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Richter MM, Thomsen MN, Skytte MJ, Kjeldsen SAS, Samkani A, Frystyk J, Magkos F, Holst JJ, Madsbad S, Krarup T, Haugaard SB, Wewer Albrechtsen NJ. Effect of a 6-Week Carbohydrate-Reduced High-Protein Diet on Levels of FGF21 and GDF15 in People With Type 2 Diabetes. J Endocr Soc 2024; 8:bvae008. [PMID: 38379856 PMCID: PMC10875725 DOI: 10.1210/jendso/bvae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Indexed: 02/22/2024] Open
Abstract
Context Fibroblast growth factor 21 (FGF21) and growth differentiation factor 15 (GDF15) are increased in type 2 diabetes and are potential regulators of metabolism. The effect of changes in caloric intake and macronutrient composition on their circulating levels in patients with type 2 diabetes are unknown. Objective To explore the effects of a carbohydrate-reduced high-protein diet with and without a clinically significant weight loss on circulating levels of FGF21 and GDF15 in patients with type 2 diabetes. Methods We measured circulating FGF21 and GDF15 in patients with type 2 diabetes who completed 2 previously published diet interventions. Study 1 randomized 28 subjects to an isocaloric diet in a 6 + 6-week crossover trial consisting of, in random order, a carbohydrate-reduced high-protein (CRHP) or a conventional diabetes (CD) diet. Study 2 randomized 72 subjects to a 6-week hypocaloric diet aiming at a ∼6% weight loss induced by either a CRHP or a CD diet. Fasting plasma FGF21 and GDF15 were measured before and after the interventions in a subset of samples (n = 24 in study 1, n = 66 in study 2). Results Plasma levels of FGF21 were reduced by 54% in the isocaloric study (P < .05) and 18% in the hypocaloric study (P < .05) in CRHP-treated individuals only. Circulating GDF15 levels increased by 18% (P < .05) following weight loss in combination with a CRHP diet but only in those treated with metformin. Conclusion The CRHP diet significantly reduced FGF21 in people with type 2 diabetes independent of weight loss, supporting the role of FGF21 as a "nutrient sensor." Combining metformin treatment with carbohydrate restriction and weight loss may provide additional metabolic improvements due to the rise in circulating GDF15.
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Affiliation(s)
- Michael M Richter
- Department of Clinical Biochemistry, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Mads N Thomsen
- Department of Endocrinology, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
| | - Mads J Skytte
- Department of Endocrinology, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, 2100, Denmark
| | - Sasha A S Kjeldsen
- Department of Clinical Biochemistry, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
| | - Jan Frystyk
- Department of Endocrinology, Odense University Hospital, Odense, 5000, Denmark
| | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital—Hvidovre, Hvidovre, 2650, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Nicolai J Wewer Albrechtsen
- Department of Clinical Biochemistry, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
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2
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Kjeldsen SAS, Thomsen MN, Skytte MJ, Samkani A, Richter MM, Frystyk J, Magkos F, Hansen E, Thomsen HS, Holst JJ, Madsbad S, Haugaard SB, Krarup T, Wewer Albrechtsen NJ. Markers of Glucagon Resistance Improve With Reductions in Hepatic Steatosis and Body Weight in Type 2 Diabetes. J Endocr Soc 2023; 7:bvad122. [PMID: 37818402 PMCID: PMC10561012 DOI: 10.1210/jendso/bvad122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Indexed: 10/12/2023] Open
Abstract
Context Hyperglucagonemia may develop in type 2 diabetes due to obesity-prone hepatic steatosis (glucagon resistance). Markers of glucagon resistance (including the glucagon-alanine index) improve following diet-induced weight loss, but the partial contribution of lowering hepatic steatosis vs body weight is unknown. Objective This work aimed to investigate the dependency of body weight loss following a reduction in hepatic steatosis on markers of glucagon resistance in type 2 diabetes. Methods A post hoc analysis was conducted from 2 previously published randomized controlled trials. We investigated the effect of weight maintenance (study 1: isocaloric feeding) or weight loss (study 2: hypocaloric feeding), both of which induced reductions in hepatic steatosis, on markers of glucagon sensitivity, including the glucagon-alanine index measured using a validated enzyme-linked immunosorbent assay and metabolomics in 94 individuals (n = 28 in study 1; n = 66 in study 2). Individuals with overweight or obesity with type 2 diabetes were randomly assigned to a 6-week conventional diabetes (CD) or carbohydrate-reduced high-protein (CRHP) diet within both isocaloric and hypocaloric feeding-interventions. Results By design, weight loss was greater after hypocaloric compared to isocaloric feeding, but both diets caused similar reductions in hepatic steatosis, allowing us to investigate the effect of reducing hepatic steatosis with or without a clinically relevant weight loss on markers of glucagon resistance. The glucagon-alanine index improved following hypocaloric, but not isocaloric, feeding, independently of macronutrient composition. Conclusion Improvements in glucagon resistance may depend on body weight loss in patients with type 2 diabetes.
