Diabetes Type 1 and 2

DM: Carbohydrates (2007)

• Intervention
  What is the relationship between carbohydrate intake and metabolic outcomes in persons with type 1 and type 2 diabetes?

  • Conclusion

    Nine studies investigated the relationship between carbohydrate intake and metabolic control in type 1 and type 2 diabetes.  Two studies in subjects with Type I diabetes based the adjustment of mealtime insulin to match planned carbohydrate intake and three studies based on day-to-day consistency in carbohydrate intake resulted in improved glycemic control.  Of four studies evaluating differing percentages of carbohydrate, the evidence was inconclusive.

  • Grade: I
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between carbohydrate intake and metabolic outcomes in persons with type 1 and type 2 diabetes?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Boden G, Sargrad K, Homko C, Mozzoli M, Stein TP.  Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes.  Ann Intern Med 2005; 142:403-411. 
      • DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. Brit Med J. 2002; 325:746-751.
      • The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977-986.  
      • Garg A, Bantle JP, Henry RR, Coulston AM, Griver KA, Raatz SK, Brinkley L, Chen Y-D I, Grundy SM, Huet BA, Reaven GM. Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetes mellitus. JAMA. 1994;271:1421-1428.
      • Komiyama N, Kaneko T, Sato A, Sato W, Asami K, Onaya T, Tawata M.  The effect of high carbohydrate diet on glucose tolerance in patients with type 2 diabetes mellitus.  Diabetes Research and Clinical Practice 2002; 57:163-170.
      • Nielsen JV, Jonsson E, Ivarsson A.  A low-carbohydrate diet in type 1 diabetes:  clinical experience--a brief report.  Upsala J Med Sci 2005;110:267-273. 
      • Nielsen JV, Jonsson E, Nilsson AK.  Lasting improvement of hyperglycemia and bodyweight:  low-carbohydrate diet in type 2 diabetes.  A brief report.  Upsala J Med Sci 2005; 109:179-184.
      • Wolever TMS, Hamad S, Chiasson JL, Josse RG, Leiter LA, Rodger NW, Ross SA, Ryan EA. Day-to-day consistency in amount and source of carbohydrate intake associated with improved glucose control in type 1 diabetes. J Amer Coll Nutr. 1999;18:242-247.
  • Search Plan and Results: Carbohydrate Intake 2007
     
• Basic Research
  What is the relationship between fiber and metabolic outcomes in persons with type 1 and type 2 diabetes?

  • Conclusion
    There is inconclusive evidence that increasing dietary fiber will influence glycemic outcome in people with diabetes.  

     

    Two studies with higher fiber and lower fiber diets both containing similar macronutrient percents of energy  showed no significant difference between diets for A1C, and one study showed a 2% reduction in A1C only in subjects compliant with the 50 gram fiber diet. Three studies found 24-hr glycemic profiles significantly lower on the higher fiber diet vs the lower fiber diet and one study showed significantly lower postprandial glucose levels on the higher fiber vs the lower fiber diet. Two studies with higher fiber and lower fiber diets having different macronutrient percents of energy showed no change in A1C between diets; however, two studies showed significant improvement in A1C with the higher fiber diet vs the lower fiber diet. Three studies found no change in fasting blood glucose between diets, and one study found significant improvement in FBG for the higher fiber vs the lower fiber diet. One cross-sectional study found that fiber intake was inversely related to A1C and the other showed no relationship.

     

    When the above studies are divided according to environment (controlled or free living), type of diabetes, or “good” or “poor” control, they showed the same  results. 

     

    There appears to be conclusive evidence that higher fiber diets will lower total cholesterol significantly vs lower fiber diets. In eight studies lipids were a measured outcome.   Seven studies showed a significant decrease in total cholesterol in the higher fiber group compared to the lower fiber group and one showed no change. Three of the eight studies reported significantly reduced HDL-cholesterol. 

