Decreased Consumption of Added Fructose Reduces Waist Circumference and Blood Glucose Concentration in Patients with Overweight and Obesity. The DISFRUTE Study: A Randomised Trial in Primary Care.

The relationship between fructose intake and insulin resistance remains controversial. Our purpose was to determine whether a reduction in dietary fructose is effective in decreasing insulin resistance (HOMA2-IR). This field trial was conducted on 438 adults with overweight and obese status, without diabetes. A total of 121 patients in a low fructose diet (LFD) group and 118 in a standard diet (SD) group completed the 24-week study. Both diets were prescribed with 30-40% of energy intake restriction. There were no between-group differences in HOMA2-IR. However, larger decreases were seen in the LFD group in waist circumference (-7.0 vs. -4.8 = -2.2 cms, 95% CI: -3.7, -0.7) and fasting blood glucose -0.25 vs. -0.11 = -0.14 mmol/L, 95% CI: -0.028, -0.02). The percentage of reduction in calorie intake was similar. Only were differences observed in the % energy intake for some nutrients: total fructose (-2 vs. -0.6 = -1.4, 95% CI: -2.6, -0.3), MUFA (-1.7 vs. -0.4 = -1.3, 95% CI: -2.4, -0.2), protein (5.1 vs. 3.6 = 1.4, 95% CI: 0.1, 2.7). The decrease in fructose consumption originated mainly from the reduction in added fructose (-2.8 vs. -1.9 = -0.9, 95% CI: -1.6, -0.03). These results were corroborated after multivariate adjustments. The low fructose diet did not reduce insulin resistance. However, it reduced waist circumference and fasting blood glucose concentration, which suggests a decrease in hepatic insulin resistance.

Effectiveness of a low-fructose and/or low-sucrose diet in decreasing insulin resistance (DISFRUTE study): study protocol for a randomized controlled trial.

BACKGROUND: Research published to date on the relationship between insulin resistance (IR) and fructose consumption is scarce, has used different methods, and has yielded sometimes contradictory results. This study aims to determine whether a low-fructose and/or low-sucrose diet supervised by a physician or nurse decreases IR compared to a standard diet. METHODS/DESIGN: This field trial is located at primary care centers. The participants are adults aged 29 to 66 years, with a Body mass Index (BMI) between 29 and 40.99 kg/m2 and without diabetes. To date, 245 participants have been assigned randomly to the low-fructose diet intervention group (LFDI) at health centers in the western health service zone of Tenerife island, and 245 to the standard-diet control group (SDC) at health centers in the eastern health service zone. Recruitment is opportunistic and is carried out by physicians and nurses at participating health centers. Initially (baseline), and after 24 weeks of intervention, dietary records, physical activity, waist circumference, BMI, blood pressure, fasting blood glucose and insulin concentrations (HOMA2-IR) and lipid profile are recorded; blood glucose and insulin and lipid profile are also recorded 2 h after a 75-g glucose overload. After 48 weeks (24 weeks after the intervention), fasting blood samples are again obtained and a physical examination is performed. All tests and measures are repeated and recorded except dietary records, physical activity and oral glucose overload. Low-fructose diets are designed by calculating free and total (free + fructose associated with sucrose) fructose contents in standard diets, and removing foods with a fructose content in the highest quartile for the amounts in the standard diet. Participants in both groups are prescribed a diet that contains 30 to 40% less than the participant's energy requirements. The primary endpoint is change in HOMA2-IR between baseline and week 24, and other outcomes are change in HDL-cholesterol, LDL-cholesterol, triglycerides , waist circumference to height ratio and BMI. The secondary endpoint is change in HOMA2-IR between week 24 and week 48 together with the outcomes noted above. Comparisons between groups for variables used to indicate IR levels are done with a Student's t test for unpaired variables or the Mann-Whitney U test if the distribution is not normal. Multivariate regression models will be used to control for confounding factors not accounted for in the study design, and for independent prognostic factors. DISCUSSION: If the dietary intervention being tested, i.e., a diet low in fructose/sucrose, is able to reduce IR, the results - if translated into regular clinical practice - could provide a hitherto unavailable tool to prevent type-2 diabetes mellitus. TRIAL REGISTRATION: ISRCTN, ID: ISRCTN41579277 . Registered retrospectively on 15 November 2016.