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Affiliation(s)
- Sasha A S Kjeldsen
- Department of Clinical Biochemistry, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Mads N Thomsen
- Department of Endocrinology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
| | - Mads J Skytte
- Department of Endocrinology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
| | - Michael M Richter
- Department of Clinical Biochemistry, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Jan Frystyk
- Department of Endocrinology, Odense University Hospital, Odense, 5000, Denmark
| | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, 1958, Denmark
| | - Elizaveta Hansen
- Department of Radiology, Copenhagen University Hospital-Herlev, Herlev, 2730, Denmark
| | - Henrik S Thomsen
- Department of Radiology, Copenhagen University Hospital-Herlev, Herlev, 2730, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital-Hvidovre, Hvidovre, 2650, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, 1958, Denmark
| | - Nicolai J Wewer Albrechtsen
- Department of Clinical Biochemistry, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, 2400, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 2200, Denmark
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3
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Weber P, Thomsen MN, Skytte MJ, Samkani A, Carl MH, Astrup A, Frystyk J, Holst JJ, Hartmann B, Madsbad S, Magkos F, Krarup T, Haugaard SB. Effects of Carbohydrate Restriction on Body Weight and Glycemic Control in Individuals with Type 2 Diabetes: A Randomized Controlled Trial of Efficacy in Real-Life Settings. Nutrients 2022; 14:nu14245244. [PMID: 36558403 PMCID: PMC9788105 DOI: 10.3390/nu14245244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
A fully provided, hypocaloric, carbohydrate-reduced high-protein (CRHP) diet compared to a hypocaloric conventional diabetes (CD) diet for 6 weeks improved glycemic control to a greater extent in face of an intended 6% weight loss in individuals with type 2 diabetes mellitus (T2DM). The present 24-week extension of that study reports on the efficacy of CRHP and CD diets in a real-life setting. Sixty-five individuals with T2DM who completed the initial 6-week fully provided diet period (% energy from carbohydrate, protein, and fat was 30/30/40 in CRHP, and 50/17/33 in CD) continued a free-living, dietician guided 24-week period of which 59 individuals completed. The CRHP compared to CD group reported a 4% lower carbohydrate intake and had higher urea excretion by 22% (both p ≤ 0.05) at week 30, suggesting less difference in carbohydrate and protein intake between groups during the 24-week extension compared to week 6. The loss of body weight during the initial 6 weeks was maintained in both groups during the 24-week extension (-5.5 ± 4.5 and -4.6 ± 4.8 kg) as well as HbA1c (-8.4 ± 6.2 and -8.4 ± 6.9 mmol/mol) with no significant differences between groups. The additional benefits on glucoregulation harnessed by carbohydrate restriction under full diet provision for 6 weeks combined with titrated weight loss could not be maintained in a real-life setting of self-prepared diet aiming on similar diets for 6 months.
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Affiliation(s)
- Philip Weber
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, 2400 Copenhagen, Denmark
- Correspondence:
| | - Mads N. Thomsen
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, 2400 Copenhagen, Denmark
| | - Mads Juul Skytte
- Department of Forensic Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, 2400 Copenhagen, Denmark
| | - Martin Hansen Carl
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, 2400 Copenhagen, Denmark
| | - Arne Astrup
- Department of Obesity and Nutritional Sciences, Novo Nordisk Foundation, 2900 Hellerup, Denmark
| | - Jan Frystyk
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
- Department of Endocrinology, Odense University Hospital, 5000 Odense, Denmark
| | - Jens J. Holst
- NNF Centre for Basic Metabolic Research, University of Copenhagen, 2200 Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Bolette Hartmann
- NNF Centre for Basic Metabolic Research, University of Copenhagen, 2200 Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Amager Hvidovre, 2650 Hvidovre, Denmark
| | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, 2400 Copenhagen, Denmark
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Steen B. Haugaard
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, 2400 Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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Thomsen MN, Skytte MJ, Samkani A, Astrup A, Fenger M, Frystyk J, Hartmann B, Holst JJ, Larsen TM, Madsbad S, Magkos F, Rehfeld JF, Haugaard SB, Krarup T. Weight loss improves β-cell function independently of dietary carbohydrate restriction in people with type 2 diabetes: A 6-week randomized controlled trial. Front Nutr 2022; 9:933118. [PMID: 36061897 PMCID: PMC9437620 DOI: 10.3389/fnut.2022.933118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background Carbohydrate restriction may benefit β-cell function and glucose metabolism in type 2 diabetes (T2D) but also leads to weight loss which in itself is beneficial. Methods In order to determine the additional effect of carbohydrate restriction in addition to a fixed body weight loss, we randomly assigned 72 adults with T2D and obesity (mean ± SD HbA1c 7.4 ± 0.7%, BMI 33 ± 5 kg/m2) to a carbohydrate-reduced high-protein diet (CRHP; energy percent from carbohydrate/protein/fat: 30/30/40) or an isocaloric conventional diabetes diet (CD; 50/17/33) for 6 weeks. All foods were provided free of charge and total energy intake was tailored individually, so both groups lost 6% of baseline body weight. Results Despite significantly greater reductions in HbA1c (mean [95% CI] −1.9 [−3.5, −0.3] mmol/mol) after 6 weeks, the CRHP diet neither improved glucose tolerance, β-cell response to glucose, insulin sensitivity, during a 4-h oral glucose tolerance test, nor basal proinsulin secretion when compared to the CD diet, but increased C-peptide concentration and insulin secretion rate (area under the curve [AUC] and peak) significantly more (~10%, P ≤ 0.03 for all). Furthermore, compared with the CD diet, the CRHP diet borderline increased basal glucagon concentration (16 [−0.1, 34]%, P = 0.05), but decreased glucagon net AUC (−2.0 [−3.4, −0.6] mmol/L ×240 min, P < 0.01), decreased basal triglyceride and total AUC (~20%, P < 0.01 for both), and increased gastric inhibitory polypeptide total AUC (14%, P = 0.01). Conclusion A moderately carbohydrate-restricted diet for 6 weeks decreased HbA1c but did not improve β-cell function or glucose tolerance beyond the effects of weight loss when compared with a conventional diabetes diet in people with T2D. Clinical trials registration www.Clinicaltrials.gov, Identifier: NCT02472951.