  • Grade: I
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between fiber and metabolic outcomes in persons with type 1 and type 2 diabetes?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Anderson JW, Zeigler JA, Deakins DA, Floore TL, Dillon DW, Wood CL, Oeltgen PR, Whitley RJ. Metabolic effects of high-carbohydrate, high-fiber diets for insulin-dependent diabetic individuals. Am J Clin Nutr 1991;54:936-943.
      • Buyken AE, Toeller M, Heitkamp G, Vitelli F, Stehle P, Scherbaum WA, Fuller JH and the EURODIAB IDDM Complications Study Group.  Relation of fibre intake to HbA_1c and the prevalence of severe ketoacidosis and severe hypoglycaemia.  Diabetologia 1998;41:882-890.
      • Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy SM, Brinkley LJ. Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus. N Engl J Med. 2000:342:1392-1398.
      • Del Toma E, Lintas C, Clementi A, Marcelli M.  Soluble and insoluble dietary fiber in diabetic diets. Eur J Clin Nutr. 1988;42: 313-319.
      • Giacco R, Parillo M, Rivellese AA, Lasorella G, Giacco A, D'Episcopo L, Riccardi G. Long-term dietary treatment with increased amounts of fiber-rich low-glycemic index natural foods improves blood glucose control and reduces the number of hypoglycemic events in type 1 diabetic patients. Diabetes Care. 2000;23:1461-1466.
      • Hagander B, Asp N-G; Efendic S, Nilsson-Ehle P, Schersten B. Dietary fiber decreases fasting blood glucose levels and plasma LDL concentration in noninsulin-dependent diabetes mellitus patients. Am J Clin Nutr 1988;47(5):852-858.
      • Kinmonth A-L, Angus RM, Jenkins PA, Smith MA, Baum JD. Whole foods and increased dietary fibre improve blood glucose control in diabetic children. Arch Dis Childhood.  1982;57:187-194.
      • Lindsay AN, Hardy S, Jarrett L, Rallison ML. High-carbohydrate, high-fiber diet in children with type 1 diabetes mellitus.  Diabetes Care 1984;7(1):63-67.
      • McCulloch DK, Mitchell RD, Ambler J, Tattersall RB. A prospective comparison of "conventional" and high carbohydrate/high fibre/low fat diets in adults with established type 1 (insulin-dependent) diabetes.  Diabetologia 1985;28:208-212.
      • Milne RM, Mann JI, Chisholm AW, Williams SM. Long-term comparison of three dietary prescriptions in the treatment of NIDDM.  Diabetes Care 1994;17:74-80.
      • Riccardi G, Rivellese A, Pacioni D, Genovese S, Mastranzo P, Mancini M. Separate influence of dietary carbohydrate and fibre on the metabolic control in diabetes.  Diabetologia. 1984;26:116-121. 
      • Shimakawa T, Warram JH, Herrera-Acena MG, Krolewski AS. Usual dietary intake and hemoglobin A₁ level in patients with insulin-dependent diabetes.  J Am Diet Assoc 1993;93:1409-1412, 1415.
      • Simpson RW, McDonald J, Wahlqvist ML, Balasz N, Sissons M, Atley L. Temporal study of metabolic change when poorly controlled noninsulin-dependent diabetics change from low to high carbohydrate and fiber diet.  Am J Clin Nutr 1988;48:104-109.
      • Stevens J, Burgess MB, Kaiser DL, Sheppa CM.  Outpatient management of diabetes mellitus with patient education to increase dietary carbohydrate and fiber.  Diabetes Care. 1985;8:359-366.
      • Story L, Anderson JW, Chen W-JL, Karounos D, Jefferson B.  Adherence to high-carbohydrate, high-fiber diets: long-term studies of non-obese diabetic men.  J Am Diet Assoc.  1985; 85:1105-1110.
  • Search Plan and Results: Dietary Fiber 2007
     
  What is the relationship between glycemic index and metabolic outcomes in persons with type 1 and type 2 diabetes?

  • Conclusion

    Fifteen short-term studies ranging from two to 12 weeks and one longer term (one year) studies report mixed effects on A1C levels.  These studies are complicated by differing definitions of "high GI" and "low GI" diets or quartiles, as well as possible confounding dietary factors. 

