Personalized Nutrition in Patients with Type 2 Diabetes and Chronic Kidney Disease:The Two-Edged Sword of Dietary Protein Intake

In type 2 diabetes (T2D), there is a general and strong focus on carbohydrate restriction. However, this may have unwarranted consequences for those with concomitant chronic kidney disease (CKD) since decreasing intake of carbohydrates implies a higher proportion of dietary protein, which is of critical debate in patients with CKD due to its ambiguous implications in maintaining either kidney function or nutritional status. We evaluated adherence to the protein recommendations, taking into account the nutritional status of patients with T2D with or without CKD. Patients were divided in three groups according to their estimated Glomerular Filtration Rate (eGFR): mild to no CKD (eGFR > 60 mL/min/1.73 m(2)), moderate CKD (eGFR 30–60 mL/min/1.73 m(2)), or advanced CKD (eGFR 1.3 g/kg/day, and 60% of the patients with advanced CKD consumed > 1.0 g/kg/day. In addition, patients with moderate- or advanced CKD tend to have a lower muscle mass, normalized by height, compared to patients with mild to no CKD (p < 0.001), while body mass index was not significantly different between patients with or without CKD (p = 0.44). We found that although dietary protein restriction has not been indicated in either of the CKD stages, approximately 10% had a dietary protein intake < 0.8 g/kg/day, with accompanying risks of malnourishment and sarcopenia. Our main advice is to maintain a dietary protein intake of at least 0.8 g/kg/day in order to prevent patients from becoming malnourished and sarcopenic

Urinary creatinine excretion is an indicator of physical performance and function

Muscle mass is essential for performing physical activity, and low muscle mass (sarcopenia) has been found to have a strong association with all-cause mortality in patients with type 2 diabetes (T2D).1 However, muscle mass is not routinely assessed in clinical practice and low muscle mass can easily go unnoticed in obese patients (sarcopenic obesity), which was emphasized in previous DIALECT findings.2 The current definition of sarcopenia requires presence of either low muscle mass, low muscle strength or poor physical performance rather than low muscle mass alone.3 Two methods for estimating muscle mass independent of kidney function in clinical practice are the 24 h urinary creatinine excretion rate (CER) and bioelectric impedance analysis (BIA), but their association with physical performance and function is unclear.4 In this study we investigate whether CER or BIA-derived predicted muscle mass also indicate physical performance and function in patients with T2D, in order to indirectly screen patients on sarcopenia

Determinants of Increased Serum Calprotectin in Patients with Type 2 Diabetes Mellitus

Circulating calprotectin is a potential biomarker for endovascular inflammation in type 2 diabetes mellitus (T2DM). We investigated the determinants of calprotectin and its relationship with the presence of cardiovascular disease (CVD) in 362 T2DM patients included in the Diabetes and Lifestyle Cohort Twente-1 (DIALECT-1) study. Lifestyle exposures, including nutrition, were determined by validated questionnaires. CVD was defined as coronary artery diseases, strokes, and peripheral artery diseases. Median serum calprotectin levels were 1.04 mg/L [IQR: 0.73-1.46 mg/L] and were higher in women (1.11 mg/L) than men (0.96 mg/L, p = 0.007). Current smoking was a major independent determinant of circulating calprotectin, with a 51% higher calprotectin compared to never smoking (p <0.001). Albuminuria (p = 0.011), former smoking (p = 0.023), and intake of mono- and disaccharides (p = 0.005) also contributed independently to circulating calprotectin. Each incremental increase in calprotectin level was associated with 1.36-times higher odds for CVD (95% CI 1.04-1.77, p = 0.026). In the current study, calprotectin was the only inflammatory parameter significantly associated with CVD. The strong association of circulating calprotectin with smoking, a well-known direct cause of vascular inflammation, and also with CVD, stresses the urge for further research to define its role as a biomarker in T2DM

Low Physical Activity in Patients with Complicated Type 2 Diabetes Mellitus Is Associated with Low Muscle Mass and Low Protein Intake