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Affiliation(s)
- Mads N. Thomsen
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- *Correspondence: Mads N. Thomsen
| | - Mads J. Skytte
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Arne Astrup
- Healthy Weight Center, Novo Nordisk Foundation, Hellerup, Denmark
| | - Mogens Fenger
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Jan Frystyk
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bolette Hartmann
- Novo Nordisk Foundation Center for Basic Metabolic Research, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J. Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas M. Larsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Jens F. Rehfeld
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Steen B. Haugaard
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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5
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Thomsen MN, Skytte MJ, Samkani A, Carl MH, Weber P, Astrup A, Chabanova E, Fenger M, Frystyk J, Hartmann B, Holst JJ, Larsen TM, Madsbad S, Magkos F, Thomsen HS, Haugaard SB, Krarup T. Dietary carbohydrate restriction augments weight loss-induced improvements in glycaemic control and liver fat in individuals with type 2 diabetes: a randomised controlled trial. Diabetologia 2022; 65:506-517. [PMID: 34993571 PMCID: PMC8739348 DOI: 10.1007/s00125-021-05628-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS Lifestyle modification and weight loss are cornerstones of type 2 diabetes management. However, carbohydrate restriction may have weight-independent beneficial effects on glycaemic control. This has been difficult to demonstrate because low-carbohydrate diets readily decrease body weight. We hypothesised that carbohydrate restriction enhances the beneficial metabolic effects of weight loss in type 2 diabetes. METHODS This open-label, parallel RCT included adults with type 2 diabetes, HbA1c 48-97 mmol/mol (6.5-11%), BMI >25 kg/m2, eGFR >30 ml min-1 [1.73 m]-2 and glucose-lowering therapy restricted to metformin or dipeptidyl peptidase-4 inhibitors. Participants were randomised by a third party and assigned to 6 weeks of energy restriction (all foods were provided) aiming at ~6% weight loss with either a carbohydrate-reduced high-protein diet (CRHP, percentage of total energy intake [E%]: CH30/P30/F40) or a conventional diabetes diet (CD, E%: CH50/P17/F33). Fasting blood samples, continuous glucose monitoring and magnetic resonance spectroscopy were used to assess glycaemic control, lipid metabolism and intrahepatic fat. Change in HbA1c was the primary outcome; changes in circulating and intrahepatic triacylglycerol were secondary outcomes. Data were collected at Copenhagen University Hospital (Bispebjerg and Herlev). RESULTS Seventy-two adults (CD 36, CRHP 36, all white, 38 male sex) with type 2 diabetes (mean duration 8 years, mean HbA1c 57 mmol/mol [7.4%]) and mean BMI of 33 kg/m2 were enrolled, of which 67 (CD 33, CRHP 34) completed the study. Body weight decreased by 5.8 kg (5.9%) in both groups after 6 weeks. Compared with the CD diet, the CRHP diet further reduced HbA1c (mean [95% CI] -1.9 [-3.5, -0.3] mmol/mol [-0.18 (-0.32, -0.03)%], p = 0.018) and diurnal mean glucose (mean [95% CI] -0.8 [-1.2, -0.4] mmol/l, p < 0.001), stabilised glucose excursions by reducing glucose CV (mean [95% CI] -4.1 [-5.9, -2.2]%, p < 0.001), and augmented the reductions in fasting triacylglycerol concentration (by mean [95% CI] -18 [-29, -6]%, p < 0.01) and liver fat content (by mean [95% CI] -26 [-45, 0]%, p = 0.051). However, pancreatic fat content was decreased to a lesser extent by the CRHP than the CD diet (mean [95% CI] 33 [7, 65]%, p = 0.010). Fasting glucose, insulin, HOMA2-IR and cholesterol concentrations (total, LDL and HDL) were reduced significantly and similarly by both diets. CONCLUSIONS/INTERPRETATION Moderate carbohydrate restriction for 6 weeks modestly improved glycaemic control, and decreased circulating and intrahepatic triacylglycerol levels beyond the effects of weight loss itself compared with a CD diet in individuals with type 2 diabetes. Concurrent differences in protein and fat intakes, and the quality of dietary macronutrients, may have contributed to these results and should be explored in future studies. TRIAL REGISTRATION ClinicalTrials.gov NCT03814694. FUNDING The study was funded by Arla Foods amba, The Danish Dairy Research Foundation, and Copenhagen University Hospital Bispebjerg Frederiksberg.
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Affiliation(s)
- Mads N Thomsen
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
| | - Mads J Skytte
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Martin H Carl
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Philip Weber
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Elizaveta Chabanova
- Department of Radiology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Mogens Fenger
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Jan Frystyk
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bolette Hartmann
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas M Larsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik S Thomsen
- Department of Radiology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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6
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Alzahrani AH, Skytte MJ, Samkani A, Thomsen MN, Astrup A, Ritz C, Chabanova E, Frystyk J, Holst JJ, Thomsen HS, Madsbad S, Haugaard SB, Krarup T, Larsen TM, Magkos F. Body weight and metabolic risk factors in patients with type 2 diabetes on a self-selected high-protein low-carbohydrate diet. Eur J Nutr 2021; 60:4473-4482. [PMID: 34101004 DOI: 10.1007/s00394-021-02605-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 06/02/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE We previously reported beneficial glucoregulatory effects of a fully provided carbohydrate-reduced, high-protein (CRHP) diet in patients with type 2 diabetes mellitus (T2DM) in a crossover 2 × 6-week trial, in which patients maintained their body weight. Here, we investigated physiological changes during an additional 6-month period on a self-selected and self-prepared CRHP diet. METHODS Twenty-eight patients with T2DM were instructed to consume a CRHP diet (30% of energy from carbohydrate and 30% from protein) for 24 weeks, after an initial 2 × 6-week trial when all food was prepared and provided to them. Patients received dietary advice every 2 weeks. At weeks 0, 6, 12 and 36, they underwent a 3-h intravenous glucose tolerance test, a 4-h mixed meal test, and a 48-h continuous glucose monitoring. Liver, muscle, pancreas, and visceral fat contents were measured by magnetic resonance imaging. RESULTS During the 24-week self-selected diet period (weeks 12-36), body weight, visceral fat, liver fat, and glycated haemoglobin were maintained at the same levels achieved at the end of the fully provided diet period, and were still lower than at baseline (P < 0.05). Postprandial insulinaemia and insulin secretion were significantly greater (P < 0.05). At week 36, fasting insulin and C-peptide levels increased (P < 0.01) and daily glycaemia decreased further (P < 0.05) when compared with the end of the fully provided diet period. CONCLUSION Substituting dietary carbohydrate for protein and fat has metabolic benefits in patients with T2DM. These beneficial effects are maintained or augmented over the next 6 months when patients self-select and self-prepare this diet in a dietitian-supported setting. TRIAL REGISTRATION ClinicalTrials.gov NCT02764021.
