Glycemic index in the diet of European outpatients with type 1 diabetes: relations to glycated hemoglobin and serum lipids.

BACKGROUND: Little is known about the variation of the glycemic index (GI) in the diet of European outpatients with type 1 diabetes and how the GI of a commonly consumed diet is associated with metabolic control. OBJECTIVE: The present study examined the calculated dietary GI of European outpatients with type 1 diabetes for possible relations to glycated hemoglobin (Hb A(1c)) and serum lipid concentrations. DESIGN: The relation of the GI (calculated from a 3-d dietary record) to Hb A(1c), serum cholesterol (total, LDL, and HDL), and fasting triacylglycerol was analyzed in 2810 people with type 1 diabetes from the EURODIAB Complications Study. RESULTS: The GI was independently related to Hb A(1c) (P = 0.0001). Compared with the highest GI quartile (median GI: 89), adjusted Hb A(1c) in the lowest GI quartile (median GI: 75) was 11% lower in patients from southern European centers and 6% lower in patients from northern, western, and eastern European centers. Of the serum lipids, only the HDL cholesterol in patients from these European centers was independently related to the GI (P = 0.002). In southern European centers, the consumption of pasta, temperate-climate fruit, white bread, and potatoes largely determined the patients' dietary GI, whereas in the northern, western, and eastern European centers, consumption of bread, potatoes, and temperate-climate fruit was most relevant. CONCLUSIONS: This study in European patients with type 1 diabetes showed that a lower dietary GI is related to lower Hb A(1c) concentrations, independently of fiber intake. The consumption of bread and pasta had the biggest effect on the overall dietary GI of European outpatients.

Nutrient intakes as predictors of body weight in European people with type 1 diabetes.

BACKGROUND: Overweight and obesity are also found among persons with type 1 diabetes. OBJECTIVE: The present study examined which nutrients predict the body mass index (BMI), the waist-to-hip ratio (WHR) and the waist circumference (WC) of European persons with type 1 diabetes. DESIGN: Cross-sectional, clinic-based study (EURODIAB Complications Study). SUBJECTS AND METHODS: Nutrient intakes (assessed by a 3-day dietary record) predicting measures of body weight (BMI, WHR and WC) were determined by stepwise forward regression analysis in 1458 males and 1410 females with type 1 diabetes (P< or =0.05 for inclusion). RESULTS: In men, a higher carbohydrate intake was a significant independent predictor for lower levels of BMI, WHR and WC, an increased saturated fat intake and a lower intake of cereal fibre predicted a higher WHR, a higher monounsaturated fat intake and a lower glycaemic index of the diet determined lower levels of WHR and WC, and a moderate consumption of alcohol determined an increased WC. In women, a higher carbohydrate intake predicted a lower BMI and a thinner WC, no alcohol consumption determined a lower BMI, and an increased intake of saturated fat and a lower consumption of cereal fibre were significant independent predictors for a higher WHR. CONCLUSIONS: A modified fat intake, an increase of carbohydrate and cereal fibre intake and a preferred consumption of low glycaemic index foods are independently related to lower measures of body weight in European persons with type 1 diabetes.

Carbohydrate sources and glycaemic control in Type 1 diabetes mellitus. EURODIAB IDDM Complications Study Group.

AIMS: Little information is available on the relationship between glycated haemoglobin levels and the source or amount of dietary carbohydrate. The present study compares the association of carbohydrate intake with HbA1c between European individuals with Type 1 diabetes mellitus injecting insulin once or twice per day and those with > or = 3 daily injections. METHODS: The relation of carbohydrate intake (total, cereal, fruit, vegetable, milk, and potato carbohydrate assessed by a 3-day dietary record) to HbA1c was examined in 2084 patients (age 32.6 +/- 10.2 years, duration of diabetes 14.8 +/- 9.5 years) included in the EURODIAB Complications Study. RESULTS: In both insulin injection regimens, an increased intake of total carbohydrate (% of energy) and a higher consumption of potato carbohydrates (g) were associated with higher levels of HbA1c, whereas an increased intake of vegetable carbohydrate (g) was inversely related to HbA1c. These tendencies were all more pronounced in persons with one or two daily insulin injections. Consumption of cereal and fruit carbohydrates (g) was not related to HbA1c, irrespective of the insulin injection regimen. A trend of HbA1c to increase with higher intakes of milk carbohydrate was confined to those with one or two insulin injections per day (test for interaction: P = 0.01). CONCLUSIONS: In particular, subjects with only 1 or 2 daily insulin injections per day should receive specific advice to correctly consider milk and potato carbohydrates. On the other hand, people with Type 1 diabetes may profit from a higher consumption of vegetable carbohydrates for their levels of HbA1c.

