2005 to 2008.

MAIN OUTCOME MEASURES

We determined the proportions of real-world patients who fulfilled the eligibility criteria for HPS and CARDS trials and assessed the cardiovascular disease (CVD) event rates, assumed to reflect the background CVD risk, for those eligible and ineligible. We used descriptive statistics to identify the patient characteristics, lipid-lowering interventions and adherence to statin therapy.

RESULTS

Of the real-world patients, 57% (N=32 582) fulfilled the eligibility criteria for HPS (DM) and 49% (N=20 499) of those without CVD for CARDS. The patients ineligible for HPS (DM) had a higher cumulative risk for CVD events than those eligible, whereas regarding CARDS the cumulative risks were of similar magnitude. The overall CVD event rates seemed to be comparable to those in the reviewed trials. Both trials were under-representative of women and users of antihypertensive agents and metformin. 27% and 29% of real-world patients had an initial statin dose corresponding to <20 mg of simvastatin. The proportions of patients who were deemed adherent were 57% in the real world and 85% in both trials.

CONCLUSIONS

Only half of the real-world patients would have qualified for the HPS (DM) and CARDS, limiting their representativeness for clinical practice. Women and users of antihypertensive agents and metformin were under-represented in both trials. These deviations reflect the changes in diabetes treatment over the years and are not expected to modify the average treatment effects of statins on CVD. Prescribing of lower statin doses in clinical practice than used in the trials and lower adherence may, however, attenuate the benefits in the real world.

Reducing the modifiable risks of cardiovascular disease in Turkish patients with type 2 diabetes: the effectiveness of training

Our goal was to reduce the number of modifiable risk factors for cardiovascular disease (CVD) through providing lifestyle adjustment training and counseling to patients with type 2 diabetes. In this pre-post intervention study, 139 patients with diabetes were provided with training to reduce the modifiable risks of CVD. One hundred three patients attended the post-training evaluation. Two phone counseling sessions were provided with 1-month intervals. Consumption of red meat and processed food decreased and water consumption, carrying on the recommended diet, and the frequency of exercise increased (p = .000), A1C decreased (p = .05), and the use of aspirin increased (p = .03). Thus, a contribution to the reduction of CVD risk factors in patients with type 2 diabetes was achieved. The training program for reducing CVD risk factors in patients with type 2 diabetes was effective in improving nutrition and lifestyle behaviors and decreasing glycemic control.

Fecal microbiota imbalance in Mexican children with type 1 diabetes

Dysbiosis of the intestinal microbiota affecting the gut barrier could be triggering Type 1 Diabetes (T1D), the second most frequent autoimmune disease in childhood. This study compared the structure of the fecal microbiota in 29 mestizo children aged 7-18 years, including 8 T1D at onset, 13 T1D after 2 years treatment, and 8 healthy controls. Clinical information was collected, predisposing haplotypes were determined; the fecal DNA was extracted, the V4 region of the 16S rRNA gene amplified and 454-pyrosequenced. The newly diagnosed T1D cases had high levels of the genus Bacteroides (p < 0.004), whereas the control group had a gut microbiota dominated by Prevotella. Children with T1D treated for ≥2 years had levels of Bacteroides and Prevotella compared to those of the control group. The gut microbiota of newly diagnosed T1D cases is altered, but whether it is involved in disease causation or is a consequence of host selection remains unclear.

Sources of vegetables, fruits and vitamins A, C and E among five ethnic groups: results from a multiethnic cohort study

OBJECTIVES

Data are limited on how dietary sources of food and nutrients differ among ethnic groups. The objective of this study was to determine the main sources of fruit, vegetables and vitamins A, C and E for five ethnic groups.

SUBJECTS/METHODS

Dietary data were collected using a validated quantitative food frequency questionnaire from participants in a multiethnic cohort in Hawaii and Los Angeles county between 1993 and 1996. Data were analyzed for 186,916 participants representing five ethnic groups: African-Americans, Japanese-Americans, native Hawaiians, Latinos and Caucasians.

RESULTS

Lettuce was the most consumed vegetable (6.0-9.9%) in all ethnic-sex groups, except among African-American women and Mexican-born Latino men and women. Oranges and bananas contributed more than one-quarter to total fruit intake among all groups. Overall, more ethnic variation in food choices was observed for the top 10 vegetables than for fruits. The top sources of vitamins A, C and E were carrots, orange/grapefruit/pomelo and combined dishes, respectively. Among the micronutrients studied, the greatest ethnic variation in foods consumed was observed for the top 10 food sources of vitamin A.

CONCLUSIONS

This is the first study providing data on the main types of fruit and vegetables consumed and the major sources of vitamins A, C and E among these ethnic groups in the U.S. Such data are valuable for developing and implementing public health strategies to meet the USDA dietary recommendations and for guiding ethnicity-specific nutrition education and intervention programs.

