Effect of baking process on postprandial metabolic consequences: randomized trials in normal and type 2 diabetic subjects.

OBJECTIVE: To determine the impact of the form, fibre content, baking and processing on the glycaemic, insulinaemic and lipidaemic responses of different French breads. DESIGN AND SUBJECTS: First study: Nine healthy subjects were randomized to consume in a crossover design one of six kinds of French bread (each containing 50 g available carbohydrate): classic baguette, traditional baguette, loaf of wholemeal bread (WM-B), loaf of bread fermented with yeast or with leaven, a sandwich and a glucose challenge as reference. RESULTS: The glycaemic index (GI) values ranged from 57+/-9% (mean+/-s.e.m.), for the traditional baguette, to 85+/-27% for the WM-B. No significant difference was found among the different tested bread. The insulinaemic index (II), however, of the traditional baguette and of the bread fermented with leaven were lower than the other breads (analysis of variance: P<0.01). Postprandial plasma triglycerides showed similar profiles. The traditional baguette tended to decrease postprandial free fatty acids compared to levels after the classic baguette. RESULTS: The GI of the traditional baguette was lower than that of the classic baguette (n=8, venous blood: 70+/-4 vs 75+/-4, P=0.002; capillary blood: 69+/-5 vs 83+/-6, P=0.028, respectively). CONCLUSIONS: Some varieties of French bread (the TB) have lower II, in healthy subjects, and lower GI, in type 2 diabetic subjects, than that of the other varieties. These results might be due to bread processing difference rather than fibre content. SPONSORSHIPS: Supported by grants from the National French Milling Association.

A cost-benefit comparison of intensive diabetes management with implantable pumps versus multiple subcutaneous injections in patients with type I diabetes.

OBJECTIVE: To investigate if intraperitoneal (IP) insulin infusion via programmable implantable pumps is a potential alternative to subcutaneous (SC) insulin via multiple injections. RESEARCH DESIGN AND METHODS: We compared the cost-benefits of the two methods using a randomized, prospective, 6-month, crossover design in 10 adult type I diabetic patients. RESULTS: When judged on the last month of IP versus SC periods in the nine patients who completed the study, metabolic data showed better glycemic control (HbA1c: 7.2 +/- 0.2 IP vs. 8.5 +/- 0.7% SC, mean +/- SE, P = 0.02), reduced glycemic fluctuations (SD of capillary glucose values: 3.4 +/- 0.2 IP vs. 4.6 +/- 0.2 mM SC, P < 0.01), and fewer mild hypoglycemic events (5.7 +/- 2.0 IP vs. 10.0 +/- 3.1 events/month SC, P = 0.02). Quality of life, judged by Diabetes Control and Complications Trial questionnaires, was unaffected by pump therapy. Direct costs, including pump acquisition, implantation, and follow-up, were 2.6-fold higher with IP than with SC delivery. CONCLUSIONS: The implantable pump is more effective in the short term, equally accepted, but more costly than multiple injections and should be limited to patients with unsatisfactory glycemic control despite intensive diabetes management with SC insulin. In addition, longer-term, larger-scale, and comparative evaluation is required.

Glycaemic and insulinaemic responses to a new hydrogenated starch hydrolysate in healthy and type 2 diabetic subjects.

BACKGROUND: Industrialists are searching for a sugar replacement in confectioneries such as hard candies, gum and chocolate. Lycasin HBC is a suitable candidate. Nevertheless, no information on its plasma glucose and insulin responses exists. Therefore, we aimed to evaluate the glycaemic and insulinaemic indices of Lycasin HBC in healthy subjects and in subjects with type 2 diabetes mellitus. METHODS: Six healthy and six type 2 diabetic men participated in the study. Each subject absorbed, after an overnight fast, a challenge of either 50 g of glucose or 50 g of Lycasin HBC using a randomised double-blind crossover design. Blood samples for measuring plasma glucose and insulin concentrations were collected during a 3 hour period. RESULTS: The calculated glycaemic index of Lycasin HBC was 47 +/- 10% in healthy subjects and 25 +/- 6% in patients with type 2 diabetes mellitus. The insulinaemic index of Lycasin HBC was 23 +/- 4% and 39 +/- 14%, respectively. As glucose levels oscillate in a very limited range in normal healthy subjects, the insulinaemic index must be considered here. On the other hand, it is the glycaemic rather than the insulinaemic index that must be assessed in diabetic subjects due to impairment of insulin secretion. CONCLUSIONS: The tested Lycasin HBC showed a low insulinaemic index in healthy subjects (23 +/- 4%) and a low glycaemic index (25 +/- 6%) in type 2 diabetic patients. Thus, it might be considered as an interesting sucrose substitute in confectionery for individuals with or without diabetes.

