Sugar and Type 2 diabetes

Background: Consumption of sugar, specifically sugar-sweetened beverages, has been widely held responsible by the media for the global rise in Type 2 diabetes (T2DM). Sources of data: Systematic reviews and dietary guidelines relating dietary sugars to T2DM. Areas of agreement: Weight gain and T2DM incidence are associated with diet and lifestyle patterns characterized by high consumptions of any sweetened beverages. High sugar intakes impair risk factors for macrovascular complications of T2DM. Areas of controversy: Much of the association between sugars and T2DM is eliminated by adjusting data for body mass index (BMI). However, BMI adjustment does not fully account for adiposity (r2=0.65–0.75). Excess sugar can promote weight gain, thus T2DM, through extra calories, but has no unique diabetogenic effect at physiological levels. Growing points: Ethical concerns about caffeine added to sweetened beverages, undetectable by consumers, to increase consumption. Areas timely for developing research: Evidence needed for limiting dietary sugar below 10% energy intake

Iodine and pregnancy – a qualitative study focusing on dietary guidance and information

Iodine is essential for thyroid hormones synthesis and normal neurodevelopment; however, ~60% of pregnant women do not meet the WHO (World Health Organization) recommended intake. Using a qualitative design, we explored the perceptions, awareness, and experiences of pregnancy nutrition, focusing on iodine. Women in the perinatal period (n = 48) were interviewed and filled in a food frequency questionnaire for iodine. Almost all participants achieved the recommended 150 μg/day intake for non-pregnant adults (99%), but only 81% met the increased demands of pregnancy (250 μg/day). Most were unaware of the importance, sources of iodine, and recommendations for iodine intake. Attitudes toward dairy products consumption were positive (e.g., helps with heartburn; easy to increase). Increased fish consumption was considered less achievable, with barriers around taste, smell, heartburn, and morning sickness. Community midwives were the main recognised provider of dietary advice. The dietary advice received focused most often on multivitamin supplements rather than food sources. Analysis highlighted a clear theme of commitment to change behaviour, motivated by pregnancy, with a desired focus on user-friendly documentation and continued involvement of the health services. The study highlights the importance of redirecting advice on dietary requirements in pregnancy and offers practical suggestions from women in the perinatal period as the main stakeholder group

'Language is the source of misunderstandings'–impact of terminology on public perceptions of health promotion messages

Background: The high level of premature death due to non-communicable diseases has been associated with unhealthful lifestyles, including poor diet. The effectiveness of public health strategies designed to promote health via messages focusing on food and diets depends largely on the perception of the messages by the public. The aim of this study was to explore public perceptions of language commonly used to communicate concepts linking health, food and the diet.<p></p> Methods: This study is a qualitative and semi-quantitative cross-sectional survey exploring public perceptions of terms used to improve eating habits within public health strategies. We recruited adults with no background in nutrition or health-care, from May to July 2013, from urban areas of varying deprivation (n = 12) in Glasgow and Edinburgh, UK. Four key prompt-terms used to convey the idea of improving health through diet were selected for testing: Healthy Eating, Eating for Health, Balanced Diet and Nutritional Balance. Consumer understanding of these terms was explored using mixed-methods, including qualitative focus groups (n = 17) and an interviewer-led word-association exercise (n = 270).<p></p> Results: The word-association exercise produced 1,386 individual responses from the four prompt-terms, with 130 unique responses associated with a single term. Cluster analysis revealed 16 key themes, with responses affected by prompt-term used, age, gender and socio-economic status. Healthy Eating was associated with foods considered ‘healthy’ (p <0.05); Eating for Health and Balanced Diet with negative connotations of foods to avoid (both p <0.001) and Nutritional Balance with the benefits of eating healthily (p <0.01). Focus groups revealed clear differences in perceptions: Eating for Health = positive action one takes to manage existing medical conditions, Healthy Eating = passive aspirational term associated with weight management, Balanced Diet = old fashioned, also dieting for weight loss, Nutritional Balance = maximising physical performance. Food suppliers use Healthy Eating terminology to promote weight management products. Focus group participants welcomed product reformulation to enhance food health properties as a strategy to overcome desensitisation to health-messages.<p></p> Conclusions: Public perceptions of messages communicating concepts linking health, food and the diet are influenced by terminology, resulting in confusion. To increase individual commitment to change eating habits in the long term, public health campaigns need strengthening, potentially by investing in tailored approaches to meet the needs of defined groups of consumers