Glycemic index, glycemic load, carbohydrates, and type 2 diabetes: systematic review and dose-response meta-analysis of prospective studies

OBJECTIVE

Diets with high glycemic index (GI), with high glycemic load (GL), or high in all carbohydrates may predispose to higher blood glucose and insulin concentrations, glucose intolerance, and risk of type 2 diabetes. We aimed to conduct a systematic literature review and dose-response meta-analysis of evidence from prospective cohorts.

RESEARCH DESIGN AND METHODS

We searched the Cochrane Library, MEDLINE, MEDLINE in-process, Embase, CAB Abstracts, ISI Web of Science, and BIOSIS for prospective studies of GI, GL, and total carbohydrates in relation to risk of type 2 diabetes up to 17 July 2012. Data were extracted from 24 publications on 21 cohort studies. Studies using different exposure categories were combined on the same scale using linear and nonlinear dose-response trends. Summary relative risks (RRs) were estimated using random-effects meta-analysis.

RESULTS

The summary RR was 1.08 per 5 GI units (95% CI 1.02-1.15; P = 0.01), 1.03 per 20 GL units (95% CI 1.00-1.05; P = 0.02), and 0.97 per 50 g/day of carbohydrate (95% CI 0.90-1.06; P = 0.5). Dose-response trends were linear for GI and GL but more complex for total carbohydrate intake. Heterogeneity was high for all exposures (I(2) >50%), partly accounted for by different covariate adjustment and length of follow-up.

CONCLUSIONS

Included studies were observational and should be interpreted cautiously. However, our findings are consistent with protective effects of low dietary GI and GL, quantifying the range of intakes associated with lower risk. Future research could focus on the type of sugars and other carbohydrates associated with greatest risk.

Erythrocyte caspase-3 activation and oxidative imbalance in erythrocytes and in plasma of type 2 diabetic patients

An increased oxidative stress and a decreased life span of erythrocytes (RBCs) are reported in patients with diabetes. Aim of this study was to assess in RBCs from patients with type 2 diabetes whether downstream effector mechanisms of apoptosis, such as activation of caspase-3, is operative, and whether an iron-related oxidative imbalance, occurring inside RBCs and in plasma, could be involved in caspase-3 activation. In 26 patients with type 2 diabetes and in 12 healthy subjects, oxidative stress was evaluated by means of different markers; non-protein-bound iron, methemoglobin and glutathione were determined in RBCs, and non-protein-bound iron was also determined in plasma. Erythrocyte caspase-3 activation was evaluated by an immunosorbent enzyme assay. Arterial hypertension, demographic and standard biochemical data were also evaluated. The results show, for the first time, that type 2 diabetic RBCs put into motion caspase-3 activation, which is significantly higher than in control RBCs. Such an effector mechanism of "eryptosis" was positively correlated to blood glucose levels and to the increased plasma NPBI level. Caspase-3 activation was also positively correlated to occurrence of arterial hypertension. The results suggest that an extracellular oxidative milieu can be responsible for erythrocyte caspase-3 activation in patients with type 2 diabetes. In turn, caspase-3 activation can be envisaged as a novel mechanism which, by impairing the maintenance of erythrocyte shape and function, might contribute to the shortened life span of RBCs from patients with type 2 diabetes and to hemorheological disorders observed in these patients.

ILSI Brazil International Workshop on Functional Foods: a narrative review of the scientific evidence in the area of carbohydrates, microbiome, and health

To stimulate discussion around the topic of ‘carbohydrates’ and health, the Brazilian branch of the International Life Sciences Institute held the 11th International Functional Foods Workshop (1–2 December 2011) in which consolidated knowledge and recent scientific advances specific to the relationship between carbohydrates and health were presented. As part of this meeting, several key points related to dietary fiber, glycemic response, fructose, and impacts on satiety, cognition, mood, and gut microbiota were realized: 1) there is a need for global harmonization of a science-based fiber definition; 2) low-glycemic index foods can be used to modulate the postprandial glycemic response and may affect diabetes and cardiovascular outcomes; 3) carbohydrate type may influence satiety and satiation; glycemic load and glycemic index show links to memory, mood, and concentration; 4) validated biomarkers are needed to demonstrate the known prebiotic effect of carbohydrates; 5) negative effects of fructose are not evident when human data are systematically reviewed; 6) new research indicates that diet strongly influences the microbiome; and 7) there is mounting evidence that the intestinal microbiota has the ability to impact the gut–brain axis. Overall, there is much promise for development of functional foods that impact the microbiome and other factors relevant to health, including glycemic response (glycemic index/glycemic load), satiety, mood, cognition, and weight management.

Overweight and obesity in youth with type 1 diabetes

Overweight and obesity in youth with type 1 diabetes (T1D) is now prevalent and accounts for significant health consequences, including cardiovascular complications and dual diagnosis of type 2 diabetes. Physical activity and lifestyle are modifiable and play an important role in the prevention and management of excessive weight, but it is unclear how these factors relate to overweight and obese youth with T1D. Thus, a systematic review was conducted to examine how physical activity, sedentary behavior, sleep, and diet are related to overweight/obesity in youth with T1D. Seven observational and intervention studies published between 1990 and 2013 were included in the review. Prevalence of overweight ranged from 12.5% to 33.3%. Overweight in youth with T1D was associated with infrequent napping, increased screen time, and skipping breakfast and dinner but was not related to time engaged in physical activity. Weight-related interventions indicated modest weight loss along with improved glycemic control. In light of this review, there is a need for high quality research that examines all levels of activity in youth with T1D to identify lifestyle modification targets for weight prevention and management.