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Affiliation(s)
- Ahmad H Alzahrani
- Department of Nutrition, Exercise and Sports, Københavns Universitet, Copenhagen, Denmark.,Department of Physiology, Faculty of Medicine, The University of Jeddah, Jeddah, Saudi Arabia
| | - Mads J Skytte
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Mads N Thomsen
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, Københavns Universitet, Copenhagen, Denmark
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, Københavns Universitet, Copenhagen, Denmark
| | - Elizaveta Chabanova
- Department of Radiology, Copenhagen University Hospital Herlev Gentofte, Copenhagen, Denmark
| | - Jan Frystyk
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark.,The Research Unit for Endocrinology, Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Jens J Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Henrik S Thomsen
- Department of Radiology, Copenhagen University Hospital Herlev Gentofte, Copenhagen, Denmark
| | - Sten Madsbad
- Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Internal Medicine, Copenhagen University Hospital Amager Hvidovre, Copenhagen, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.,Department of Internal Medicine, Copenhagen University Hospital Amager Hvidovre, Copenhagen, Denmark
| | - Thure Krarup
- Department of Nutrition, Exercise and Sports, Københavns Universitet, Copenhagen, Denmark.,Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Thomas Meinert Larsen
- Department of Nutrition, Exercise and Sports, Københavns Universitet, Copenhagen, Denmark
| | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, Københavns Universitet, Copenhagen, Denmark. .,Department of Nutrition, Exercise and Sports, Københavns Universitet, Rolighedsvej 26, 1958, Frederiksberg C, Denmark.
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Skytte MJ, Samkani A, Astrup A, Frystyk J, Rehfeld JF, Holst JJ, Madsbad S, Burling K, Fenger M, Thomsen MN, Larsen TM, Krarup T, Haugaard SB. Effects of carbohydrate restriction on postprandial glucose metabolism, β-cell function, gut hormone secretion, and satiety in patients with Type 2 diabetes. Am J Physiol Endocrinol Metab 2021; 320:E7-E18. [PMID: 33103448 DOI: 10.1152/ajpendo.00165.2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Dietary carbohydrate restriction may improve the phenotype of Type 2 diabetes (T2D) patients. We aimed to investigate 6 wk of carbohydrate restriction on postprandial glucose metabolism, pancreatic α- and β-cell function, gut hormone secretion, and satiety in T2D patients. Methods In a crossover design, 28 T2D patients (mean HbA1c: 60 mmol/mol) were randomized to 6 wk of carbohydrate-reduced high-protein (CRHP) diet and 6 wk of conventional diabetes (CD) diet (energy-percentage carbohydrate/protein/fat: 30/30/40 vs. 50/17/33). Twenty-four-hour continuous glucose monitoring (CGM) and mixed-meal tests were undertaken and fasting intact proinsulin (IP), 32,33 split proinsulin concentrations (SP), and postprandial insulin secretion rates (ISR), insulinogenic index (IGI), β-cell sensitivity to glucose (Bup), glucagon, and gut hormones were measured. Gastric emptying was evaluated by postprandial paracetamol concentrations and satiety by visual analog scale ratings. A CRHP diet reduced postprandial glucose area under curve (net AUC) by 60% (P < 0.001), 24 h glucose by 13% (P < 0.001), fasting IP and SP concentrations (both absolute and relative to C-peptide, P < 0.05), and postprandial ISR (24%, P = 0.015), while IGI and Bup improved by 31% and 45% (both P < 0.001). The CRHP diet increased postprandial glucagon net AUC by 235% (P < 0.001), subjective satiety by 18% (P = 0.03), delayed gastric emptying by 15 min (P < 0.001), decreased gastric inhibitory polypeptide net AUC by 29% (P < 0.001), but had no significant effect on glucagon-like-peptide-1, total peptide YY, and cholecystokinin responses. A CRHP diet reduced glucose excursions and improved β-cell function, including proinsulin processing, and increased subjective satiety in patients with T2D.
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Affiliation(s)
- Mads J Skytte
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Jan Frystyk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens F Rehfeld
- Department. of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens J Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Keith Burling
- Core Biochemical Assay Laboratory, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Mogens Fenger
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Copenahagen, Denmark
| | - Mads N Thomsen
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Thomas M Larsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
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Thomsen MN, Skytte MJ, Astrup A, Deacon CF, Holst JJ, Madsbad S, Krarup T, Haugaard SB, Samkani A. The clinical effects of a carbohydrate-reduced high-protein diet on glycaemic variability in metformin-treated patients with type 2 diabetes mellitus: A randomised controlled study. Clin Nutr ESPEN 2020; 39:46-52. [PMID: 32859328 DOI: 10.1016/j.clnesp.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/01/2020] [Accepted: 07/03/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND & AIMS High glycaemic variability (GV) is associated with late complications in type 2 diabetes (T2D). We hypothesised that a carbohydrate-reduced high-protein (CRHP) diet would reduce GV acutely in patients with T2D compared with a conventional diabetes (CD) diet. METHODS In this controlled, randomised crossover study, 16 patients with metformin-treated T2D (median (IQR) age: 64.0 (58.8-68.0) years; HbA1c: 47 (43-57) mmol/mol; duration of T2D: 5.5 (2.8-10.3) years) were assigned to an energy-matched CRHP diet and CD diet (31E%/54E% carbohydrate, 29E%/16E% protein and 40E%/30E% fat, respectively) for two separate 48-h intervention periods. Interstitial continuous glucose monitoring (CGM) was performed to assess accepted measures of glycaemic variability, i.e. standard deviation (SD) around the sensor glucose level; coefficient of variation in percent (CV); mean amplitude of glucose excursions (MAGE); continuous overlapping net glycaemic action (CONGA1, CONGA4) of observations 1 and 4 h apart; and mean absolute glucose (MAG) change. RESULTS All indices of glycaemic variability (mean ± SD) were significantly reduced during CRHP diet compared with CD diet; including SD (1.0 ± 0.3 (CRHP) vs 1.6 ± 0.5 mmol/L (CD)), CV (12.3 ± 3.8 vs 19.3 ± 5.5%), MAGE (2.3 ± 0.9 vs 4.2 ± 1.3 mmol/L), CONGA1 (0.8 ± 0.3 vs 1.5 ± 0.4 mmol/L), CONGA4 (1.4 ± 0.5 vs 2.5 ± 0.8 mmol/L), and MAG change (0.9 ± 0.3 vs 1.4 ± 0.4 mmol/L/h) (p < 0.001 for all). Compared with the CD diet, the CRHP diet improved the diurnal glucose profile by reducing 24-h mean sensor glucose (7.7 ± 1.6 vs 8.6 ± 2.0 mmol/L). CONCLUSIONS In T2D patients treated with diet and metformin, two days of iso-energetic replacement of dietary carbohydrates by protein and fat reduced all indices of glycaemic variability by 36%-45% when compared with a conventional diabetes diet. These data may support reduction of carbohydrates as dietary advice for T2D patients. CLINICALTRIALS. GOV IDENTIFIER NCT02472951.