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between glycemic index and metabolic outcomes in persons with type 1 and type 2 diabetes?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Brand-Miller J, Petocz P, Hayne S, Colagiuri S.  Low-glycemic index diets in the management of diabetes: a meta-analysis of randomized controlled trials.  Diabetes Care 2003; 26:2261-2267.
      • Burani J, Longo P.  Low glycemic index carbohydrates:  an effective behavioral change for glycemic control and weight management in patients with type 1 and 2 diabetes.  The Diabetes Educator 2006; 32:78-88. 
      • Buyken AE, Toeller M, Heitkamp G, Karamanos B, Rottiers R, Muggeo M, Fuller JH.  Glycemic index in the diet of European outpatients with type 1 diabetes: relations to glycated hemoglobin and serum lipids.  Am J clin Nutr 2001; 73:574-581. 
      • Fontvieille AM, Rizkalla SW, Penfornis A, Acosta M, Bornet FRJ, Slama G.  The use of low glycemic index foods improves metabolic control of diabetic patients over five weeks.  Diabet Med 1992;9(5):444-50.
      • Frost G, Wilding J, Beecham J.  Dietary advice based on the glycemic index improves dietary profile and metabolic control in type 2 diabetic patients.  Diabet Med 1994;11(4):397-401.
      • Gilbertson HR, Thorburn AW, Brand-Miller JC, Chondros P, Werther GA. Effect of low-glycemic-index dietary advice on dietary quality and food choice in children with type 1 diabetes.  Am J Clin Nutr 2003; 77:83-90.
      • Gilbertson HR, Brand-Miller JC, Thorburn AW, Evans S, Chondros P, Werther GA. The effect of flexible low glycemic index dietary advice versus measured carbohydrate exchange diets on glycemic control in children with type 1 diabetes. Diabetes Care. 2001;24:1137-1143.
      • Heilbronn LK, Noakes M, Clifton PM.  The effect of high- and low-glycemic index energy restricted diets on plasma lipid and glucose profiles in type 2 diabetic subjects with varying glycemic control.  J Am Coll Nutr 2002; 21:120-127.
      • Jarvi AE, Karlstrom BE, Granfeldt YE, Bjorck IE, Asp NGL, Vessby BOH. Improved glycemic control and lipid profile and normalized fibrinolytic activity on a low glycemic index diet in type 2 diabetic patients. Diabetes Care. 1999; 22: 10-18.
      • Kabir M, Oppert JM, Vidal H, Bruzzo F, Fiquet C, Wursch P, Slama G, Rizkalla SW.  Four-week low-glycemic index breakfast with a modest amount of soluble fibers in type 2 diabetic men.  Metabolism 2002; 51:819-826.
      • Rizkalla SW, Boillot J, Taghrid L, Rigoir A, Laromiguiere M, Elgrably F, Huet D, Slama G.  Improved plasma glucose control, whole-body glucose utilization, and lipid profile on a low-glycemic index diet in type 2 diabetic men: a randomized controlled trial.  Diabetes Care 2004; 27:1866-1872.
      • Wolever TMS, Jenkins DJA, Jenkins AL, Josse RG.  The glycemic index:  methodology and clinical implications.  Am J Clin Nutr. 1991;54:846-854.
      • Wolever TMS, Hamad S, Chiasson JL, Josse RG, Leiter LA, Rodger NW, Ross SA, Ryan EA. Day-to-day consistency in amount and source of carbohydrate intake associated with improved glucose control in type 1 diabetes. J Amer Coll Nutr. 1999;18:242-247.
      • Wolever TMS, Nguyen PM, Chiasson JL, Hunt JA, Josse RG, Palmason C, Rodger NW, Ross SA, Ryan EA, Tan MH.  Determinants of diet glycemic index calculated retrospectively from diet records of 342 individuals with non-insulin-dependent diabetes mellitus. Am J Clin Nutr. 1994;59:1265-1269.
      • Wolever TMS, Jenkins DJA, Vuksan V, Jenkins AL, Buckley GC, Wong GS, Josse RG.  Beneficial effect of a low glycemic index diet in type 2 diabetes.  Diabet Med 1992;9(5):451-8.
  • Search Plan and Results: Glycemic Index/Glycemic Load 2007
     
  What is the relationship between sucrose and metabolic outcomes in persons with type 1 and type 2 diabetes?