Grasas de la dieta y salud cardiovascular / Dietary fats and cardiovascular health

La importancia de la grasa en la dieta, y su papel en la prevención cardiovascular, es uno de los tópicos nutricionales mejor estudiados y, a pesar de ello, está en continua revisión. Ahora ya conocemos, en especial gracias a los estudios relacionados con la dieta mediterránea, que es más importante la calidad de la grasa, que la cantidad de su ingesta. En ese sentido, la grasa saturada y la grasa trans están implicadas en el riesgo aterogénico, por lo que se recomienda que para el diseño de una dieta sana dichos nutrientes se deben sustituir por hidratos de carbono complejos o por grasas insaturadas, manteniendo el consumo de grasa saturada en < 10% y el de trans en < 1% de la ingesta calórica. Estudios poblacionales recientes, en especial el estudio de Kuopio y los trabajos realizados con el modelo de dieta mediterránea, están afianzando cada vez más la importancia de las grasas monoinsaturadas y poliinsaturadas, como nutrientes claves para la prevención de las enfermedades crónicas de las sociedades modernas(AU)

Por otra parte, un tipo especial de ácidos grasos poliinsaturados, los de la serie omega 3 (n-3), están gradualmente convirtiéndose en nutrientes claves de una dieta sana, especialmente en niños. Por ello parece razonable, que cuatro sociedades, fuertemente implicadas en difundir los beneficios de la dieta como herramienta para prevenir las enfermedades cardiovasculares, desarrollen un consenso para difundir los nuevos conocimientos sobre la importancia de conseguir un aporte equilibrado y adecuado de grasa, en la dieta de las poblaciones industrializadas. Esto justifica este documento realizado por un grupo de expertos de la Sociedad Española de Arteriosclerosis, la Sociedad Española de Medicina Familiar y Comunitaria, la Asociación Española de Pediatría, la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica y la Sociedad Española de Dietética y Ciencias de la Alimentación, en un esfuerzo porque resulte un trabajo multidisciplinar, orientado tanto a los adultos como a los niños, en distintos tramos de edad(AU)

Although dietary fat and its role in cardiovascular prevention has been one of the most extensively studied nutritional topics, it continues to be an ever-expanding research area. Particularly thanks to studies on Mediterranean diet, we now know that fat quality is more relevant than the amount of fat we eat in the diet. Thus, saturated and trans fats have been found to increase the risk of atherogenic disease. This is why it is recommended to substitute complex carbohydrates or unsaturated fat for unsaturated and trans fats with the aim of reducing saturated and trans fat intake to <10% and <1%, respectively, of the total calorie intake. Recent population studies, particularly that conducted in Kuopio, Finland, and those on Mediterranean diet, stress the important role of monounsaturated and polyunsaturated fats as key nutrients in preventing cardiovascular disease in modern societies. Furthermore, a special type of polyunsaturated fatty acids, i.e. those of the omega-3 (n-3) series, is increasingly becoming essential nutrients for a healthy diet, especially in the case of children. Therefore, there is a rationale for four the Scientific Societies that are strongly committed to disseminate the benefits of a healthy diet in preventing cardiovascular disease, and to prepare a joint statement with the purpose of spreading improved knowledge on the importance of changing to a healthy diet with a well-balanced fat intake for industrialized populations. Accordingly, a multidisciplinary panel of experts from the following institutions has developed the present joint statement targeted at both adults and children of different ages: Spanish Society of Arteriosclerosis, Spanish Society of Family and Community Medicine, Spanish Association of Paediatrics, Spanish Society of Gastroenterology, Hepatology and Paediatric Nutrition and Dietetics, and Spanish Society for Food Sciences(AU)

Association between glycemic index, glycemic load, and fructose with insulin resistance: the CDC of the Canary Islands study.