Objective: In order to promote physical activity (PA) in patients with complicated type 2 diabetes, a better understanding of daily movement is required. We (1) objectively assessed PA in patients with type 2 diabetes, and (2) studied the association between muscle mass, dietary protein intake, and PA. Methods: We performed cross-sectional analyses in all patients included in the Diabetes and Lifestyle Cohort Twente (DIALECT) between November 2016 and November 2018. Patients were divided into four groups: = 10,000 steps/day. We studied the association between muscle mass (24 h urinary creatinine excretion rate, CER) and protein intake (by Maroni formula), and the main outcome variable PA (steps/day, Fitbit Flex device) using multivariate linear regression analyses. Results: In the 217 included patients, the median steps/day were 6118 (4115-8638). Of these patients, 48 patients (22%) took 7000-9999 steps/day, 37 patients (17%) took >= 10,000 steps/day, and 78 patients (36%) took = 10,000 steps/day, a higher body mass index (BMI) (33 +/- 6 vs. 30 +/- 5 kg/m(2), p = 0.009), lower CER (11.7 +/- 4.8 vs. 14.8 +/- 3.8 mmol/24 h, p = 0.001), and lower protein intake (0.84 +/- 0.29 vs. 1.08 +/- 0.22 g/kg/day, p < 0.001). Both creatinine excretion (beta = 0.26, p < 0.001) and dietary protein intake (beta = 0.31, p < 0.001) were strongly associated with PA, which remained unchanged after adjustment for potential confounders. Conclusions: Prevalent insufficient protein intake and low muscle mass co-exist in obese patients with low physical activity. Dedicated intervention studies are needed to study the role of sufficient protein intake and physical activity in increasing or maintaining muscle mass in patients with type 2 diabetes

Adherence to Statin Therapy and Attainment of LDL Cholesterol Targets in an Outpatient Population of Type 2 Diabetes Patients:Analysis in the DIAbetes and LifEstyle Cohort Twente (DIALECT)

Objective: To assess adherence to statin therapy and its association with sociodemographic data, medical characteristics, LDLc levels, and LDLc target attainment in real-world T2D patients treated in secondary care.Research Design and Methods: Cross-sectional analyses were performed on baseline data of 393 patients in the DIAbetes and LifEstyle Cohort Twente (DIALECT). The medication possession ratio (MPR), calculated with pharmacy dispensing data, was used to determine adherence to statins for an intended period of 24 months. Statins were included in the analyses if they were used for at least six consecutive months with at least three dispenses. Adherence was defined as an MPR >= 80%. Associations with adherence were assessed using descriptive statistics and binary logistic regression.Results: Overall, 80% of the patients had a statin prescription and of those, 89% were adherent. The proportion of patients who reached LDLc targets o

Personalized Nutrition in Patients with Type 2 Diabetes and Chronic Kidney Disease: The Two-Edged Sword of Dietary Protein Intake

In type 2 diabetes (T2D), there is a general and strong focus on carbohydrate restriction. However, this may have unwarranted consequences for those with concomitant chronic kidney disease (CKD) since decreasing intake of carbohydrates implies a higher proportion of dietary protein, which is of critical debate in patients with CKD due to its ambiguous implications in maintaining either kidney function or nutritional status. We evaluated adherence to the protein recommendations, taking into account the nutritional status of patients with T2D with or without CKD. Patients were divided in three groups according to their estimated Glomerular Filtration Rate (eGFR): mild to no CKD (eGFR &gt; 60 mL/min/1.73 m2), moderate CKD (eGFR 30&ndash;60 mL/min/1.73 m2), or advanced CKD (eGFR &lt; 30 mL/min/1.73 m2). Regarding adherence to the protein recommendations, 17% of the patients without advanced CKD consumed &lt; 0.8 g/kg/day, 29% of the patients with moderate CKD consumed &gt; 1.3 g/kg/day, and 60% of the patients with advanced CKD consumed &gt; 1.0 g/kg/day. In addition, patients with moderate- or advanced CKD tend to have a lower muscle mass, normalized by height, compared to patients with mild to no CKD (p &lt; 0.001), while body mass index was not significantly different between patients with or without CKD (p = 0.44). We found that although dietary protein restriction has not been indicated in either of the CKD stages, approximately 10% had a dietary protein intake &lt; 0.8 g/kg/day, with accompanying risks of malnourishment and sarcopenia. Our main advice is to maintain a dietary protein intake of at least 0.8 g/kg/day in order to prevent patients from becoming malnourished and sarcopenic