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Affiliation(s)
- Mads N Thomsen
- Dept. of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
| | - Mads J Skytte
- Dept. of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Arne Astrup
- Dept. of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Carolyn F Deacon
- Endocrinology Research Section, Dept. of Biomedical Sciences, University of Copenhagen, Denmark; Section for Translational Physiology, NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Jens J Holst
- Endocrinology Research Section, Dept. of Biomedical Sciences, University of Copenhagen, Denmark; Section for Translational Physiology, NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Sten Madsbad
- Dept. of Endocrinology, Copenhagen University Hospital Amager Hvidovre, Copenhagen, Denmark
| | - Thure Krarup
- Dept. of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Steen B Haugaard
- Dept. of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark; Dept. of Internal Medicine, Copenhagen University Hospital Amager Hvidovre, Copenhagen, Denmark
| | - Amirsalar Samkani
- Dept. of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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Skytte MJ, Samkani A, Astrup A, Larsen TM, Frystyk J, Poulsen HE, Henriksen T, Holst JJ, Andersen O, Madsbad S, Haugaard SB, Krarup T, Larsen EL. Effects of a highly controlled carbohydrate-reduced high-protein diet on markers of oxidatively generated nucleic acid modifications and inflammation in weight stable participants with type 2 diabetes; a randomized controlled trial. Scand J Clin Lab Invest 2020; 80:401-407. [PMID: 32374188 DOI: 10.1080/00365513.2020.1759137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Carbohydrate-restricted diets are increasingly recognized as options for dietary management of type 2 diabetes mellitus (T2DM). We investigated the effects of a carbohydrate-reduced high-protein (CRHP) and a conventional diabetes (CD) diet on oxidative stress and inflammation in weight stable individuals with T2DM. We hypothesized that the CRHP diet would improve markers of oxidatively generated RNA and DNA modifications as well as inflammatory parameters. Thirty participants with T2DM were randomized to 6 weeks of CRHP or CD dietary treatment (30/50 energy percentage (E%) carbohydrate, 30/17E% protein, 40/33E% fat), followed by a cross-over to the opposite diet for a subsequent 6-week period. All meals were provided during the study and body weight was controlled. Diurnal urine samples were collected after 4 weeks on each diet and oxidatively generated RNA and DNA modifications were measured as 8-oxo-7,8-dihydroguanosine (8-oxoGuo) and 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG), respectively. Fasting concentrations of soluble urokinase plasminogen activator receptor, high-sensitivity C-reactive protein, tumor necrosis factor alpha and interleukin-6 were measured before and after 6 weeks of interventions. Compared with the CD diet, the CRHP diet increased 24-hour urinary excretion of 8-oxoGuo by 9.3% (38.6 ± 12.6 vs. 35.3 ± 11.0 nmol/24 h, p = .03), whereas 8-oxodG did not differ between diets (24.0 ± 9.5 vs. 24.8 ± 11.1 nmol/24 h, p = .17). Changes in plasma inflammatory parameters did not differ between CRHP and CD diets, all p ≥ .2. The clinical implications of increased RNA oxidation following a CRHP diet as well as long-term effects of carbohydrate-restriction on markers of oxidatively generated nucleic acid modifications should be a field of future study.
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Affiliation(s)
- Mads Juul Skytte
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Meinert Larsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Jan Frystyk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Henrik Enghusen Poulsen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Trine Henriksen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Jens Juul Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ove Andersen
- Clinical Research Centre and the Emergency Department, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Steen Bendix Haugaard
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Emil List Larsen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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Skytte MJ, Samkani A, Petersen AD, Thomsen MN, Astrup A, Chabanova E, Frystyk J, Holst JJ, Thomsen HS, Madsbad S, Larsen TM, Haugaard SB, Krarup T. A carbohydrate-reduced high-protein diet improves HbA 1c and liver fat content in weight stable participants with type 2 diabetes: a randomised controlled trial. Diabetologia 2019; 62:2066-2078. [PMID: 31338545 DOI: 10.1007/s00125-019-4956-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS Dietary recommendations for treating type 2 diabetes are unclear but a trend towards recommending a diet reduced in carbohydrate content is acknowledged. We compared a carbohydrate-reduced high-protein (CRHP) diet with an iso-energetic conventional diabetes (CD) diet to elucidate the effects on glycaemic control and selected cardiovascular risk markers during 6 weeks of full food provision of each diet. METHODS The primary outcome of the study was change in HbA1c. Secondary outcomes reported in the present paper include glycaemic variables, ectopic fat content and 24 h blood pressure. Eligibility criteria were: men and women with type 2 diabetes, HbA1c 48-97 mmol/mol (6.5-11%), age >18 years, haemoglobin >6/>7 mmol/l (women/men) and eGFR >30 ml min-1 (1.73 m)-2. Participants were randomised by drawing blinded ballots to 6 + 6 weeks of an iso-energetic CRHP vs CD diet in an open label, crossover design aiming at body weight stability. The CRHP/CD diets contained carbohydrate 30/50 energy per cent (E%), protein 30/17E% and fat 40/33E%, respectively. Participants underwent a meal test at the end of each diet period and glycaemic variables, lipid profiles, 24 h blood pressure and ectopic fat including liver and pancreatic fat content were assessed at baseline and at the end of each diet period. Data were collected at Copenhagen University Hospital, Bispebjerg and Copenhagen University Hospital, Herlev. RESULTS Twenty-eight participants completed the study. Fourteen participants carried out 6 weeks of the CRHP intervention followed by 6 weeks of the CD intervention, and 14 participants received the dietary interventions in the reverse order. Compared with a CD diet, a CRHP diet reduced the primary outcome of HbA1c (mean ± SEM: -6.2 ± 0.8 mmol/mol (-0.6 ± 0.1%) vs -0.75 ± 1.0 mmol/mol (-0.1 ± 0.1%); p < 0.001). Nine (out of 37) pre-specified secondary outcomes are reported in the present paper, of which five were significantly different between the diets, (p < 0.05); compared with a CD diet, a CRHP diet reduced the secondary outcomes (mean ± SEM or medians [interquartile range]) of fasting plasma glucose (-0.71 ± 0.20 mmol/l vs 0.03 ± 0.23 mmol/l; p < 0.05), postprandial plasma glucose AUC (9.58 ± 0.29 mmol/l × 240 min vs 11.89 ± 0.43 mmol/l × 240 min; p < 0.001) and net AUC (1.25 ± 0.20 mmol/l × 240 min vs 3.10 ± 0.25 mmol/l × 240 min; p < 0.001), hepatic fat content (-2.4% [-7.8% to -1.0%] vs 0.2% [-2.3% to 0.9%]; p < 0.01) and pancreatic fat content (-1.7% [-3.5% to 0.6%] vs 0.5% [-1.0% to 2.0%]; p < 0.05). Changes in other secondary outcomes, i.e. 24 h blood pressure and muscle-, visceral- or subcutaneous adipose tissue, did not differ between diets. CONCLUSIONS/INTERPRETATION A moderate macronutrient shift by substituting carbohydrates with protein and fat for 6 weeks reduced HbA1c and hepatic fat content in weight stable individuals with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT02764021. FUNDING The study was funded by grants from Arla Food for Health; the Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen; the Department of Clinical Medicine, Aarhus University; the Department of Nutrition, Exercise and Sports, University of Copenhagen; and Copenhagen University Hospital, Bispebjerg.