BACKGROUND: The involvement of carbohydrates in triggering insulin resistance (IR) remains a source of controversy. AIM OF THE STUDY: To study the relation between glycemic index (GI), glycemic load (GL), and fructose with insulin resistance in a predominantly rural population in the Canary Islands. METHODS: Cross-sectional study carried out in 668 nondiabetic people aged 18-75. IR was estimated with serum glucose and C-peptide (HOMA2-IR). Nutrient intakes were obtained from a validated food frequency questionnaire. ANOVA was used to analyze nutrient distribution across quartiles of HOMA2-IR. Four multivariate nutrient density models (dependent variable: log-transformed HOMA2-IR) which differed only in the kinds of carbohydrates included were tested (Model 1: carbohydrates; Model 2: GI and then GL; Model 3: free fructose, other simple sugars and starch; Model 4: total fructose, remaining sugars and starch). RESULTS: There was no association between GI and IR. There was a direct association between GL (P < 0.001), fructose (free [P = 0.001], total [P = 0.013]), energy intake (P < 0.001), fruit fiber (<0.001), and glucose (P = 0.003) with IR. There was an inverse association between cereal (P = 0.008) and vegetable fiber (P < 0.001) and IR. Multivariate models corroborated the association of carbohydrates, GL, fructose, vegetable fiber, and energy intake with IR. The association between GL and IR disappeared when Model 2 was adjusted by total fructose intake. CONCLUSIONS: There was a direct association between fructose intake and IR. There was no relationship between GI and IR. Although a direct association of GL with IR was detected, it was attributable to the consumption of fructose.

El cociente perímetro abdominal/estatura como índice antropométrico de riesgo cardiovascular y de diabetes / The waist to height ratio as an index of cardiovascular risk and diabetes

Fundamento y objetivos: Identificar el índice antropométrico que mejor detecta riesgo cardiovascular (RCV) y diabetes mellitus de tipo 2 (DM2) en población adulta española y cuál es su punto de corte ideal. Sujetos y métodos: Estudio transversal en población general (n=6.729). Se estimó sensibilidad y especificidad de varios índices antropométricos: cintura abdominal, índice de masa corporal, ratio abdomen/pelvis y ratio abdomen/estatura (RA/E). Se obtuvieron sus áreas bajo la curva operador-receptor con respecto a los siguientes factores de RCV: riesgo coronario alto estimado según la ecuación de Framingham, hipertensión arterial, hiperlipidemia, DM2, síndrome metabólico (SM) y glucemia en ayunas alterada (GAA). Para estimar los riesgos relativos, calculamos la razón de ventajas con intervalo de confianza (IC) del 95%. Resultados: La RA/E produjo la mayor área de los 4 índices en DM2 y demás factores de RCV, que osciló entre 0,65 para GAA en varones (IC del 95%: 0,63–0,68) y 0,87 para SM en mujeres (IC del 95%: 0,86–0,89). La RA/E alcanzó la máxima sensibilidad (0,91) y especificidad (0,70) en el SM, y su punto de corte óptimo fue 0,55; con él, los riesgos estimados por la RA/E fueron también mayores que con los demás índices, y variaron desde 2,30 para GAA (IC del 95%: 1,96–2,70) hasta 16,20 para SM (IC del 95%: 13,68–19,20).Conclusiones: La RA/E es el índice con mejor capacidad de detección de DM2 y demás factores de RCV en esta población, y es el que mayor fuerza alcanza en su asociación con ellos. De su punto de corte (0,55) se deduce que conviene evitar que la cintura abdominal supere la mitad de la estatura (AU)

