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840
Nutrition of insulin treated patients with diabetes mellitus in Germany: Recommendations and reality - The 10 year follow-up of a prospective, population-based survey (JEVIN)
S. Siefke, R. Schiel, C. Helbich, A. Braun, A. Rillig, U. A. Müller;
Department of Internal Medicine II, University of Jena Medical School, Jena, Germany.
Background/Aims: Since 1989/90 in diabetes therapy there was a liberalisation of diet in Germany: Fixed nutrition plans and highly restricted eating (no sugar, no sweets) were abandoned. Today, regular intake of sugar and sweets is allowed for all patients with diabetes. However, to manage a liberal diet, patients‘ participation in structured treatment and teaching programmes is mandatory. Here, patients learn to calculate their carbohydrate intake, the insulin dose adjustment and the measurements in the case of high or low blood glucose values. Up to the present data about the impact of diet liberalisation, of "free eating", are only few and mostly anecdotal. Hence, in 1989/90 JEVIN was designed as a 10 years, population-based, prospective survey of all patients with type 1 and insulin treated type 2 diabetes aged 16-60 years and living in the city of Jena (100,000 inhabitants).
Methods: In 1989/90, 1994/95 and 1999/2000 totally 190, 244 and 261 patients, respectively, were examined. (1999/2000: 90% of the target population were studied: type 1/2: n=114/147, age 42.5±11/52.2±7 years, BMI 25.9±3.7/30.4±5.6 kg/m2, HbA1c [mean normal 4.7%, Tosho] 6.96±1.41/6.91±1.18%).
Results: In 1989/90 all the patients studied had a fixed nutrition plan. For all patients the intake of sugar and sweets were abandoned. In 1994/95 only 22.0% of patients (n=28/127) with type 1 and 37.6% of patients (n=44/117) with type 2 diabetes still had fixed nutrition plans. Up to 1999/2000 there was a further decrease in the number of patients with fixed nutrition plans: Only 10/114 patients (8.8%) with type 1 (p<0.0001 vs 1994/95 and 1989/90) and 17/147 patients (11.6%) with type 2 diabetes (p<0.0001 vs 1994/95 and 1989/90) had fixed nutrition plans. In 1999/2000 92/114 (80.7%) patients with type 1 and 102/147 patients (69.4%) with type 2 diabetes eat sugar and sweets in every days life. In the mean patients with type 1 diabetes eat 14.6±4.8 (range, 5-33) and patients with type 2 diabetes 12.7±3.5 (range, 5-31) carbohydrate units [=10g carbohydrate] per day. Assessing daily energy intake derived from carbohydrates the results found were 600,1±197,3/522,0±143,9 kcal/d (1 carbohydrate unit» 41,1 kcal) for patients with type 1/2 diabetes. Calculating real daily energy intake the results (based on the mean body weight of 76.9±13.4/88.4±17.3 kg in patients with type 1/2 diabetes) in patients with type 1/2 diabetes were 2460.8±428.8/2828.8±553.6 kcal (32 kcal/kg body weight). Following these assessments in daily real life patients with type 1 diabetes eat 24%, insulin treated patients with type 2 diabetes eat 18% of the daily energy intake in form of carbohydrates.
Conclusions: During the 10-years follow-up, in the present population-based survey the quality of diabetes control in patients with type 1 and insulin treated type 2 diabetes improved (JEVIN, 1994/95 vs 1999/2000: type 1: 7.76±1.65% vs 6.69±1.41%, p<0.001, type 2: 8.23±1.88% vs 6.91±1.18%, p<0.001), "although" the liberalisation of diet and regular eating of sugar and sweets. However, in contrast to the national guidelines ("50% of daily energy should derived from carbohydrates), in reality in patients with diabetes less than 25% of daily’s energy derived from carbohydrates. Guidelines should be critically evaluated and maybe adapted.
839
A high protein (30%) diet improves blood glucose control in people with untreated Type 2 diabetes.
M. C. Gannon, F. Q. Nuttall;
Medicine, VA Medical Center & Univ of Minnesota, Minneapolis, MN, USA.
Background and Aims: Ingested protein does not increase blood glucose, but does increase insulin concentration. Thus, an increase in dietary protein should result in an improvement in blood glucose control in people with type 2 diabetes. To test this hypothesis, we have compared the effect of a 30% protein diet vs a 15% protein diet on blood glucose control in people with untreated type 2 diabetes. Protein was substituted for carbohydrate. The fat content of the diet was unchanged.
Materials and Methods: A randomized 5-week crossover design was used in which a weight-maintaining diet composed of 30% protein, 30% fat, 40% carbohydrate was compared with an isocaloric diet of 15% protein, 30% fat, 55% carbohydrate in 11 subjects (9 males:2 females) with untreated type 2 diabetes. The fat distribution of both diets was 10% mono- 10% poly-, and 10% saturated. All food was provided from the metabolic kitchen at the medical center. Subjects remained weight stable throughout the study period. Compliance was determined by measuring the urine urea:creatinine ratio twice per week during each of the 5 week periods.
Results: Fasting glucose concentrations were similar after 5 weeks on either diet (6.3 ± 0.3 mmol/L). However, the 24 hour integrated total glucose area response was 187 ± 12.5 vs 174 ± 7.4 mmol.hr/L following 5 weeks on the 15% vs 30% protein diet, respectively (i.e., a decrease of 7%). The mean total glycohemoglobin (tGHb) was modestly but not statistically significantly decreased following the 15% protein diet (7.9 to 7.6%). The decrease was greater after the 30% protein diet (8.1 to 7.3%). This was statistically significant (P< 0.05). The greater decrease in % tGHb (0.8 - 0.3 = 0.5%) represents a mean decrease of ~ 0.5 mmol/L glucose integrated over 24 hours. Extrapolating this to a red blood cell turnover time of 100 days yields an expected decrease in integrated glucose of 1.0 mmol/L or 18 mg/dl.
The fasting insulin concentrations were similar following 5 weeks on the diet (107 ± 23 vs 115 ± 22 pmol/L for the 15 and 30% protein diet, respectively). The 24 hour integrated net insulin area response using the fasting insulin concentration as baseline was modestly, but not significantly greater (117 ± 31 vs 139 ± 34 pmol.hr/L for the 15 and 30% protein diet, respectively). The over-night fasting triglyceride concentration was significantly decreased following the 30% vs 15% protein diet (1.8 ± 0.3 vs 2.3 ± 0.2 mmol/L, respectively) (P< 0.05). Total-, HDL-, and LDL-cholesterol, and urinary microalbumin and creatinine clearance were not different between diets.
Conclusion: We conclude that a high protein diet results in improved blood glucose control without having an adverse effect on plasma lipids or kidney function.
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