Exercise is not associated with better diabetes control in type 1 and type 2 diabetic subjects.

In the clinical setting, the impact of educational efforts on the amount of regular exercise and its effects on diabetes control are unclear. Fifty type 1 diabetic, 50 type 2 diabetic and 70 non-diabetic subjects were evaluated using a questionnaire for type, duration and intensity of exercise to assess weekly energy expenditure. Diabetic subjects did not exercise more than controls: 36% of the type 1, 46% of the type 2 and 46% of the control subjects admitted no physical activity, and those exercising regularly had similar energy expenditure: 1808 +/- 320, 2722 +/- 617, 2523 +/- 304 (mean +/- SEM) kcal/week respectively (P = NS). There was no correlation between the degree of activity and HbA1c levels, or hypoglycaemic events. HbA1c levels were less than 6,8% in 31% of nonactive patients versus 21% of active patients (P = NS). A negative correlation was found between physical activity and daily insulin usage (r = 0.27, P less than 0.05), but differences between patients averaged only 4IU/1000 kcal energy expenditure/day. We conclude that patients' attitude towards exercise was not improved by our educational methods and that physical exercise was not necessarily associated with good blood glucose control.

Comparison between a rapid glycohaemoglobin (HbA1c) immunoassay and other indices of glycaemic control.

The aims of the study were to compare glycohaemoglobin (HbA1c) values measured by DCA (a benchtop analyzer primarily designed for within-clinic rapid HbA1c determination) to a reference HbA1c method and home blood glucose monitoring, and to explore the possibility of an uniform expression of data. A total of 103 blood samples and the corresponding mean capillary glucose values (4.4 +/- 1.2 tests/day) of the preceding 2 months were collected from 34 insulin-dependent diabetic adults. We measured the correlations and agreements using the residual plots method and regression equations between HbA1c measured by DCA and high-pressure liquid chromatography (HPLC), and between DCA and capillary glucose values. A highly significant correlation (r2 = 0.85, P < 0.001) and an acceptable agreement (97% of values within 2 SD of the mean difference of 0.9% +/- 0.4%) was found between DCA and HPLC values. The regression equation calculated on the first half of the cases was: DCA (%) = 0.72 HPLC (%) +1.38. Of DCA values expressed in HPLC terms using this equation 87% fell within a clinically acceptable confidence interval when compared with measured HPLC data. A significant correlation (r2 = 0.40, P < 0.01) was found between DCA and capillary glucose values, and the regression equation was: DCA (%) = 0.34 capillary glucose (mM) +4.44. Of glycaemic levels calculated from DCA values using this formula 82% fell within a clinically acceptable error range when compared with measured glycaemic values. We conclude that the three methods of assessment of diabetes control are well correlated and that it is possible, with a degree of precision acceptable for the clinical setting, to express all data in uniform units, e.g. mM of capillary glucose or percentage of HPLC-HbA1c, though a simple correspondence table based on our transfer equations may be clinically sufficient and more handy.

[Cardiac tamponade caused by vascular erosion. A case report]. / Tamponamento cardiaco da erosione vascolare. Analisi di un caso.

Cardiac tamponade may be caused by erosion of the right cardiac walls or of the intrapericardial superior vena cava in subjects with a central venous catheter. The underlying cause of this rare complication is direct parietal trauma by the catheter and endarterial damage produced by infused hyperosmolar solutions. High mortality is closely related to erroneous or late diagnosis. Both correct positioning techniques and the use of soft venous catheters are fundamentally important in preventing this complication.