Background and objectives: To identify the anthropometric index that best detects cardiovascular risk (CVR) and type 2 diabetes (DM2) in the adult Spanish population and to determine its cut-off point. Subjects and methods: cross-sectional study in the general population (n=6279). Sensitivity and specificity were estimated for the anthropometric indexes: abdominal waist, body mass index, waist to hip ratio and waist to height ratio (WtHR). The areas of these indexes under ROC curve (AUC) were obtained for the following CVR factors: high coronary risk computed with Framingham model, Hypertension, Hyperlipemia, DM2, Metabolic Syndrome (MS) and Impaired Fasting Glucose (IFG). The odds ratio, with 95% confidence interval (CI95%), was calculated. Results: WtHR was the index showing the highest AUC for DM2 and the remaining CVR factors, varying between 0.65 (CI95%=0.63–0.68) for IFG in men and 0.87 (CI95%=0.86–0.89) for MS in women. RA/E reached the maximum sensitivity (0.91) and specificity (0.70) in SM and its optimal cut-off point was 0.55, which displayed the highest risks amongst indexes, varying from 2.30 (1.96–2.70) in IFG to 16’20 (13.68–19.20) in MS. Conclusions: RA/E is the index presenting the best ability to detect DM2 and CVR in this population, and it shows the stronger association with them. Its cut-off point, 0.55, confirms the convenience of keeping the abdominal waist to less than half the height (AU)

[The waist to height ratio as an index of cardiovascular risk and diabetes]. / El cociente perímetro abdominal/estatura como índice antropométrico de riesgo cardiovascular y de diabetes.

BACKGROUND AND OBJECTIVES: To identify the anthropometric index that best detects cardiovascular risk (CVR) and type 2 diabetes (DM2) in the adult Spanish population and to determine its cut-off point. SUBJECTS AND METHODS: Cross-sectional study in the general population (n=6279). Sensitivity and specificity were estimated for the anthropometric indexes: abdominal waist, body mass index, waist to hip ratio and waist to height ratio (WtHR). The areas of these indexes under ROC curve (AUC) were obtained for the following CVR factors: high coronary risk computed with Framingham model, Hypertension, Hyperlipemia, DM2, Metabolic Syndrome (MS) and Impaired Fasting Glucose (IFG). The odds ratio, with 95% confidence interval (CI(95%)), was calculated. RESULTS: WtHR was the index showing the highest AUC for DM2 and the remaining CVR factors, varying between 0.65 (CI(95%)=0.63-0.68) for IFG in men and 0.87 (CI(95%)=0.86-0.89) for MS in women. RA/E reached the maximum sensitivity (0.91) and specificity (0.70) in SM and its optimal cut-off point was 0.55, which displayed the highest risks amongst indexes, varying from 2.30 (1.96-2.70) in IFG to 16'20 (13.68-19.20) in MS. CONCLUSIONS: RA/E is the index presenting the best ability to detect DM2 and CVR in this population, and it shows the stronger association with them. Its cut-off point, 0.55, confirms the convenience of keeping the abdominal waist to less than half the height.

Estilo de vida y adherencia al tratamiento de la población canaria con diabetes mellitus tipo 2 / Lifestyle and treatment adherence of type 2 diabetes mellitus people in the Canary Islands

