Diewertje Sluik

Physical Activity and Mortality in Individuals With Diabetes Mellitus: A Prospective Study and Meta-analysis.

BACKGROUND Physical activity (PA) is considered a cornerstone of diabetes mellitus management to prevent complications, but conclusive evidence is lacking. METHODS This prospective cohort study and meta-analysis of existing studies investigated the association between PA and mortality in individuals with diabetes. In the EPIC study (European Prospective Investigation Into Cancer and Nutrition), a cohort was defined of 5859 individuals with diabetes at baseline. Associations of leisure-time and total PA and walking with cardiovascular disease (CVD) and total mortality were studied using multivariable Cox proportional hazards regression models. Fixed- and random-effects meta-analyses of prospective studies published up to December 2010 were pooled with inverse variance weighting. RESULTS In the prospective analysis, total PA was associated with lower risk of CVD and total mortality. Compared with physically inactive persons, the lowest mortality risk was observed in moderately active persons: hazard ratios were 0.62 (95% CI, 0.49-0.78) for total mortality and 0.51 (95% CI, 0.32-0.81) for CVD mortality. Leisure-time PA was associated with lower total mortality risk, and walking was associated with lower CVD mortality risk. In the meta-analysis, the pooled random-effects hazard ratio from 5 studies for high vs low total PA and all-cause mortality was 0.60 (95% CI, 0.49-0.73). CONCLUSIONS Higher levels of PA were associated with lower mortality risk in individuals with diabetes. Even those undertaking moderate amounts of activity were at appreciably lower risk for early death compared with inactive persons. These findings provide empirical evidence supporting the widely shared view that persons with diabetes should engage in regular PA.

Associations Between General and Abdominal Adiposity and Mortality in Individuals With Diabetes Mellitus

Individuals with diabetes mellitus are advised to achieve a healthy weight to prevent complications. However, fat mass distribution has hardly been investigated as a risk factor for diabetes complications. The authors studied associations between body mass index, waist circumference, waist/hip ratio, and waist/height ratio and mortality among individuals with diabetes mellitus. Within the European Prospective Investigation into Cancer and Nutrition, a subcohort was defined as 5,435 individuals with a confirmed self-report of diabetes mellitus at baseline in 1992-2000. Participants were aged 57.3 (standard deviation, 6.3) years, 54% were men, the median diabetes duration was 4.6 (interquartile range, 2.0-9.8) years, and 22% of the participants used insulin. Body mass index, as indicator of general obesity, was not associated with higher mortality, whereas all measurements of abdominal obesity showed a positive association. Associations generally were slightly weaker in women. The strongest association was observed for waist/height ratio: In the fifth quintile, the hazard rate ratio was 1.88 (95% confidence interval: 1.33, 2.65) for men and 2.46 (95% confidence interval: 1.46, 4.14) for women. Measurements of abdominal, but not general, adiposity were associated with higher mortality in diabetic individuals. The waist/height ratio showed the strongest association. Respective indicators might be investigated in risk prediction models.

Dietary fiber, carbohydrate quality and quantity, and mortality risk of individuals with diabetes mellitus

Background Dietary fiber, carbohydrate quality and quantity are associated with mortality risk in the general population. Whether this is also the case among diabetes patients is unknown. Objective To assess the associations of dietary fiber, glycemic load, glycemic index, carbohydrate, sugar, and starch intake with mortality risk in individuals with diabetes. Methods This study was a prospective cohort study among 6,192 individuals with confirmed diabetes mellitus (mean age of 57.4 years, and median diabetes duration of 4.4 years at baseline) from the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at baseline (1992–2000) with validated dietary questionnaires. Cox proportional hazards analysis was performed to estimate hazard ratios (HRs) for all-cause and cardiovascular mortality, while adjusting for CVD-related, diabetes-related, and nutritional factors. Results During a median follow-up of 9.2 y, 791 deaths were recorded, 306 due to CVD. Dietary fiber was inversely associated with all-cause mortality risk (adjusted HR per SD increase, 0.83 [95% CI, 0.75–0.91]) and CVD mortality risk (0.76[0.64–0.89]). No significant associations were observed for glycemic load, glycemic index, carbohydrate, sugar, or starch. Glycemic load (1.42[1.07–1.88]), carbohydrate (1.67[1.18–2.37]) and sugar intake (1.53[1.12–2.09]) were associated with an increased total mortality risk among normal weight individuals (BMI≤25 kg/m2; 22% of study population) but not among overweight individuals (P interaction≤0.04). These associations became stronger after exclusion of energy misreporters. Conclusions High fiber intake was associated with a decreased mortality risk. High glycemic load, carbohydrate and sugar intake were associated with an increased mortality risk in normal weight individuals with diabetes.