Associations of fat and cholesterol intake with serum lipid levels and cardiovascular disease: the EURODIAB IDDM Complications Study.

The EURODIAB IDDM Complications Study, a cross-sectional, clinic-based study examined the fat and cholesterol intakes of European individuals with type 1 diabetes for possible relations to serum lipid levels (total cholesterol, HDL- and LDL-cholesterol, fasting triglycerides) and to the prevalence of cardiovascular disease (past history or electrocardiogram abnormalities). Fat intake (total fat, saturated fat, cholesterol) from 2,868 subjects with type 1 diabetes (mean age 32.9 +/- 10.2 years (range: 14-61 years), mean diabetes duration 14.7 +/- 9.4 years (range: 1-56 years)) was assessed by a standardized 3-day dietary record at the Nutrition Co-Ordinating Centre (Düsseldorf). Serum lipid levels were determined in the central laboratory (London) by standard enzymatic methods. Energy-adjusted total and LDL-cholesterol levels increased significantly with higher intakes of total fat, saturated fat and cholesterol. However, these relations were largely explained by concomitant decreases in dietary fibre intake. For levels of HDL-cholesterol and triglycerides no independent associations were observed with fat or cholesterol intake. Increased intakes of total fat, saturated fat and cholesterol were also related to higher prevalences of cardiovascular disease. These associations were, however, no longer significant after adjustment for dietary fibre intake for which we previously demonstrated independent associations with the serum cholesterol pattern and CVD. Since higher fat intakes are commonly accompanied by lower carbohydrate and fibre intakes we conclude that restricted intakes of cholesterol, saturated fat and total fat combined with higher fibre intakes beneficially affect both the levels of total and LDL-cholesterol and the risk for cardiovascular disease in European individuals with type 1 diabetes.

Fiber intake, serum cholesterol levels, and cardiovascular disease in European individuals with type 1 diabetes. EURODIAB IDDM Complications Study Group.

OBJECTIVE: A cross-sectional analysis of dietary fiber intake was performed in European type 1 diabetic patients enrolled in the EURODIAB IDDM Complications Study to explore its potential relationship to serum cholesterol levels and the prevalence of cardiovascular disease (CVD). RESEARCH DESIGN AND METHODS: Dietary intake was assessed by a standardized 3-day dietary record. For analysis of fiber intake (total, soluble, and insoluble) and its associations with CVD (past history or electrocardiogram abnormalities), complete data were available from 1,050 male and 1,012 female individuals. Relationships of fiber intakes to serum cholesterol levels (total, HDL, and LDL cholesterol) were examined in 926 men and 881 women with type 1 diabetes. RESULTS: Higher intakes of total fiber (g/day) were independently associated with significantly higher levels of HDL cholesterol in male (P = 0.01) and female individuals (P = 0.03). Fiber intakes of men with type 1 diabetes were also inversely related to ratios of total cholesterol to HDL cholesterol (P = 0.0001) and levels of LDL cholesterol (P = 0.0002). A protective effect of total fiber intake against CVD was observed for female subjects, where a significant trend was maintained after adjustment for potential confounders, including energy and saturated fat (P = 0.03 vs. P = 0.2 in men). Results were similar in separate analyses of soluble and insoluble fiber. CONCLUSIONS: The present study demonstrates that higher fiber intakes are independently related to beneficial alterations of the serum cholesterol pattern in men and to a lower risk for CVD in European insulin-dependent women. Beneficial effects can already be observed for fiber amounts within the range commonly consumed by outpatients with type 1 diabetes.

