Effects Of Dietary Intervention On Management For IGR And T2DM

Association of target hemoglobin ale control with nutritional status in Community-based patients with type 2 diabetesObjective:At present, the rate of blood glucose control in community-based patients with type 2 diabetes is relatively low. It is very urgent to take further rigorous treatment for diabetes patients. Dietary therapy is essentially for any stage of diabetes treatment, but diabetes patients still have many misunderstandings with it. To further guide the rational diet and control blood sugar in patients with type 2 diabetes, Our study divided patients into two groups according to glycosylated hemoglobin (HbAlc) levels. We compared the level of glucose and lipid metabolism, oxidative stress and nutritional status between the HbAlc level controlled group and the uncontrolled group, and explored the possible correlation between HbAlc control and nutritional status in community-based patients with type 2 diabetes.Methods:In four community health service centers in Shanghai, we recruited 336 patients with type 2 diabetes. According to "China Type 2 Diabetes Prevention Guide" (2007 version) recommended target HbAlc control, subjects were divided into 2 groups:the group with HbAlc level controlled (HbAlc<6.5%, n=167), the group with HbAlc level uncontrolled (HbAlc≥6.5%, n=169). Height, weight, waist circumference and blood pressure were measured by standard methods. Subjects received oral glucose tolerance test (OGTT). Blood glucose, blood lipids were detected by automatic biochemical analyzer, Hitachi. Insulin and C peptide measured by radioimmunoassay. We also examined the level of oxidative stress, indicators including maleic dialdehyde (MDA), glutathione (GSH) and superoxide dismutase (SOD). We asked subjects directly face to face, using the quantitative food frequency questionnaire. We used specialized software (Shanghai SY develop software) to analyze survey results, calculated per capita daily intake of nutrients. Metabolic parameters, food components and nutritional status were compared among 2 groups.Results:(1) The percentage of HbAlc<6.5% among all the participants was 49.25%. (2) After adjusting for age and sex, the level of waist circumference, waist-hip ratio, fasting glucose, postprandial 2 hour glucose, HOMA-IR in the group with HbAlc level controlled were significantly lower than compliance group, and the level of GSH was higher than compliance group (P<0.05). As to HbAlc level, it was positively correlated with fasting plasma glucose,2-hour postprandial plasma glucose, HOMA-IR, Fasting Insulin, Fasting C-Peptide, Weight, waist circumference and waist to hip ratio(r=0.648,0.539,0448,0.269,0.134,0.236,0.157,0.179 respectively, P＜0.05 or P＜0.01), and negatively correlated with high lipoprotein-cholesterol, GSH and SOD (r=-0.148,-0.220,-0.180 respectively, P＜0.05 or P＜0.01). (3) The nutritional status were significant different between two groups. The intake of pure energy-providing foods in the HbA1c level uncontrolled group were significantly higher than the other group, P<0.05. The level of HbAlc was positively correlated with meats food intake(r= 0.118, P＜0.05), and negatively correlated with fruit intake(r=-0.115, P＜0.05). Multiple linear regression analysis showed that fruits and meats food have great impact on FBG,2h-PBG and HbA1c. (4) The intake of protein, total fat, SFA, MUFA and PUFA of patients in the HbAlc level uncontrolled group were significantly higher than the other group (P<0.05). The intake of mineral and vitamin between two groups are different. Both groups intake less calcium, zinc, magnesium, potassium, Vit B1 and Vit B2 than the recommended intake. Correlation analysis, HbAlc was positively correlated with total fat, SFA (r=0.157,0.197, P＜0.01). Principal component regression analysis showed that blood sugar levels in diabetic patients are affected by many dietary nutrients.Conclusion:In community-based patients with type 2 diabetes mellitus, the percentage of HbAlc level controlled was higher than other studies. The level of HbAlc controlled helped diabetic patients to reduce the level of other metabolic risk factors, and increase the antioxidant capacity of. In our study, the level of BMI, waist circumference and serum triglycerides of diabetic patients were excess the normal reference values. The outcome of dietary survey showed that the nutritional status of type 2 diabetic patients has been improving, while some irrational phenomenons still existed. The main