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Affiliation(s)
- Mads J Skytte
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark.
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - Amy D Petersen
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - Mads N Thomsen
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Elizaveta Chabanova
- Department of Radiology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Jan Frystyk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens J Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Henrik S Thomsen
- Department of Radiology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Amager Hvidovre, Copenhagen, Denmark
| | - Thomas M Larsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
- Department of Internal Medicine, Copenhagen University Hospital Amager Hvidovre, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
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Kandel D, Bojsen-Møller KN, Svane MS, Samkani A, Astrup A, Holst JJ, Madsbad S, Krarup T. Mechanisms of action of a carbohydrate-reduced, high-protein diet in reducing the risk of postprandial hypoglycemia after Roux-en-Y gastric bypass surgery. Am J Clin Nutr 2019; 110:296-304. [PMID: 30624666 DOI: 10.1093/ajcn/nqy310] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/11/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Postprandial hypoglycemia is a risk after Roux-en-Y gastric bypass (RYGB). OBJECTIVES We speculated that a carbohydrate-reduced, high-protein (CRHP) diet might reduce the risk of hypoglycemia and therefore compared the acute effects of a conventionally recommended (CR) diet and CRHP diet [55/30 energy percent (E%) carbohydrate and 15/30 E% protein, respectively] in RYGB patients. METHODS Ten individuals (2 males, 8 females, mean ± SD age 47 ± 7 y; stable body mass index 31 ± 6 kg/m2; 6 ± 3 y post-RYGB) with recurrent postprandial hypoglycemia documented by plasma glucose (PG) ≤3.4 mmol/L were examined on 2 d with isoenergetic CRHP or CR diets comprising a breakfast and subsequent lunch meal. RESULTS Peak PG was significantly reduced on the CRHP diet after breakfast and lunch by 11% and 31% compared with the CR diet. Nadir PG increased significantly on CRHP (by 13% and 9%). Insulin secretion was reduced, and glucagon secretion increased on the CRHP diet after both meals. Glucagon-like peptide 1 and glucose-dependent insulinotropic polypeptide secretion were lower after lunch but unaltered after breakfast on CRHP; β-cell function and insulin clearance were unchanged. CONCLUSIONS The CRHP diet lowered glucose excursions and reduced insulin secretion and incretin hormone responses, but enhanced glucagon responses compared with the CR diet. Taken together, the results may explain the decreased glucose variability and lower risk of postprandial hypoglycemia. This study was registered at clinicaltrials.gov as NCT02665715.
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Affiliation(s)
- Daniel Kandel
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | | | - Maria Saur Svane
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports
| | - Jens J Holst
- Endocrinology Research Section, Department of Biomedical Sciences
- Section for Translational Physiology, Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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Anholm C, Kumarathurai P, Samkani A, Pedersen LR, Boston RC, Nielsen OW, Kristiansen OP, Fenger M, Madsbad S, Sajadieh A, Haugaard SB. Effect of liraglutide on estimates of lipolysis and lipid oxidation in obese patients with stable coronary artery disease and newly diagnosed type 2 diabetes: A randomized trial. Diabetes Obes Metab 2019; 21:2012-2016. [PMID: 31050161 DOI: 10.1111/dom.13761] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 01/16/2023]
Abstract
Elevated levels of non-esterified fatty acids (NEFA) play a role in insulin resistance, impaired beta-cell function and they are a denominator of the abnormal atherogenic lipid profile that characterizes obese patients with type 2 diabetes (T2DM). We hypothesized that the GLP-1 receptor agonist liraglutide, in combination with metformin, would reduce lipolysis. In a randomized, double-blind, placebo-controlled, cross-over trial, 41 T2DM patients with coronary artery disease were randomized and treated with liraglutide-metformin vs placebo-metformin during 12- + 12-week periods with a wash-out period of at least 2 weeks before and between the intervention periods. NEFA kinetics were estimated using the Boston Minimal Model of NEFA metabolism, with plasma NEFA and glucose levels measured during a standard 180-minute frequently sampled intravenous glucose tolerance test. Liraglutide-metformin reduced estimates of lipolysis. Furthermore, placebo-metformin increased estimates of lipid oxidation, while treatment with liraglutide eliminated this effect. We conclude that liraglutide exerts a clinically relevant reduction in estimates of lipolysis and lipid oxidation which is explained, in part, by improved insulin secretion, as revealed by an intravenous glucose tolerance test.