Prevalence of chronic complications, metabolic control and nutritional intake in type 1 diabetes: comparison between different European regions. EURODIAB Complications Study group.

This study compares the prevalence of chronic complications, the quality of metabolic control and the nutritional intake in people with type 1 diabetes in different European regions. The EURODIAB Complications Study included a sample of 3250 European patients with type 1 diabetes stratified for gender, age and diabetes duration. All examinations were performed using standardised, validated methods. HBA1c, LDL-cholesterol and fasting triglycerides were higher in the eastern European centres than in the southern or north-western European centres. Acute (severe ketoacidosis, severe hypoglycaemia) and chronic diabetes complications (retinopathy, nephropathy, neuropathy, cardiovascular disease) were all considerably more frequent in the eastern European centres. HbA1c was lower in the German centres than in the total EURODIAB cohort or in the north-western European centres, but severe hypoglycaemia and proliferative retinopathy were more common. Persons from the eastern European and the German centres consumed undesirably high amounts of cholesterol, total and saturated fat. Overall, improvements in the prevention, detection and management of diabetes complications in persons with type 1 diabetes are essential throughout Europe, particularly in eastern European regions. Since elevated LDL-cholesterol levels and hypertension were strikingly common in this relatively young cohort of European people with type 1 diabetes, generally more attention should be directed towards an adequate management of these cardiovascular risk factors.

Relation of fibre intake to HbA1c and the prevalence of severe ketoacidosis and severe hypoglycaemia. EURODIAB IDDM Complications Study Group.

The effect of dietary fibre intake on glycaemic control is still controversial. This study analysed the intake of natural dietary fibre in patients with Type I diabetes mellitus enrolled in the EURODIAB IDDM Complications Study to determine any associations with HbA1c levels and with the prevalence of severe ketoacidosis or severe hypoglycaemia. Dietary intake was assessed by a 3-day dietary record. The relation between intake of fibre (total, soluble and insoluble) and HbA1c was examined in 2065 people with Type I diabetes. Associations with severe ketoacidosis (requiring admission to hospital) and severe hypoglycaemia (requiring the help of another person) were analysed in 2687 people with Type I diabetes. Total fibre intake (g/day) was inversely related to HbA1c (p = 0.02), independently of carbohydrate intake, total energy intake and other factors regarding lifestyle and diabetes management. Severe ketoacidosis risk fell significantly with higher fibre intake (p = 0.002), with an adjusted odds ratio of 0.48 (95 % confidence interval 0.27 to 0.84) in the highest quartile ( > or = 23.0 g fibre/day) compared with the lowest quartile ( < or = 13.7 g fibre/day). The occurrence of severe hypoglycaemia was not related to fibre intake. Beneficial effects of fibre on HbA1c and the risk of severe ketoacidosis were particularly pronounced in patients from southern European centres. This study shows that higher fibre intake is independently related to a reduction in HbA1c levels in European people with Type I diabetes. Furthermore, increased fibre intake may reduce the risk of severe ketoacidosis. These beneficial effects were already observed for fibre intake within the range commonly consumed by people with Type I diabetes.

Repeatability of three-day dietary records in the EURODIAB IDDM Complications Study.