Association of 1-y changes in diet pattern with cardiovascular disease risk factors and adipokines: Results from the 1-y randomized oslo diet and exercise study

BACKGROUND We hypothesized that favorable changes in dietary patterns would lead to a reduction in body size and an improvement in metabolic status. OBJECTIVE The objective was to study changes in diet patterns relative to changes in body size, blood pressure, and circulating concentrations of lipids, glucose, insulin, adiponectin, and other cytokines in the context of a 1-y randomized intervention study. DESIGN For 1 y, 187 men aged 45 +/- 2 y, approximately 50% of whom met the criteria of the metabolic syndrome, were randomly assigned to a diet protocol (n = 45), an exercise protocol (n = 48), a protocol of diet plus exercise (n = 58), or a control protocol (n = 36). A previously defined a priori diet score was created by summing tertile rankings of 35 food group variables; a higher score generally reflected recommended dietary changes in the trial (mean +/- SD at baseline: 31 +/- 6.5; range: 15-47). RESULTS Over the study year, the diet score increased by approximately 2 +/- 5.5 in both diet groups, with a decrease of an equivalent amount in the exercise and control groups. The weight change was -3.5 +/- 0.6 kg/10-point change in diet score (P < 0.0001), similarly within each intervention group, independently of the change in energy intake or baseline age and smoking status. Weight change was attenuated but remained significant after adjustment for intervention group and percentage body fat. Subjects with an increased diet score had more favorable changes in other body size variables, systolic blood pressure, and blood lipid, glucose, insulin, and adiponectin concentrations. Change in diet score was unrelated to resistin and several cytokines. CONCLUSION The change toward a more favorable diet pattern was associated with improved body size and metabolic profile.

Food intake of individuals with and without diabetes across different countries and ethnic groups

Background/Objectives:Given the importance of nutrition therapy in diabetes management, we hypothesized that food intake differs between individuals with and without diabetes. We investigated this hypothesis in two large prospective studies including different countries and ethnic groups.Subjects/Methods:Study populations were the European Prospective Investigation into Cancer and Nutrition Study (EPIC) and the Multiethnic Cohort Study (MEC). Dietary intake was assessed by food frequency questionnaires, and calibrated using 24h-recall information for the EPIC Study. Only confirmed self-reports of diabetes at cohort entry were included: 6192 diabetes patients in EPIC and 13 776 in the MEC. For the cross-sectional comparison of food intake and lifestyle variables at baseline, individuals with and without diabetes were matched 1:1 on sex, age in 5-year categories, body mass index in 2.5 kg/m2 categories and country.Results:Higher intake of soft drinks (by 13 and 44% in the EPIC and MEC), and lower consumption of sweets, juice, wine and beer (>10% difference) were observed in participants with diabetes compared with those without. Consumption of vegetables, fish and meat was slightly higher in individuals with diabetes in both studies, but the differences were <10%. Findings were more consistent across different ethnic groups than countries, but generally showed largely similar patterns.Conclusions:Although diabetes patients are expected to undergo nutritional education, we found only small differences in dietary behavior in comparison with cohort members without diabetes. These findings suggest that emphasis on education is needed to improve the current behaviors to assist in the prevention of complications.

Self-rated health and mortality in individuals with diabetes mellitus: prospective cohort study

Objectives To investigate whether low self-rated health (SRH) is associated with increased mortality in individuals with diabetes. Design Population-based prospective cohort study. Setting Enrolment took place between 1992 and 2000 in four centres (Bilthoven, Heidelberg, Potsdam, Umeå) in a subcohort nested in the European Prospective Investigation into Cancer and Nutrition. Participants 3257 individuals (mean ± SD age was 55.8±7.6 years and 42% women) with confirmed diagnosis of diabetes mellitus. Primary outcome measure The authors used Cox proportional hazards modelling to estimate HRs for total mortality controlling for age, centre, sex, educational level, body mass index, physical inactivity, smoking, insulin treatment, hypertension, hyperlipidaemia and history of myocardial infarction, stroke or cancer. Results During follow-up (mean follow-up ± SD was 8.6±2.3 years), 344 deaths (241 men/103 women) occurred. In a multivariate model, individuals with low SRH were at higher risk of mortality (HR 1.38, 95% CI 1.10 to 1.73) than those with high SRH. The association was mainly driven by increased 5-year mortality and was stronger among individuals with body mass index of <25 kg/m2 than among obese individuals. In sex-specific analyses, the association was statistically significant in men only. There was no indication of heterogeneity across centres. Conclusions Low SRH was associated with increased mortality in individuals with diabetes after controlling for established risk factors. In patients with diabetes with low SRH, the physician should consider a more detailed consultation and intensified support.