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Affiliation(s)
- Christian Anholm
- Department of Internal Medicine, Copenhagen University Hospital, Glostrup, Denmark
- Department of Internal Medicine, Copenhagen University Hospital, Amager, Denmark
| | - Preman Kumarathurai
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Lene R Pedersen
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Raymond C Boston
- Departments of Medicine, St. Vincent's Hospital, University of Melbourne, Fitzroy, Victoria, Australia
| | - Olav W Nielsen
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Ole P Kristiansen
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Mogens Fenger
- Department of Clinical Biochemistry, Copenhagen University Hospital, Hvidovre, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Steen B Haugaard
- Department of Internal Medicine, Copenhagen University Hospital, Amager, Denmark
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
- Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark
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13
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Anholm C, Kumarathurai P, Pedersen LR, Samkani A, Walzem RL, Nielsen OW, Kristiansen OP, Fenger M, Madsbad S, Sajadieh A, Haugaard SB. Liraglutide in combination with metformin may improve the atherogenic lipid profile and decrease C-reactive protein level in statin treated obese patients with coronary artery disease and newly diagnosed type 2 diabetes: A randomized trial. Atherosclerosis 2019; 288:60-66. [PMID: 31326727 DOI: 10.1016/j.atherosclerosis.2019.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 06/28/2019] [Accepted: 07/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Atherosclerosis in obesity and type 2 diabetes (T2DM) is associated with low-grade inflammation (LGI) and dyslipidemia, where especially small, dense lipoprotein particles are atherogenic. The glucagon-like peptide-1 receptor agonist, liraglutide, reduces cardiovascular events by poorly understood mechanisms. We investigated the effect of liraglutide combined with metformin on LGI and lipoprotein density profiles in patients with stable coronary artery disease (CAD) and newly diagnosed T2DM. METHODS We conducted a randomized, double-blind, placebo-controlled, cross-over trial over a 12 + 12-week period, with ≥2-week wash-out. INTERVENTION liraglutide/metformin vs. placebo/metformin. Lipoproteins were separated by continuous density gradient ultracentrifugation, and LDL divided into five subfractions between 226 and 270 Å, considering particle size ≤255 Å as the atherogenic pattern. Plasma C-reactive protein and tumor necrosis factor-α were assessed by the enzyme-linked immunosorbent-assay. RESULTS 28 out of 41 randomized patients completed all visits. Intention-to-treat analysis was performed but one patient had statin dosage and was excluded from the analysis. 95% of the patients were on statin therapy. Overall, liraglutide did not affect lipid subfractions or markers of LGI compared to placebo. The combination of liraglutide and metformin reduced the total LDL subfractions, primarily by reducing the most atherogenic subfraction LDL5, and reduced CRP but not TNF-α. Explorative analyses suggested that the subfraction LDL5 during the wash-out period rebounded significantly at least in a per-protocol analysis of the sub-group of patients starting the liraglutide therapy. CONCLUSIONS In patients with CAD and newly diagnosed T2DM on stable statin therapy, liraglutide combined with metformin may improve the atherogenic LDL lipid profile and CRP.
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Affiliation(s)
- Christian Anholm
- Department of Internal Medicine, Copenhagen University Hospital, Glostrup, Denmark; Department of Internal Medicine, Copenhagen University Hospital, Amager, Denmark.
| | - Preman Kumarathurai
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg, Denmark
| | | | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Rosemary L Walzem
- Department of Poultry Science and Faculty of Nutrition, Texas A&M University, Texas, USA
| | | | | | - Mogens Fenger
- Department of Clinical Biochemistry, Copenhagen University Hospital, Hvidovre, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Steen Bendix Haugaard
- Department of Internal Medicine, Copenhagen University Hospital, Amager, Denmark; Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, Denmark
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14
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Samkani A, Skytte MJ, Anholm C, Astrup A, Deacon CF, Holst JJ, Madsbad S, Boston R, Krarup T, Haugaard SB. The acute effects of dietary carbohydrate reduction on postprandial responses of non-esterified fatty acids and triglycerides: a randomized trial. Lipids Health Dis 2018; 17:295. [PMID: 30591062 PMCID: PMC6309080 DOI: 10.1186/s12944-018-0953-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/18/2018] [Indexed: 02/08/2023] Open
Abstract
Background Postprandial non-esterified fatty acid (NEFA) and triglyceride (TG) responses are increased in subjects with type 2 diabetes mellitus (T2DM) and may impair insulin action and increase risk of cardiovascular disease and death. Dietary carbohydrate reduction has been suggested as non-pharmacological therapy for T2DM, but the acute effects on NEFA and TG during subsequent meals remain to be investigated. Methods Postprandial NEFA and TG responses were assessed in subjects with T2DM by comparing a carbohydrate-reduced high-protein (CRHP) diet with a conventional diabetes (CD) diet in an open-label, randomized, cross-over study. Each diet was consumed on two consecutive days, separated by a wash-out period. The iso-caloric CRHP/CD diets contained 31/54 E% from carbohydrate, 29/16 E% energy from protein and 40/30 E% from fat, respectively. Sixteen subjects with well-controlled T2DM (median HbA1c 47 mmol/mol, (37–67 mmol/mol) and BMI 30 ± 4.4 kg/m2) participated in the study. NEFA and TG were evaluated following breakfast and lunch. Results NEFA net area under curve (AUC) was increased by 97 ± 38 μmol/Lx270 min (p = 0.024) after breakfast but reduced by 141 ± 33 μmol/Lx180 min (p < 0.001) after lunch on the CRHP compared with CD diet. Likewise, TG net AUC was increased by 80 ± 28 μmol/Lx270 min (p = 0.012) after breakfast but reduced by 320 ± 60 μmol/Lx180 min (p < 0.001) after lunch on the CRHP compared with CD diet. Conclusions In well-controlled T2DM a modest reduction of dietary carbohydrate with a corresponding increase in protein and fat acutely reduced postprandial serum NEFA suppression and increased serum TG responses after a breakfast meal but had the opposite effect after a lunch meal. The mechanism behind this second-meal phenomenon of CRHP diet on important risk factors for aggravating T2DM and cardiovascular disease awaits further investigation. Trial registration The study was registered at clinicaltrials.gov ID: NCT02472951. https://clinicaltrials.gov/ct2/show/NCT02472951. Registered June 16, 2015.