  • Conclusion

    Sucrose intakes of 10 percent to 35 percent of total energy intake do not have a negative effect on glycemic or lipid responses in persons with either type 1 or type 2 diabetes when sucrose is substituted for isocaloric amounts of starch. Ten randomized crossover/controlled studies, four non-randomized crossover studies and one cross-over study examined the effect of sucrose on glycemic control. All but one study showed no effect of sucrose.

  • Grade: I
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between sucrose and metabolic outcomes in persons with type 1 and type 2 diabetes?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Bantle JP, Laine DC, Castle GW, Thomas JW, Hoogwerf BJ, Goetz FC.  Postprandial glucose and insulin responses to meals containing different carbohydrates in normal and diabetic subjects.  New Eng J Med 1983; 309:7-12.
      • Bantle JP, Laine DC, Thomas JW.  Metabolic effects of dietary fructose and sucrose in Types I and II diabetic subjects.  JAMA 1986; 256:3241-3246.
      • Bantle JP, Swanson JE, Thomas W, Laine DC.  Metabolic effects of dietary sucrose in type II diabetic subjects.  Diabetes Care 1993; 16:1301-1305.
      • Buysschaert M, Sory R, Mpoy M, Lambert AE.  Effect of the addition of simple sugars to mixed meals on the glycemic control of insulin treated diabetic patients.  Diabete & Metabolisme 1987;13:625-629.
      • Chantelau EA, Gosseringer G, Sonnenberg GE, Berger M.  Moderate intake of sucrose does not impair metabolic control in pump-treated diabetic outpatients.  Diabetologia 1985; 29(4):204-207.     
      • Cooper PL, Wahlqvist ML, Simpson RW. Sucrose versus saccharin as an added sweetener in non-insulin-dependent diabetes: short- and medium-term metabolic effects. Diabet Med. 1988 Oct; 5 (7): 676-680. PMID: 2975554.
      • Coulston AM, Hollenbeck CB, Donner CC, Williams R, Chiou YM, Reaven GM.  Metabolic effects of added dietary sucrose in individuals with non-insulin-dependent diabetes mellitus (NIDDM).  Metabolism 1985; 34(10):962-966.
      • Loghmani E, Rickard K, Washburne L, Vandagriff J, Fineberg N, Golden M.  Glycemic response to sucrose-containing mixed meals in diets of children with insulin-dependent diabetes mellitus.  Journal of Pediatrics 1991; 119:531-537.
      • Malerbi DA, Duarte AL, Paiva ESA, Wajchenberg BL.  Metabolic effects of dietary sucrose and fructose in Type II diabetic subjects.  Diabetes Care 1996:1249-1256.
      • Nadeau J, Koski KG, Strychar I, Yale JF.  Teaching subjects with type 2 diabetes how to incorporate sugar choices into their daily meal plan promotes dietary compliance and does not deteriorate metabolic profile.  Diabetes Care 2001; 24:222-227.
      • Peterson DB, Lambert J, Gerring S, Darling P, Carter RD, Jelfs R, Mann JI.  Sucrose in the diet of diabetic patients - just another carbohydrate?  Diabetologia 1986:29(4):216-220.
      • Rickard KA, Cleveland JL, Loghmani ES, Fineberg NS, Freidenberg GR.  Similar glycemic responses to high versus moderate sucrose-containing foods in test meals for adolescents with type 1 diabetes and fasting euglycemia.  J Am Diet Assoc 2001;101:1202-1205. 
      • Santacroce G, Forlani G, Giangiulio S, Galuppi V, Pagani M, Vannini P.  Long-term effects of eating sucrose on metabolic control of type 1 (insulin dependent) diabetic outpatients. Acta Diabetol Lat 1990; 27:365-370. 
      • Schwingshandl J, Rippel S, Unterluggauer M, Borkenstein M.  Effect of the introduction of dietary sucrose on metabolic control in children and adolescents with type 1 diabetes.  Acta Diabetol 1994; 31:205-209.
      • Shimakawa T, Warram JH, Herrera-Acena MG, Krolewski AS. Usual dietary intake and hemoglobin A₁ level in patients with insulin-dependent diabetes.  J Am Diet Assoc 1993;93:1409-1412, 1415.
  • Search Plan and Results: Sucrose Intake 2007