Fundamento: la población canaria sufre la mayor mortalidadpor diabetes tipo 2 (DM2) en España. El objetivo de esteestudio es conocer el estilo de vida de las personas diabéticasdel archipiélago y su adherencia al tratamiento, así como laDM2 desconocida.Métodos: estudio transversal de 6.729 personas de la poblacióngeneral participantes en la cohorte “CDC de Canarias”(edad 18-75 años). Se obtuvieron sus antecedentes médicos,dieta, actividad física, medicamentos consumidos, tabaco, etc.Resultados: la prevalencia de DM2 fue 12% en varones y10% en mujeres (p=0,005). El 22% de varones y 9% de mujeresdesconocían su enfermedad (p<0,001). Sumando DM2desconocida, DM2 no tratada e incumplimiento terapéutico, el48% de los hombres y 28% en mujeres no seguían tratamientocorrecto. Los varones diabéticos eran más obesos que los nodiabéticos (45 versus 25%; p<0,001) pero no presentaban diferenciasen tabaquismo (28%; IC95%=23-33) o sedentarismo(62%; IC95%=56-68). Las mujeres diabéticas también eran másobesas (54 versus 27%; p<0,001) y, aunque fumaban menos(11 versus 22%; p<0,001), eran igual de sedentarias (75%;IC95%=70-79). La ingesta calórica era menor en quienes sufríanDM2 (p<0,001), pero el 93% (IC95%=91-95) superaba elconsumo recomendado de grasas saturadas y el 69%(IC95%=65-72) padecía síndrome metabólico.Conclusiones: la población diabética en Canarias essedentaria y obesa, muestra un consumo alto de grasas saturadasy gran prevalencia de síndrome metabólico. El porcentajeque sigue tratamiento regular es muy bajo, sobretodo en varones,que además mantienen el tabaquismo(AU)

Background: The Canary Islands population experiencesthe highest type 2 diabetes (DM2) mortality in Spain. We studiedlifestyle, unknown DM2 and treatment adherence in diabeticsof these islands.Methods: cross-sectional study of 6729 subjects from thegeneral population (age 18-75) that participate in the cohortstudy “CDC of the Canary Islands”. We found out their medicalproblems, diet, physical activity, medications, smoking, etc.Results: Prevalence of DM2 was 12% in men and 10% inwomen (p=0.005). The disease was unknown in 22% of menand 9% of women (p<0.001). Considering unknown DM2, lackof treatment and lack of adherence, 48% of men and 28% ofwomen did not follow a regular treatment. Diabetics’ men prevalencesof smoking (28%; CI95%=23-33) and sedentariness(62%; CI95%=56-68) were similar to non diabetic men, but obesitywas more frequent in diabetics (45 versus 25%; p<0.001).Diabetics women showed a higher obesity (54 versus 27%;p<0.001) and a lower smoking prevalence (11 versus 22%;p<0,001) than non diabetics, but they presented a similar sedentariness(75%; CI95%=70-79). In both sexes, energy intake waslower in diabetics (p<0.001), but 93% of them (CI95%=91-95)showed a high consumption of calories from saturated fat and69% (CI95%=65-72) presented metabolic syndrome.Conclusions: The Canarian diabetics are a sedentary andobese population that show a high consumption of saturatedfats and high prevalence of metabolic syndrome. The proportionof them following regular treatment is low, specially indiabetic men that, in addition, still smoke(AU)

[Validation of a food intake frequency questionnaire adapted for the study and monitoring of the adult population of the Canary Islands, Spain]. / Validación de un cuestionario de frecuencia de consumo de alimentos adaptado para el estudio y seguimiento de la población adulta de las Islas Canarias.

BACKGROUND: The registering of eating habits requires a valid and reliable method. The purpose of this study is to validate the food intake frequency questionnaire, CDC-FFQ, which is an adaptation of another questionnaire, in order to assess the nutrition of the adult population of the Canary Islands. METHODS: The CDC-FFQ questionnaire was given to 1,067 individuals taken from the general population (GP) and to 106 university students, aged 19 to 30. The second group was surveyed also in three 24-hour follow-ups. The nutrients were compared according to the CDC-FFQ in the GP and university students. The correlations were estimated between the CDC-FFQ and the follow-ups for nutrients and groups of foods and the concordance of the intakes of nutrients and groups of foods in the extreme quintiles, for the university students. RESULTS: The mean values between nutrients of the CDC-FFQ between the GP, university students and the general population with university studies showed no significant differences except for vitamin B12 (p=0.004) and vitamin D (p=0.005). Correlations between the CDC-FFQ and the mean of the three follow-ups were obtained in the 0.202-0.601 range between nutrients adjusted by calories consumed in the case of the university students. By groups of foods, the correlations ranged between 0.243-0.542 for the CDC-FFQ and the follow-ups. The concordance of nutrients ranged between 39% and 100% and for groups of foods, between 41% and 100%. CONCLUSIONS: The CDC-FFQ questionnaire is valid for classifying the subjects in the relative ranges of their level of intake of foods and nutrients and, therefore, it could be useful in epidemiological studies with a diet assessment in the adult population of the Canary Islands.