Making progress on the global crisis of obesity and weight management

No abstract available

A clinical perspective of obesity, metabolic syndrome and cardiovascular disease

The metabolic syndrome is a condition characterized by a special constellation of reversible major risk factors for cardiovascular disease and type 2 diabetes. The main, diagnostic, components are reduced HDL-cholesterol, raised triglycerides, blood pressure and fasting plasma glucose, all of which are related to weight gain, specifically intra-abdominal/ectopic fat accumulation and a large waist circumference. Using internationally adopted arbitrary cut-off values for waist circumference, having metabolic syndrome doubles the risk of cardiovascular disease, but offers an effective treatment approach through weight management. Metabolic syndrome now affects 30–40% of people by age 65, driven mainly by adult weight gain, and by a genetic or epigenetic predisposition to intra-abdominal/ectopic fat accumulation related to poor intra-uterine growth. Metabolic syndrome is also promoted by a lack of subcutaneous adipose tissue, low skeletal muscle mass and anti-retroviral drugs. Reducing weight by 5–10%, by diet and exercise, with or without, anti-obesity drugs, substantially lowers all metabolic syndrome components, and risk of type 2 diabetes and cardiovascular disease. Other cardiovascular disease risk factors such as smoking should be corrected as a priority. Anti-diabetic agents which improve insulin resistance and reduce blood pressure, lipids and weight should be preferred for diabetic patients with metabolic syndrome. Bariatric surgery offers an alternative treatment for those with BMI ≥ 40 or 35–40 kg/m2 with other significant co-morbidity. The prevalence of the metabolic syndrome and cardiovascular disease is expected to rise along with the global obesity epidemic: greater emphasis should be given to effective early weight-management to reduce risk in pre-symptomatic individuals with large waists

Banting Memorial Lecture 2021 Banting, banting, banter and bravado: convictions meet evidence in the scientific process

This personal account presents some glimpses into the clinical research processes which have made radical changes to our understanding of disease and treatment, and some characteristics of researchers, drawn from history and personal experiences around obesity and type 2 diabetes. Some summary messages emerge: •The history of clinical diabetes research has shown how, perhaps through skilful leadership, combining very different personalities, skills and motivations can solve great challenges •Type 2 diabetes is a primary nutritional disease, secondary to the disease-process of obesity, not a primary endocrine disease •Type 2 diabetes is a manifestation of the disease-process of obesity, revealed by weight gain in people with underlying metabolic syndrome genetics/diathesis, mediated in large part at least by reversible ectopic fat accumulation impairing function of organs (liver, pancreas, brown adipose tissue) •Treat overweight/obesity more seriously (defined as a disease-process with multiple organ-specific complications - not as a BMI state or cut-off) •Discuss the complications and risks of T2D openly: remission is as important as for cancers •Offer and support an optimal dietary weight-management programme as soon as possible from diagnosis, specifically aiming for remission oWarn against non-evidence-based programs that look similar or claim to have similar potential: we have fully evidence based programmes oTarget sustained loss of >15kg for Europeans, (possibly less, eg >10kg for Asians?) •Increase future research support to enhance long-term weight loss maintenance. Several approaches need consideration: oPersonalise diet compositions (recognising there is no intrinsic advantage from different carbohydrate/fat content) oNovel diet strategies (eg 5:2, time-restricted, flexible diet compositions) oNew Pharmaceutical agents as adjuncts to diet if necessary oFood supplements to increase endogenous GLP-1 secretio

Low and reduced carbohydrate diets: challenges and opportunities for type 2 diabetes management and prevention

Low-carbohydrate diets (LCD) have been promoted for weight control and type 2 diabetes (T2D) management, based on an emerging body of evidence, including meta-analyses with an indication of publication bias. Proposed definitions vary between 50 and 130 g/d, or <10 and <40 % of energy from carbohydrate, with no consensus on LCD compositional criteria. LCD are usually followed with limited consideration for other macronutrients in the overall diet composition, introducing variance in the constituent foods and in metabolic responses. For weight management, extensive evidence supports LCD as a valid weight loss treatment, up to 1–2 years. Solely lowering carbohydrate intake does not, in the medium/long term, reduce HbA1c for T2D prevention or treatment, as many mechanisms interplay. Under controlled feeding conditions, LCD are not physiologically or clinically superior to diets with higher carbohydrates for weight-loss, fat loss, energy expenditure or glycaemic outcomes; indeed, all metabolic improvements require weight loss. Long-term evidence also links the LCD pattern to increased CVD risks and mortality. LCD can lead to micronutrient deficiencies and increased LDL-cholesterol, depending on food selection to replace carbohydrates. Evidence is limited but promising regarding food choices/sources to replace high-carbohydrate foods that may alleviate the negative effects of LCD, demanding further insight into the dietary practice of medium to long term LCD followers. Long-term, high-quality studies of LCD with different food sources (animal and/or plant origins) are needed, aiming for clinical endpoints (T2D incidence and remission, cardiovascular events, mortality). Ensuring micronutrient adequacy by food selection or supplementation should be considered for people who wish to pursue long-term LCD