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Affiliation(s)
- Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark.
| | - Mads J Skytte
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - Christian Anholm
- Department of Internal Medicine, Copenhagen University Hospital, Glostrup, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Carolyn F Deacon
- Endocrinology Research Section, Department of Biomedical Sciences, Copenhagen, Denmark.,Section for Translational Physiology, Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Endocrinology Research Section, Department of Biomedical Sciences, Copenhagen, Denmark.,Section for Translational Physiology, Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital, Amager Hvidovre, Copenhagen, Denmark
| | - Ray Boston
- School of Medicine, Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark.,Department of Internal Medicine, Copenhagen University Hospital, Amager Hvidovre, Copenhagen, Denmark
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Samkani A, Skytte MJ, Thomsen MN, Astrup A, Deacon CF, Holst JJ, Madsbad S, Rehfeld JF, Krarup T, Haugaard SB. Acute Effects of Dietary Carbohydrate Restriction on Glycemia, Lipemia and Appetite Regulating Hormones in Normal-Weight to Obese Subjects. Nutrients 2018; 10:nu10091285. [PMID: 30213037 PMCID: PMC6163561 DOI: 10.3390/nu10091285] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 12/26/2022] Open
Abstract
Postprandial responses to food are highly dependent on the macronutrient composition of the diet. We investigated the acute effects of transition from the recommended moderately high carbohydrate (HC) diet towards a carbohydrate-reduced high-protein (CRHP) diet on postprandial glycemia, insulinemia, lipemia, and appetite-regulating hormones in non-diabetic adults. Fourteen subjects, including five males (Mean ± SD: age 62 ± 6.5; BMI 32 ± 7.6 kg/m2; hemoglobin A1c (HbA1c) 40 ± 3.0 mmol/mol; HOMA2-IR 2.1 ± 0.9) were included in this randomized, cross-over study. Iso-caloric diets were consumed for two consecutive days with a median wash-out period of 21 days (range 2–8 weeks) between diets (macronutrient energy composition: CRHP/HC; 31%/54% carbohydrate, 29%/16% protein, 40%/30% fat). Postprandial glucose, insulin secretion rate (ISR), triglycerides (TGs), non-esterified fatty acids (NEFAs), and satiety ratings were assessed after ingestion of breakfast (Br) and lunch (Lu), and gut hormones and glucagon were assessed after ingestion of Br. Compared with the HC diet, the CRHP diet reduced peak glucose concentrations (Br 11%, p = 0.024; Lu 11%, p < 0.001), glucose excursions (Br 80%, p = 0.20; Lu 85%, p < 0.001), and ISR (Br 31%; Lu 64%, both p < 0.001) whereas CRHP, as compared with HC, increased glucagon-like peptide-1 (Br 27%, p = 0.015) and glucagon values (Br 249%, p < 0.001). NEFA and TG levels increased in the CRHP diet as compared with the HC diet after Br, but no difference was found after Lu (NEFA Br 22%, p < 0.01; TG Br 42%, p = 0.012). Beta-cell glucose sensitivity, insulin clearance, cholecystokinin values, and subjective satiety ratings were unaffected. It is possible to achieve a reduction in postprandial glycemia and insulin without a deleterious effect on beta-cell glucose sensitivity by substituting part of dietary carbohydrate with iso-caloric protein and fat in subjects without type 2 diabetes mellitus (T2DM). The metabolic effects are more pronounced after the second meal.
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Affiliation(s)
- Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, DK-2400 Copenhagen NV, Denmark.
| | - Mads J Skytte
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, DK-2400 Copenhagen NV, Denmark.
| | - Mads N Thomsen
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, DK-2400 Copenhagen NV, Denmark.
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, University of Copenhagen, DK-1017 Copenhagen K, Denmark.
| | - Carolyn F Deacon
- Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, DK-1017 Copenhagen K, Denmark.
- Section for Translational Physiology, NNF Center for Basic Metabolic Research, University of Copenhagen, DK-1017 Copenhagen K, Denmark.
| | - Jens J Holst
- Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, DK-1017 Copenhagen K, Denmark.
- Section for Translational Physiology, NNF Center for Basic Metabolic Research, University of Copenhagen, DK-1017 Copenhagen K, Denmark.
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital, Amager Hvidovre, DK-2650 Hvidovre, Denmark.
| | - Jens F Rehfeld
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark.
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, DK-2400 Copenhagen NV, Denmark.
| | - Steen B Haugaard
- Department of Endocrinology, Copenhagen University Hospital, Bispebjerg, DK-2400 Copenhagen NV, Denmark.
- Department of Internal Medicine, Copenhagen University Hospital, Amager Hvidovre, DK-2650 Hvidovre, Denmark.
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Samkani A, Larsen KVL, Faber CE, Godballe C. Bronchoschopy should always be performed in children on suspicion of foreign body aspiration. Dan Med J 2013; 60:A4715. [PMID: 24083529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Foreign body aspiration (FBA) can have a fatal outcome, and the diagnosis is challenging since symptoms and signs may vary. We therefore investigated whether it was possible to identify predictors indicating the presence of a foreign body. MATERIAL AND METHODS The medical records of children undergoing bronchoscopy at Odense University Hospital for suspected FBA in the period from 1977 to 2010 were reviewed and analyzed. RESULTS A total of 143 children underwent bronchoscopy due to suspected FBA. The medical records of 137 of these children were accessible. Their median age was 1.84 years, 62.8% were male and foreign bodies were found in 76 cases (55.5%). The only variable that statistically significantly predicted the presence of a foreign body was a radiologic finding (any abnormal chest X-ray or fluoroscopy) (p = 0.023). A foreign body was found in 22 out of 47 (46.8%) patients with no radiologic findings and in three of 11 (27%) patients with neither symptoms at admission nor radiologic or physical findings. CONCLUSION Parental suspicion of an FBA indicates acute bronchoscopy in children regardless of signs, symptoms and findings.
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