[The therapy of the liver metastases of colorectal carcinoma]. / La terapia delle metastasi epatiche da carcinoma colorettale.

The treatment of liver metastases should be addressed in a multidisciplinary way, considering the manifold therapeutic options available, for each of which corresponds a particular indication. The best results are obtainable with resective surgery in cases in which there is a partial involvement of the liver (25-50%) and a variable intra-hepatic distribution (monolobar), situations that correspond to Gennari stages I and II. In the authors' experience, the extent of the liver resection does not influence possible survival and oncologically correct resections should be carried out such as segmentectomies, pluri-segmentectomies or wedge resection in compliance with the principle of removing at least 1.5 cm of healthy perineoplastic tissue. The authors reserve major hepatectomies to special situations: voluminous metastases, diffuse involvement of a single lobe, topographic localisation contraindicating segmentary resection.

Ketone bodies do not give falsely positive alcohol tests.

Ketosis, as observed in diabetic ketoacidosis or secondary to hypoglycaemia, may be associated with symptoms resembling those of acute alcoholism. It is thus essential to rule out the possibility that ketone bodies cross-react with any method of ethanol determination. Two currently used methods for detecting ethanol in the expired air (Alcotest and a fuel cell electrode), and three methods for blood determination (the nitrochromic method, gas liquid chromatography, and the TDX-REA method) were examined. No cross-reaction was found in nine grossly ketotic diabetic subjects. In vitro 3-hydroxybutyrate, acetoacetate or acetone, alone (30 mmol l-1) or in association, did not cross-react in the assays studied.

Beta-cell function evaluated by HOMA as a predictor of secondary sulphonylurea failure in Type 2 diabetes.

BACKGROUND AND AIMS: Secondary failure to oral hypoglycaemic agents, a common evolution of long-standing Type 2 diabetes, is usually assessed by non-standardized indices requiring fine clinical assessment, including hyperglycaemia resistant to maximum doses of sulphonylureas despite appropriate diet and follow-up. The goal of this study was to evaluate if HOMA, a modelized plasma insulin/glucose ratio allowing simple evaluation of residual insulin secretion and sensitivity, is a better predictor of the insulin requiring stage than clinical indices. MATERIALS AND METHODS: HOMA was measured in 84 Type 2 diabetic patients aged 58 +/- SD 6 years, with diabetes duration 11 +/- 4 years, hospitalized because of hyperglycaemia resistant to maximal doses of sulphonylureas (e.g. glibenclamide > or = 15 mg/day), with no apparent external reason for hyperglycaemia. Despite reinforced appropriate diet recommendations, 62 of these patients remained hyperglycaemic (insulin-requiring group). RESULTS: Age, duration of diabetes, body mass index (BMI) and HOMA value for insulin sensitivity (71 +/- 6% vs. 76 +/- 7%, normal values 59-161%) were comparable in the two groups. HbA(1c) was higher (10.0 +/- 0.2% vs. 8.3 +/- 0.3%, P < 0.001) and HOMA insulin secretion values lower (25 +/- 2% vs. 43 +/- 6%, normal values 70-150%, P < 0.01) in the insulin-requiring group. Of the following potential predictors: HbA(1c) > 8%, duration of diabetes > or = 10 years, HbA(1c) combined with diabetes duration, insulin sensitivity < or = 40%, insulin secretion < or = 20%, the latter showed the best positive predictivity (86% patients with low insulin secretion were insulin-requiring). CONCLUSIONS: (i) HOMA is a simple and good predictor of the insulin-requiring stage in Type 2 diabetes mellitus; (ii) this stage of diabetes is characterized by a further decline of insulin secretion rather than of insulin sensitivity. Diabet. Med. 18, 584-588 (2001)

A fructose-rich diet decreases insulin-stimulated glucose incorporation into lipids but not glucose transport in adipocytes of normal and diabetic rats.