Personalized Nutrition in Patients with Type 2 Diabetes and Chronic Kidney Disease: The Two-Edged Sword of Dietary Protein Intake

In type 2 diabetes (T2D), there is a general and strong focus on carbohydrate restriction. However, this may have unwarranted consequences for those with concomitant chronic kidney disease (CKD) since decreasing intake of carbohydrates implies a higher proportion of dietary protein, which is of critical debate in patients with CKD due to its ambiguous implications in maintaining either kidney function or nutritional status. We evaluated adherence to the protein recommendations, taking into account the nutritional status of patients with T2D with or without CKD. Patients were divided in three groups according to their estimated Glomerular Filtration Rate (eGFR): mild to no CKD (eGFR > 60 mL/min/1.73 m 2 ), moderate CKD (eGFR 30–60 mL/min/1.73 m 2 ), or advanced CKD (eGFR 1.3 g/kg/day, and 60% of the patients with advanced CKD consumed > 1.0 g/kg/day. In addition, patients with moderate-or advanced CKD tend to have a lower muscle mass, normalized by height, compared to patients with mild to no CKD (p < 0.001), while body mass index was not significantly different between patients with or without CKD (p = 0.44). We found that although dietary protein restriction has not been indicated in either of the CKD stages, approximately 10% had a dietary protein intake < 0.8 g/kg/day, with accompanying risks of malnourishment and sarcopenia. Our main advice is to maintain a dietary protein intake of at least 0.8 g/kg/day in order to prevent patients from becoming malnourished and sarcopenic

High-Normal Protein Intake Is Not Associated With Faster Renal Function Deterioration in Patients With Type 2 Diabetes: A Prospective Analysis in the DIALECT Cohort

OBJECTIVE To study the prospective association between dietary protein intake and renal function deterioration in patients with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS Prospective analyses were performed in data of 382 patients of the Diabetes and Lifestyle Cohort Twente (DIALECT) study. Dietary protein intake was determined by the Maroni equation from 24-h urinary urea excretion. Renal function deterioration was defined as need for renal replacement therapy or a persistent increase of ≥50% in serum creatinine. Cox proportional hazards models were used to calculate hazard ratios (HRs) for the association between dietary protein intake and renal function deterioration. Threshold levels represent the dietary protein intake at which there was a significantly increased and reduced hazard of renal function deterioration. RESULTS Renal function deterioration occurred in 53 patients (14%), with a median follow-up duration of 6 (interquartile range 5–9) years. Mean dietary protein intake was 91 ± 27 g/day (1.22 ± 0.33 g/kg ideal body weight/day). Dietary protein intake was inversely associated with renal function deterioration (HR 0.62 [95% CI 0.44–0.90]). Patients with an intake 163 g/day had a decreased hazard for renal function deterioration (HR 0.42 [95% CI 0.18–1.00]). Regarding dietary protein intake per kilogram body weight, patients with an intake <1.08 g/kg/day had an increased hazard for renal function deterioration (HR 1.63 [95% CI 1.00–2.65]). CONCLUSIONS In patients with T2D, unrestricted dietary protein intake was not associated with an increased hazard of renal function deterioration. Therefore, substituting carbohydrates with dietary protein is not contraindicated as a part of T2D management, although it may have a positive effect on body weight while minimizing loss of muscle mass