OBJECTIVES: Repeatability of a dietary method is important in determining the quality of nutritional data. It should be assessed in the population of interest. This study evaluated the repeatability of nutritional data from standardized three-day dietary records, from the clinic-based, cross-sectional multi-centre EURODIAB IDDM Complications Study. DESIGN AND SUBJECTS: 15% of the total EURODIAB cohort was randomly selected to test the repeatability of nutritional intake data. Two three-day records, completed three weeks apart, were available for 216 diabetic patients (7.5%) representative of the total cohort. All records were analysed centrally, for intakes of protein (animal and vegetable), fat (saturated fat and cholesterol), carbohydrate, fibre, alcohol and energy. Repeatability was measured comparing mean intakes, determining the proportion of patients classified into the same/opposite quartile by the two three-day records and assessing mean differences with standard deviations (s.d.d). RESULTS: There were no significant differences in mean energy and nutrient intakes between the first and second records. Classification of individuals into the opposite quartile occurred only in 0-4% of patients and overall about 50% (range 44-74%) of the subjects were classified into the same quartiles of intakes. Only small mean differences were found for energy intake (-156 (1633) kJ; 95% confidence limits -375, 63 kJ) and nutrients with s.d.ds comparable to intra-individual variations in the general population. The differences in energy intake were randomly distributed over the range of intakes. CONCLUSIONS: The present study demonstrates that standardized three day dietary records show a high degree of repeatability within a short period of time in a sample of European IDDM patients. The good repeatability strengthens the conclusions drawn from the nutritional data in the EURODIAB IDDM Complications Study.

Protein intake and urinary albumin excretion rates in the EURODIAB IDDM Complications Study.

For people with insulin-dependent diabetes mellitus (IDDM) renal disease represents a life-threatening and costly complication. The EURODIAB IDDM Complications Study, a cross-sectional, clinic-based study, was designed to determine the prevalence of renal complications and putative risk factors in stratified samples of European individuals with IDDM. The present study examined the relationship between dietary protein intake and urinary albumin excretion rate (AER). Food intake was assessed centrally by a standardized 3-day dietary record. Urinary AER was determined in a central laboratory from a timed 24-h urine collection. Complete data were available from 2696 persons with IDDM from 30 centres in 16 European countries. In individuals who reported protein consumption less than 20% of total food energy intake, mean AER was below 20 microg/min. In those in whom protein intake constituted more than 20%, mean AER increased, a trend particularly pronounced in individuals with hypertension and/or poor metabolic control. Trends reached statistical significance for intakes of total protein (% of energy, p = 0.01) and animal protein (% of energy, p = 0.02), while no association was seen for vegetable protein (p = 0.83). These findings support the current recommendation for people with diabetes not to exceed a protein intake of 20% of total energy. Monitoring and adjustment of dietary protein appears particularly desirable for individuals with AER exceeding 20 microg/min (approximately 30 mg/24h), especially when arterial pressure is raised and/or diabetic control is poor.

Nutritional intake of 2868 IDDM patients from 30 centres in Europe. EURODIAB IDDM Complications Study Group.

The EURODIAB IDDM Complications Study, a cross-sectional, clinic-based study, was designed to measure the prevalence of diabetic complications in stratified samples of European insulin-dependent diabetic (IDDM) patients. As diet may be related to diabetic complications, nutritional intake was analysed in the study population. The aims of this first nutritional paper are to describe the nutrient intake in 2868 IDDM patients from 30 centres in 16 countries throughout Europe, to investigate the degree of regional differences in nutrient intake and to compare current intakes with recommended levels. Nutritional intake from 1458 male and 1410 female IDDM patients was assessed by a validated 3-day record (two weekdays, Sunday) and centrally analysed. Mean energy intake for all patients was 2390 +/- 707 kcal/day. Mean protein intake was 1.5 +/- 0.5 g/kg body weight. Carbohydrate intake was 43% and fibre intake 18 g/day. Alcohol intake for the total cohort was 2% of energy. Total fat contributed 38% of energy, with 14% from saturated fat. The Italian centres reported lower total and saturated fat intakes compared with other centres. Recommendations from the Diabetes and Nutrition Study Group of the EASD for total fat, saturated fatty acids and carbohydrate were only achieved by 14%, 14% and 15% of patients, respectively. The data of the present study clearly indicate current problems in the nutritional intake of European IDDM patients. These findings contribute to the definition of future targets in the nutritional management of IDDM patients, to be achieved as part of the initiatives taken by the St. Vincent Declaration action programme.