differences of the nutritional status between two groups were unbalanced diet, high fat intake, inadequate intake of dietary fiber, some minerals and vitamins. These problems were more serious in the group with HbA1c level uncontrolled. It helped to control blood glucose for diabetes patients that appropriate increasing in intake of vegetables, fruits, grains and dried beans food, and reducing intake of meats food and pure energy material. Therefore, type 2 diabetes patients should respond to a reasonable diet therapy, to enhance the control of blood glucose and other metabolic risk factors, and to achieve diabetes control as soon as possible. Effects of dietary intervention on management for IGR and T2DMObjectives:The incidence and mortality of diabetes have been increasing in recent years in China. Impaired glucose regulation is a special clinical stage before DM. As the increasing degree of blood glucose during the period of IGR has strong positive relationship to the macro vascular complications. Therefore, correct understanding and positive intervening to IGR are quite important to the prevention of occurrence and progression of type 2 DM and macro vascular complications. Conducted as a randomized control clinical trial, this study recruited patients of IGR and type 2 DM and researched the impact of dietary and nutritional intervention on improving IGR and controlling T2DM.Methods:Patients were recruited from three community health service centers, who met the diagnostic criteria for type 2 diabetes issued by American Diabetes Association 1999. Totally,222 subjects were recruited to the study and among whom 99 were IGR patients and 123 were T2DM patients.The study lasted for 12 months and 222 patients were grouped as control (n=111, 49 were IGR and 61 were DM) and intervention (n=111,49 were IGR and 62 were DM). The patients in control group only got regular health education on diabetes prevention. The patients in intervention group got 2-phase clinical intervention:(1) Phase one (the 1-3 month of the trial). The patients got strengthening nutrition interventions, which include:①Meal replacement. Regular breakfast was partly replaced by 50g powder of MR that contains 227Kcai energy.②Diet Counseling. Calculated the total energy in the range of 25-30Kcal·Kg-1·d-1 according to each patient's height, weight and provided corresponding recipe for reference.③Health Education. Content covered the early stage of diabetes control, balanced diet, and regular exercise. Lecture format mostly was small salons. We participated in interactive discussions with participants, and provided detailed textual materials.④Weekly follow-up to get information on weight, waistline, blood glucose, blood pressure and diet. Meanwhile, dietitian gave special guide to special patient. (2) Phase two (the 4-12 month of the trial). Follow-up was conducted per months while the contents of follow-up were same as in the former phase.Patients in the intervention group got comprehensive physical evaluations at the time of baseline, interim (the end of 3rd month) and the end of the trial while patients in the control group only got examinations at baseline and the end. Examinations include:(1) Iindicators of anthropometric and clinical examination:including body weight, waist circumference and blood pressure,fasting blood glucose and oral glucose tolerance test (OGTT) 2h blood glucose, glycated hemoglobin (HbA1c), blood lipids, antioxidant index. (2) Investigation by questionnaire:①Normal questionnaire, which include gender, age, education, occupation, family history of diabetes, drug use, and so on.②Diet investigation questionnaire. Food frequency questionnaire was applied to interview and the results were analyzed to calculate the nutrients got by per capita per day.Results:1. For intervention to T2DM patients:(1) Phase One, the rate of FBG level controlled and non-FBG level controlled in DM intervention group was 46.77%,29.03% respectively, significantly higher than baseline (P<0.05 or P<0.01). DM intervention group showed significant decrease of blood pressure, weight, BMI, waistline, hip and WHR from baseline, among which weight decreased by 2.12%. Compared with control, the level of glucose metabolism in intervention group, such as FBG(-0.52±0.97mmol/L),2h-PBG(-2.96±2.84mmol/L) and FC-P(-0.62±0.93ng/ml), decreased significantly; the level of oxidative stress, such as GSH (2.11±4.41g/L) and SOD (9.70±12.91U/ml) increased remarkable, MDA(-1.06±2.18nmol/L) decreased significantly compared with control (P<0.05 or P<0.01). The indicators of lipid metabolism showed little improvement. Furthermore, the dietary and nutritional intervention decreased the quantity of total fat taken by DM patients notably and increased the intake of carbohydrates, dietary fiber, some kinds of minerals and vitamins.