What next after metformin? A retrospective evaluation of the outcome of second-line, glucose-lowering therapies in people with type 2 diabetes

CONTEXT

After failure of metformin monotherapy, many second-line, glucose-lowering therapies are available to treat people with type 2 diabetes.

OBJECTIVE

The objective of the study was to compare clinical outcomes using common alternative regimens.

DESIGN AND SETTING

This was a retrospective cohort study using data from the U.K.-based General Practice Research Database.

PATIENTS

These were primary care patients with type 2 diabetes who had metformin monotherapy as their first treatment and who then initiated on relevant second-line, glucose-lowering regimens during the study period 2000-2010. A total of 27,457 patients were prescribed a second-line therapy, of whom 26,278 (95.7%) were prescribed a regimen with 1,000 or more observations.

MAIN OUTCOME MEASURES

All-cause mortality, major adverse cardiovascular events (MACE), cancer, and a combined end point of any of these were measured. Secondary end points were change in glycosylated hemoglobin between baseline and 12 months. Time to clinical end points was compared using Cox proportional hazards models.

RESULTS

Sulfonylurea monotherapy had significantly higher hazard ratios (HRs) for all-cause mortality (HR 1.459, 1.207-1.763); MACE (HR 1.578, 1.187-2.099); stroke (HR 1.444, 1.050-1.987); and the combined end point (HR 1.381, 1.194-1.597). Metformin plus pioglitazone had significantly lower adjusted HRs for all-cause mortality (HR 0.707, 0.515-0.970) and the combined end point (HR 0.747, 0.612-0.911). Mean glycosylated hemoglobin improved between baseline and 12 months for all regimens other than sulfonylurea monotherapy.

CONCLUSION

The combination of metformin plus pioglitazone appears to provide superior clinical outcomes compared with the most commonly used regimen, metformin plus sulfonylurea. Sulfonylurea monotherapy resulted in worse outcome.

Influence of the drug exposure definition on the assessment of the antipsychotic metabolic impact in patients initially treated with mood-stabilizers

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

• Metabolic disturbances represent a well-known side effect of second generation antipsychotics. However, studies comparing second generation antipsychotic drugs (SGAPs) and first generation antipsychotic drugs (FGAPs) through administrative databases have shown contrasting findings, which may be attributable to methodological differences.

WHAT THIS PAPER ADDS

• The definition of antipsychotic exposure impacts on the association between antipsychotics and metabolic risk in studies carried out through administrative databases. • Considering cumulative exposure to antipsychotics or including patients exposed to an antipsychotic drug for months or years is likely to over-represent patients who tolerate the drug well with a depletion of susceptible effects. • Antipsychotic drug exposure is a time-varying determinant and episodes of no use, past use and current use should be distinguished over the study period to avoid any misclassification bias that might lead to misleading findings.

AIMS

To assess the influence of three definitions of antipsychotic exposure on the comparison between first generation (FGAP) and second generation (SGAP) antipsychotic drugs and 'conventional' mood stabilizers towards the risk of metabolic events using (i) a dichotomous measure (exposed/non-exposed over the follow-up), (ii) a categorical measure taking into account the chronology of exposure at the time of the metabolic event (current, recent and no use) and (iii) a continuous measure (cumulative duration).

METHODS

A historical fixed cohort was identified from the 2004-2006 claims database of the French health insurance programme for self-employed workers, including 3172 patients aged 18 years and over who used conventional mood stabilizers over a 3 month period. A metabolic event was defined as an incident dispensing of an anti-diabetic or lipid-lowering drug.

RESULTS

A metabolic event occurred in 367 patients (11.6%). At least one FGAP had been prescribed in 29% of patients who did not develop a metabolic event and in 22% of patients who developed a metabolic event. In addition, at least one SGAP had been prescribed in 12% of patients who did not develop a metabolic event and in 7% of patients who developed a metabolic event. Compared with conventional mood stabilizers, the risk of a metabolic event was negatively associated with exposure to SGAPs over the follow-up period (HR 0.53, 95% CI 0.34, 0.82, P= 0.004), positively associated with recent, but not current, exposure to SGAPs (HR 2.1, 95% CI 1.2, 3.7, P= 0.006) and not associated with cumulative duration of SGAPs (HR 1.001, 95% CI 0.999, 1.003, P= 0.20).

CONCLUSIONS

The definition of exposure to antipsychotics in epidemiological studies exploring their metabolic impact is of paramount importance in understanding this association. Different definitions can lead to opposite and seemingly nonsensical results. Not taking into account past exposure, in order to minimize the depletion of susceptible effects, may lead to absurd results.