Total, Free, and Added Sugar Consumption and Adherence to Guidelines: The Dutch National Food Consumption Survey 2007–2010

A high sugar intake is a subject of scientific debate due to the suggested health implications and recent free sugar recommendations by the WHO. The objective was to complete a food composition table for added and free sugars, to estimate the intake of total sugars, free sugars, and added sugars, adherence to sugar guidelines and overall diet quality in Dutch children and adults. In all, 3817 men and women (7–69 years) from the Dutch National Food Consumption Survey 2007–2010 were studied. Added and free sugar content of products was assigned by food composition tables and using labelling and product information. Diet was assessed with two 24-h recalls. Diet quality was studied in adults with the Dutch Healthy Diet-index. Total sugar intake was 22% Total Energy (%TE), free sugars intake 14 %TE, and added sugar intake 12 %TE. Sugar consumption was higher in children than adults. Main food sources of sugars were sweets and candy, non-alcoholic beverages, dairy, and cake and cookies. Prevalence free sugar intake <10 %TE was 5% in boys and girls (7–18 years), 29% in women, and 33% in men. Overall diet quality was similar comparing adults adherent and non-adherent to the sugar guidelines, although adherent adults had a higher intake of dietary fiber and vegetables. Adherence to the WHO free sugar guidelines of <5 %TE and <10 %TE was generally low in the Netherlands, particularly in children. Adherence to the added and free sugar guidelines was not strongly associated with higher diet quality in adults.

A review of total & added sugar intakes and dietary sources in Europe

Public health policies, including in Europe, are considering measures and recommendations to limit the intake of added or free sugars. For such policies to be efficient and monitored, a precise knowledge of the current situation regarding sugar intake in Europe is needed. This review summarizes published or re-analyzed data from 11 representative surveys in Belgium, France, Denmark, Hungary, Ireland, Italy, Norway, The Netherlands, Spain and the UK. Relative intakes were higher in children than in adults: total sugars ranged between 15 and 21% of energy intake in adults and between 16 and 26% in children. Added sugars (or non-milk extrinsic sugars (NMES), in the UK) contributed 7 to 11% of total energy intake in adults and represented a higher proportion of children’s energy intake (11 to 17%). Educational level did not significantly affect intakes of total or added sugars in France and the Netherlands. Sweet products (e.g. confectionery, chocolates, cakes and biscuits, sugar, and jam) were major contributors to total sugars intake in all countries, genders and age groups, followed by fruits, beverages and dairy products. Fruits contributed more and beverages contributed less to adults’ total sugars intakes than to children’s. Added sugars were provided mostly by sweet products (36 to 61% in adults and 40 to 50% in children), followed by beverages (12 to 31% in adults and 20 to 34% in children, fruit juices excluded), then by dairy products (4 to 15% in adults and 6 to 18% in children). Caution is needed, however, as survey methodologies differ on important items such as dietary data collection, food composition tables or estimation of added sugars. Cross-country comparisons are thus not meaningful and overall information might thus not be robust enough to provide a solid basis for implementation of policy measures. Data nevertheless confirm that intakes of total and added sugars are high in the European countries considered, especially in children, and point to sweet products and beverages as the major contributors to added sugar intakes.

Lifestyle factors and mortality risk in individuals with diabetes mellitus: are the associations different from those in individuals without diabetes?

Aims/hypothesisThus far, it is unclear whether lifestyle recommendations for people with diabetes should be different from those for the general public. We investigated whether the associations between lifestyle factors and mortality risk differ between individuals with and without diabetes.MethodsWithin the European Prospective Investigation into Cancer and Nutrition (EPIC), a cohort was formed of 6,384 persons with diabetes and 258,911 EPIC participants without known diabetes. Joint Cox proportional hazard regression models of people with and without diabetes were built for the following lifestyle factors in relation to overall mortality risk: BMI, waist/height ratio, 26 food groups, alcohol consumption, leisure-time physical activity, smoking. Likelihood ratio tests for heterogeneity assessed statistical differences in regression coefficients.ResultsMultivariable adjusted mortality risk among individuals with diabetes compared with those without was increased, with an HR of 1.62 (95% CI 1.51, 1.75). Intake of fruit, legumes, nuts, seeds, pasta, poultry and vegetable oil was related to a lower mortality risk, and intake of butter and margarine was related to an increased mortality risk. These associations were significantly different in magnitude from those in diabetes-free individuals, but directions were similar. No differences between people with and without diabetes were detected for the other lifestyle factors.Conclusions/interpretationDiabetes status did not substantially influence the associations between lifestyle and mortality risk. People with diabetes may benefit more from a healthy diet, but the directions of association were similar. Thus, our study suggests that lifestyle advice with respect to mortality for patients with diabetes should not differ from recommendations for the general population.

Gamma‐glutamyltransferase, cardiovascular disease and mortality in individuals with diabetes mellitus

Increased plasma activity of gamma‐glutamyltransferase (GGT) is associated with cardiovascular diseases (CVD) and mortality in the general population. We investigated the association between GGT, CVD and mortality in individuals with diabetes mellitus.