Validación de un cuestionario de frecuencia de consumo de alimentos adaptado para el estudio y seguimiento de la población adulta de las Islas Canarias / Validation of a food intake frequency questionnaire adapted for the study and monitoring of the adult population of the Canary Islands

Fundamento: Registrar los hábitos alimenticios exige de un método válido y fiable. El objetivo del estudio es validar el cuestionario de frecuencia de consumo de alimentos CDC-FFQ, que es una adaptación de otro cuestionario, para estudiar la alimentación de la población adulta de Canarias. Métodos: El cuestionario CDC-FFQ fue administrado a 1.067 personas de la población general (PG) y a 106 estudiantes universitarios (EU), de 19 a 30 años. El segundo grupo fue encuestado también sobre tres recordatorios de 24 horas. Se comparan los nutrientes según CDC-FFQ en PG y EU. Se estiman las correlaciones entre CDC-FFQ y los recordatorios para nutrientes y grupos de alimentos, y la concordancia de consumos de nutrientes y grupos de alimentos en los quintiles extremos, para los estudiantes universitarios. Resultados: Los valores medios entre nutrientes del CDC-FFQ entre PG, EU y población general con estudios universitarios no mostraron diferencias significativas excepto para la vitamina B12 (p=0.004) y la vitamina D (p=0,005). Entre el CDC-FFQ y la media de los tres recordatorios se obtuvieron correlaciones en el rango de 0,202-0,601 entre nutrientes ajustados por calorías consumidas para los estudiantes universitarios. Por grupos de alimentos las correlaciones oscilaron para CDC-FFQ y los recordatorios entre 0,243-0,542. La concordancia de nutrientes osciló entre 39% y 100% y para grupos de alimentos entre 41% y 100%. Conclusiones: El cuestionario CDC-FFQ resulta válido para clasificar a los sujetos en los rangos relativos de su nivel de ingesta de alimentos y nutrientes, por lo que podría ser útil en estudios epidemiológicos con valoración de dieta en población canaria adulta (AU)

Background: The registering of eating habits requires a valid and reliable method. The purpose of this study is to validate the food intake frequency questionnaire, CDC-FFQ, which is an adaptation of another questionnaire, in order to assess the nutrition of the adult population of the Canary Islands. Methods: The CDC-FFQ questionnaire was given to 1,067 individuals taken from the general population (GP) and to 106 university students, aged 19 to 30. The second group was surveyed also in three 24-hour follow-ups. The nutrients were compared according to the CDC-FFQ in the GP and university students. The correlations were estimated between the CDC-FFQ and the follow-ups for nutrients and groups of foods and the concordance of the intakes of nutrients and groups of foods in the extreme quintiles, for the university students. Results: The mean values between nutrients of the CDC-FFQ between the GP, university students and the general population with university studies showed no significant differences except for vitamin B12 (p=0.004) and vitamin D (p=0.005). Correlations between the CDC-FFQ and the mean of the three follow-ups were obtained in the 0.202-0.601 range between nutrients adjusted by calories consumed in the case of the university students. By groups of foods, the correlations ranged between 0.243-0.542 for the CDC-FFQ and the follow-ups. The concordance of nutrients ranged between 39% and 100% and for groups of foods, between 41% and 100%. Conclusions: The CDC-FFQ questionnaire is valid for classifying the subjects in the relative ranges of their level of intake of foods and nutrients and, therefore, it could be useful in epidemiological studies with a diet assessment in the adult population of the Canary Islands (AU)

Consejo y prescripción dietética en atención primaria: un largo camino por recorrer / Counselling and dietary prescription in primary care: a long road to run

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