(2) Phase Two, the rate of non-FBG level controlled (16.07 vs.3.23%) was significantly higher than baseline (P<0.05).DM intervention group showed significant decrease on the level of FBG (6.75±1.18vs.7.43±2.08mmol/L), HbA1c (6.19±0.49vs. 6.49±1.02%) and MDA (3.50±0.90vs.4.30±1.97nmol/L) compared with control (P＜0.05 or P＜0.01). However, there was no difference on anthropometric indicators and the indicators of lipid metabolism between the two groups. Compared with control, the intake of carbohydrates, MUFA, PUFA, N-6 fatty acid, calcium, Vit A, energy supply proportion of lipid and carbohydrates in the intervention group showed significant improvement (P＜0.05 or P＜0.01).(3) For T2DM patients, moderate increase in protein, dietary fiber, iron, zinc, manganese, magnesium and niacin lowered fasting glucose levels; increased in N-3 fatty acids or decreased in carbohydrate reduced 2h postprandial blood glucose levels; increased copper intake raised the level of HbA1c.2. For intervention to IGR patients:(1) Phase One, in the IGR intervention group,22 patients had transferred blood sugar levels to the usual state (vesting rate of 41.0%),2 patients meet the diabetes diagnostic criteria (change rate of 4.0%). Compared with baseline, IGR intervention group showed significant decrease of weight, BMI, waistline, hip and WHR; and indicators'of glucose metabolism such as 2h-PBG (-0.92±1.47mmol/L) and FC-P (-0.62±1.12ng/ml) decreased significantly; while oxidative stress such as SOD (10.22±15.39U/ml) increased significantly (P＜0.05 or P＜0.01). TG and LDL-C declined in IGR intervention group without statistical significance. The results showed that dietary and nutritional intervention increased the intake of carbohydrates, dietary fiber, some kinds of minerals and vitamins of IGR patients.(2) Phase Two, in the IGR intervention group,29 patients (59.0%) had transferred blood sugar levels to the usual state,6 patients (12.0%) meet the diagnostic criteria for diabetes. In the IGR control group,8 patients (16.0%) had blood glucose levels normally,9 (18.0%) became diabetic. There are significant difference between two groups (P<0.01). Compared with control, IGR intervention group showed significant decrease on BMI, waist circumference (P<0.01); significant decrease on FBG (5.57±0.68vs.6.00±0.70mmol/L),2h-PBG (7.68±2.49vs.10.36±4.16mmol/L), HbA1c (5.67±0.34vs.5.89±0.26%)and LDL-C (2.90±1.17vs.3.45±0.55mmol/L); and remarkable increase on HDL-C (1.71±0.72vs.1.31±0.25mmol/L)and SOD (62.00±14.28vs.47.42±14.32U/ml) (P<0.05 or P<0.01).However, IGR intervention group did not show any remarkable improvement of nutrition when compared with control.(3) For IGR patients, moderate increase in SFA, MFA and cholesterol intake could increased the fasting blood glucose levels in patients with IGR; increased Vit A intake raised 2h postprandial blood glucose levels, increased calcium intake improved the HbAlc level.Conclusions:1. The dietary and nutritional intervention based on meal replacement improved the glycemic control state of DM patients greatly. For IGR patients, this intervention was beneficial to transfer blood sugar levels to the usual state. Therefore, dietary intervention may; be an effective measure for management of impaired glucose regulation and type 2 diabetes patients. 2. For diabetic patients, our dietary intervention reduced fasting blood glucose levels, lowered HbAlc and MDA concentration. Dietary intervention significantly improved the nutritional status of diabetic patients. Moderate increase in protein, dietary fiber, iron, zinc, manganese, magnesium, niacin, and N-3 fatty acids could reduce the blood glucose levels of diabetic patients.3. For patients with impaired glucose regulation, dietary intervention based on meal replacement reduced fasting glucose and HbAlc levels, improved glucose tolerance. It was also effective to improve lipid metabolism, control weight, reduce waist circumference. It improved the status of oxidative stress in IGR patient. This intervention improved the nutritional status of IGR patients, but no significant effects were observed. Increased the SFA, MFA, cholesterol, Vit A and calcium intake would raise the blood glucose levels in patients with impaired glucose regulation.