To study the cellular mechanisms underlying fructose-induced insulin resistance in rats, the effects of fructose feeding on insulin-stimulated glucose transport, oxidation and incorporation into lipids in epididymal adipocytes were evaluated in 27 normal and 27 noninsulin-dependent diabetic male Sprague-Dawley rats. Diabetes was induced by streptozotocin injection 2 d after birth. At 5 wk of age, both normal and diabetic rats were fed a diet containing 62% carbohydrate as fructose, dextrose or cornstarch. Fructose feeding for 6 wk induced glucose intolerance in normal rats (P < 0.05) and aggravated that of diabetic rats (P < 0.05). Plasma triacylglycerol concentration was higher in fructose-fed than in starch-fed or dextrose-fed rats (P < 0.05). Adipocytes of fructose-fed rats had significantly lower maximum insulin-stimulated glucose incorporation into total lipids than those of rats fed starch, and tended (P = 0.22) to have lower production of CO2 from glucose than adipocytes of the other dietary groups. Glucose transport in adipocytes of dextrose-, starch- and fructose-fed rats did not differ. We conclude that in both normal and diabetic rats, a chronic fructose-rich diet induced hypertriacylglycerolemia, glucose intolerance and insulin resistance of adipocytes.

Effects of dietary propionate on hepatic glucose production, whole-body glucose utilization, carbohydrate and lipid metabolism in normal rats.

Increased intake of dietary fibres is associated with several beneficial effects on carbohydrate and lipid metabolism. The colonic fermentation of dietary fibres produces short-chain fatty acids (SCFA; acetate, propionate and butyrate). Some authors have suggested that SCFA could be partly responsible for the effects of dietary fibres. The purpose of the present study was to test the effects of one of the SCFA, propionate. The effects of moderate amounts of dietary propionate on insulin sensitivity and hepatic glucose production were studied in male Sprague-Dawley rats. Two groups of twenty-one adult rats were fed for 3 weeks on a diet containing 78 g propionate/kg (P) or 78 g/kg of a poorly fermentable cellulose (control group; C). Feed intake, body weight, fasting plasma glucose, insulin, free fatty acids, alanine, lactate, glycerol and beta-hydroxybutyrate levels were measured weekly in anaesthetized rats. At the end of the feeding period basal hepatic glucose production (BHGP) was measured with a primed continuous infusion of [3-3H]glucose and the in vivo insulin sensitivity in rats was quantified by the euglycaemic-hyperinsulinaemic clamp technique (0.6 and 2 U/kg per h). At that time fasting plasma glucose measured in anaesthetized rats was significantly lower in group P than in group C: 7.7 (SE 0.2) v. 8.5 (SE 0.2) mmol/l respectively (P < 0.002); plasma insulin levels were not significantly different. Neither the BHGP (mg/min per kg; C 14.8 (SE 1.3), P 15.1 (SE 1.3); n 7, not significant) nor the basal metabolic clearance (ml/min per kg; 8.9 (SE 0.8) v. 9.9 (SE 1.1); not significant) were different between treatments. Hepatic glucose production and glucose utilization at the two insulin concentrations (approximately 500 and 1500 mU/l respectively, n 7) did not differ significantly between the two groups. These results show that dietary propionate chronically ingested by normal rats could decrease fasting glycaemia, but from our findings, no effect on hepatic glucose production and whole-body glucose utilization could be clearly demonstrated.

Neither dietary fructose, dextrose nor starch modifies in vitro glycerol release by adipocytes from streptozotocin-diabetic rats.

Because we found previously that fructose feeding could alter lipolytic responses to isoproterenol and insulin in normal rats, we studied the effects of the same diet in neonatal, streptozotocin-diabetic rats. Twenty-seven 5-wk-old diabetic Sprague-Dawley rats were fed a diet containing 57% carbohydrate as either fructose, dextrose or starch for 6 wk. At the end of the nutritional period, plasma glucose and insulin concentrations in fed rats were similar in the three diabetic groups. Plasma triacylglycerol concentrations were higher in the fructose-fed group than in the other two groups (P < 0.05). Neither the maximal adipocyte lipolytic response (fructose = 1147 +/- 165%, starch = 1823 +/- 329% and dextrose = 1287 +/- 239% of basal values) nor the sensitivity to isoproterenol (ED50) was changed by the dietary carbohydrate exchange. The maximal antilipolytic action of insulin (starch = 68 +/- 10%, dextrose = 41 +/- 13%, fructose = 95 +/- 29% of stimulated lipolysis values) was comparable in the three diet groups. Thus, 6 wk of fructose feeding in diabetic rats increased plasma triacylglycerol concentrations, but had no detectable effect on plasma glucose or insulin concentrations, isoproterenol-induced lipolysis or the antilipolytic action of insulin.