Sugar taxation: a good start but not the place to finish

No abstract available

Carbohydrate knowledge, dietary guideline awareness, motivations and beliefs underlying low-carbohydrate dietary behaviours

To explore the factors (including knowledge and attitude) influencing the decision to follow a low-carbohydrate diet (LCD) or not in a sample of the UK population. An online questionnaire was distributed electronically to adults who had either followed LCD or not (February–December 2019). Demographics and self-reported “LCD-status” (current, past and non-follower) were collected. Multivariable linear regression was used with carbohydrate knowledge, dietary guideline agreement and theory of planned behaviour (TPB) constructs (all as predictors) to explain the intention to follow a LCD (outcome). Respondents (n = 723, 71% women, median age 34; 85% white-ethnicity) were either following (n = 170, 24%) or had tried a LCD in the preceding 3 months (n = 184, 25%). Current followers had lower carbohydrate knowledge scores (1–2 point difference, scale − 11 to 11) than past and non-followers. A majority of current LCD followers disagreed with the EatWell guide recommendations “Base meals on potatoes, bread, rice and pasta, or other starchy carbohydrates. Choose whole grains where possible” (84%) and “Choose unsaturated oils and spreads and eat in small amounts such as vegetable, rapeseed, olive and sunflower oils” (68%) compared to past (37%, 10%, respectively) and non-followers (16%, 8%, respectively). Weight-loss ranked first as a motivation, and the internet was the most influencial source of information about LCDs. Among LCD-followers, 71% reported ≥ 5% weight loss, and over 80% did not inform their doctor, nurse, or dietitian about following a diet. Approximately half of LCD followers incorporated supplements to their diets (10% used multivitamin/mineral supplements), despite the restrictive nature of the diet. TPB constructs, carbohydrate knowledge, and guideline agreement explained 60% of the variance for the intention to follow a LCD. Attitude (std-β = 0.60), perceived behavioural control (std-β = 0.24) and subjective norm (std-β = 0.14) were positively associated with the intention to follow a LCD, while higher knowledge of carbohydrate, and agreeing with national dietary guidelines were both inversely associated (std-β = − 0.09 and − 0.13). The strongest primary reason behind UK adults’ following a LCD is to lose weight, facilitated by attitude, perceived behavioural control and subjective norm. Higher knowledge about carbohydrate and agreement with dietary guidelines are found among people who do not follow LCDs

Lower carbohydrate and higher fat intakes are associated with higher hemoglobin A1c: findings from the UK National Diet and Nutrition Survey 2008-2016

Purpose: Evidence of low-carbohydrate, high-fat diets (LCHF) for type 2 diabetes (T2DM) prevention is scarce. We investigated how carbohydrate intake relates to HbA1c and T2DM prevalence in a nationally representative survey dataset. Methods: We analyzed dietary information (4-day food diaries) from 3234 individuals aged ≥ 16 years, in eight waves of the UK National Diet and Nutrition Survey (2008–2016). We calculated LCHF scores (0–20, higher score indicating lower %food energy from carbohydrate, with reciprocal higher contribution from fat) and UK Dietary Reference Value (DRV) scores (0–16, based on UK dietary recommendations). Associations between macronutrients and diet scores and diabetes prevalence were analyzed (in the whole sample) using multivariate logistic regression. Among those without diabetes, analyses between exposures and %HbA1c (continuous) were analyzed using multivariate linear regression. All analyses were adjusted for age, sex, body mass index, ethnicity, smoking status, total energy intake, socioeconomic status and survey years. Results: In the overall study sample, 194 (6.0%) had diabetes. Mean intake was 48.0%E for carbohydrates, and 34.9%E for total fat. Every 5%E decrease in carbohydrate, and every 5%E increase in fat, was associated with 12% (95% CI 0.78–0.99; P = 0.03) and 17% (95% CI 1.02–1.33; P = 0.02) higher odds of diabetes, respectively. Each two-point increase in LCHF score is related to 8% (95% CI 1.02–1.14; P = 0.006) higher odds of diabetes, while there was no evidence for association between DRV score and diabetes. Among the participants without diagnosed diabetes (n = 3130), every 5%E decrease in carbohydrate was associated with higher %HbA1c by + 0.016% (95% CI 0.004–0.029; P = 0.012), whereas every 5%E increase in fat was associated with higher %HbA1c by + 0.029% (95% CI 0.015–0.043; P < 0.001). Each two-point increase in LCHF score is related to higher %HbA1c by + 0.010% (0.1 mmol/mol), while each two-point increase in the DRV score is related to lower %HbA1c by − 0.023% (0.23 mmol/mol). Conclusions: Lower carbohydrate and higher fat intakes were associated with higher HbA1c and greater odds of having diabetes. These data do not support low(er) carbohydrate diets for diabetes prevention