Comparative effects of 6 week fructose, dextrose and starch feeding on fat-cell lipolysis in normal rats: effects of isoproterenol, theophylline and insulin.

The precise effects of fructose feeding on adipose tissue is not clearly known. Consequently, we studied the effects of fructose feeding on stimulated and inhibited in vitro lipolysis. Twenty seven male Sprague Dawley rats, 5 weeks of age, were fed for 6 weeks on one of three diets containing 57% CHO as fructose (F), dextrose (D) or starch (S). At week 6 the epididymal fat pad weights showed no difference between groups. Stimulation of lipolysis by isoproterenol or theophylline showed: decreased sensitivity of adipocytes to isoproterenol, but not to theophylline, in F (p less than 0.05); the maximal responses were decreased, but NS, after stimulation by either isoproterenol or theophylline. The maximal antilipolytic responses to insulin were increased in F (27%) and D (29%) when compared to S (16%), (p less than 0.05). Only, in F there was an increase (NS) in ED50 (0.63 +/- 0.23 ng/ml) compared to D (0.45 +/- 0.18) and S (0.29 +/- 0.18), indicating decreased sensitivity. Nonfasting plasma insulin and triglycerides were increased at the 6th week in F (p less than 0.01), without any change in plasma glucose levels. However, there was no difference in 12 h fasting plasma glucose, insulin or triglycerides. In conclusion, a 6 week 57% fructose containing diet in normal rats led to: 1) decreased lipid mobilization in the epididymal adipose tissue; and 2) increased nonfasting plasma insulin and triglycerides. Thus fructose, under these experimental conditions, seems to have adverse metabolic effects in normal rats.

Dietary amylose-amylopectin starch content affects glucose and lipid metabolism in adipocytes of normal and diabetic rats.

The aim of this study was to evaluate the effects of the chronic consumption of two starches, characterized by different glycemic indices and amylose-amylopectin content, on glucose metabolism in rat epididymal adipocytes. The two chosen starches were from mung bean (32% amylose) and cornstarch (0.5% amylose). The alpha-amylase digestibility was higher for the waxy cornstarch than that of the mung bean starch (60 +/- 4 vs. 45 +/- 3%, mean +/- SEM, respectively). The glycemic index of the waxy cornstarch diet (575 g starch /kg diet) was higher than that of the mung bean starch diet (107 +/- 7 vs. 67 +/- 5%, P < 0.01) when measured in vivo in two groups of normal rats (n = 9). In a subsequent study, normal and diabetic (streptozotocin-injected on d 2 of life) male Sprague-Dawley rats (18 per group) consumed a diet containing 575 g starch/kg diet as either waxy cornstarch or mung bean starch. After 3 wk, food intake, epididymal fat pad weights, and plasma glucose, insulin and triglyceride concentrations did not differ between diet groups. Adipocyte diameter was smaller in rats that consumed mung bean starch compared with those that consumed the waxy cornstarch diet (P < 0.01). The mung bean diet increased maximal insulin-stimulated 14C-glucose oxidation (% of basal values, P < 0. 05). In contrast, incorporation of 14C-glucose into total lipids was significantly lower in rats that consumed the mung bean diet (P < 0. 05). We conclude that in both normal and diabetic rats, the chronic replacement of a high glycemic index starch by a low glycemic index one in a mixed diet increases insulin-stimulated glucose oxidation, decreases glucose incorporation into total lipids and decreases epididymal adipocyte diameter. Thus, the type of starch mixed into the diet has important metabolic consequences at the cellular level in both normal and diabetic rats.

Effects of long-term low-glycaemic index starchy food on plasma glucose and lipid concentrations and adipose tissue cellularity in normal and diabetic rats.

The present study aimed to assess the metabolic consequences of the chronic ingestion of two starches giving different postprandial glycaemic responses in normal and diabetic rats. The two starches chosen were mung-bean (Phaseolus aureus) starch (97% pure starch) and wheat starch presented as ground French toast. First, we studied the characteristics of these two starches. In vitro the alpha-amylase (EC 3.2.1.1) digestibilities of these starches were 40 (SE 3) and 62 (SE 4)% respectively at 30 min, whereas the contents of resistant starch were 77 (SE 4) and 22 (SE 4) g/kg respectively. In vivo the mung-bean starch produced lower postprandial glycaemic responses than the wheat starch (areas under the curve were: 91 (SE 28) and 208 (SE 33) mmol.min/l, P < 0.05) in normal rats (n 8). We then submitted twenty-eight normal and twenty-eight diabetic (neonatal streptozotocin on second day of birth) male Sprague-Dawley rats (6 weeks old) to a diet containing 570 g starch/kg as either mung-bean starch or wheat starch (n 14 rats/group). After 5 weeks on the diets food intakes and body weights were identical in each group. Liver and kidney weights were comparable when expressed as relative weight. The mung-bean-starch diet slightly decreased epididymal fat-pad weight (P < 0.14, ANOVA) and led to a marked decrease in adipocyte volume (P < 0.05). Plasma triacylglycerol and phospholipid concentrations were lower after the mung-bean-starch diet than after the wheat-starch diet in both normal and diabetic rats, whereas free fatty acid concentrations were lower only in normal rats. Similarly, non-fasting plasma glucose concentrations decreased (P < 0.05) in normal rats fed on mung-bean starch but not in diabetic ones (P < 0.14). Insulin levels tended to be lower, but not significantly, after mung-bean-starch feeding than after wheat starch. We conclude that the replacement of 570 g wheat starch/kg diet with mung-bean starch for 5 weeks resulted in (1) lowered non-fasting plasma glucose and free fatty acid levels in normal but not in diabetic rats, (2) a reduction in plasma triacylglycerol concentration and adipocyte volume in both normal and diabetic rats. Thus, the type of starch mixed into the diet may have important metabolic consequences in normal and diabetic rats.

Dietary (n-3) polyunsaturated fatty acids improve adipocyte insulin action and glucose metabolism in insulin-resistant rats: relation to membrane fatty acids.

To study the effects of dietary fish oil on insulin-stimulated glucose metabolism in adipocytes of insulin-resistant rats (rats fed 50% sucrose and 30% fat), eighteen 5-wk-old Sprague-Dawley rats were fed, for 6 wk, a diet containing 30% fat as either fish oil (FO) or a mixture of vegetable and animal oils [control oils (CO)]. A third reference group was fed a standard diet (62% corn starch and 13% fat). At the end of the 6-wk period, the two experimental groups had comparable plasma glucose concentrations that were higher than that found in the reference group. FO feeding corrected the hyperinsulinemia of the experimental rats (P < 0.05) to reach values in the reference group. Plasma triacylglycerol (P < 0.01) and cholesterol (P < 0.001) concentrations were also lower in rats fed FO than in those fed CO. The body weights of FO-fed rats were similar to that of CO-fed rats, but epididymal adipose tissue weight was lower (P < 0.01). Adipocytes of FO-fed rats, compared with those of CO-fed rats, had high insulin-stimulated glucose transport (P < 0.05), oxidation (P < 0.001) and incorporation into total lipids (P < 0.05). The incorporation of (n-3) polyunsaturated fatty acids in adipocyte membrane phospholipids was higher in FO-fed rats than in those fed CO (P < 0.0001). Insulin action was positively correlated with the fatty acid unsaturation index in membrane phospholipids. Thus dietary fish oil has beneficial effects on insulinemia, plasma lipids and insulin-stimulated glucose metabolism in insulin-resistant slightly diabetic rats.