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Higher Fiber Intake Is Associated with Lower Blood Pressure Levels In

Higher Fiber Intake Is Associated with Lower Blood Pressure Levels In

Arch Metab. Endocrinol 2018;62/1 between totalfiberintakeand an inverserelationship in patientswithdiabetes(2,3). glycaemiccontrol of improved of fiberasadeterminant analysisoftheisolatedeffect which mayhavehindered -rich dietsand foodswithlowglycaemicindex, small samplesizes,andbyassessingcombinationsof periods and observation have been limited by short studies evaluatingfiberintakeinpersonswithdiabetes women and38g/dayforadultmen.However, most 25g/dayforadult of energy intake,orapproximately intakeis14gtotalfiberper1000kcal recommended fiberinparticular,the 2,300 mg.Inaddition,regarding andkeepingdailysodiumintakeunder and ; intakeofsaturatedfats,trans restricted in ; naturallycurrent grains andfiber;preferring whole 1 (T1D)(1),whichinclude:preferring T Hospital deClínicasPortoHospital Alegre Divisão deEndocrinologia, Ticiana C.Rodrigues Correspondence to: Porto Alegre, RS, Brasil Rio GrandedoSul(UFRGS), Universidade Federal do Interna, Faculdade deMedicina, 3 Porto Alegre, RS, Brasil do RioGrandeSul(UFRGS), Nutrição, Universidade Federal de e Saúde,Departamento Nutrição em Alimentação, 2 (HCPA), Porto Alegre, RS, Brasil deClínicasPortoHospital Alegre 1 DOI: 10.20945/2359-3997000000008 Accepted onMay/17/2017 Received onJuly/4/2016 [email protected] –Porto90035-003 Alegre, RS, Brasil Prédio 12, 4ºandar Rua Ramiro Barcelos, 2350, Departamento deMedicina Departamento Programa dePós-graduação Divisão deEndocrinologia, Some observational studieshavedemonstrated Some observational dietary recommendations forindividualswithtype recommendations dietary he AmericanDiabetesAssociationhasspecific Fiber; type1diabetes;bloodpressure; Keywords SBP andDBPinpatientswith T1D. that fiberconsumptionmeetingorexceedingcurrent ADA recommendationsisassociatedwithlower dosage,orpresenceofhypertension, nephropathy, orretinopathy. between-group differences wereobservedwithregard todurationofdiabetes,glycemiccontrol, BMI, indicated that higher fiber intake was associated with lower SBP and DBP levels. No significant and sodiumintake, 26.2 ±4.8,p=0.044).Linearregressionmodelling,adjustedforage,energyintake, (2164.0 ±626.0vs1632.8higher energyintake ±502.0kcal,p<0.001), andlowerBMI(24.4 ±3.5vs 25.0 mmHg,p=0.016) anddiastolicbloodpressure(DBP)(72.9±9.2vs78.59.3mmHg,p=0.009), groupexhibitedsignificantly lower systolic(SBP) in thehigherfiberintake (115.9 ± 12.2vs ± 125.1 (<14g (≥ kcal)orat/above kcal). intake recommendedintake fiber/1000 14g/1000 in relationto American Diabetes Association (ADA) recommendations:belowrecommendeddaily urinary nitrogenoutput.Patients werestratifiedintotwogroupsaccordingtoadequacyoffiberintake wasdietary intake evaluatedby3-dayweighed-dietrecords,whosereliabilitywas confirmedby24-h BMI24.8±3.85kg/m of 18 ±9years, were predominantlymale(56%)andwhite(88%),withameanageof40±10 diabetesduration years, A cross-sectionalstudywas carried outin111 outpatientswith T1D fromPorto Alegre, Brazil.Patients andbloodpressure(BP)inadultpatientswithtype1diabetes(T1D). intake Objective: ABSTRACT Thais Steemburgo Higher fiberintake isassociated Mileni VantiBeretta in patientswithtype1diabetes with lower bloodpressure levels The presentinvestigation soughttoevaluatethepotentialassociationbetweendietaryfiber 2 , Ticiana C. Rodrigues 1,2 , Fernanda R. Bernaud Arch EndocrinolMetab. 2018;62(1):40-7 patients with T1D studyof Onerecent the subjectoflittleresearch. fiberonBPin patients withT1Dhasbeen of dietary conducted indiabeticpopulations. Infact,theeffects studiesnot largely drawnfrom evidence-based, are inpatientswithdiabetes,although of hypertension and markersofinflammation(9-12). disease(CVD),endothelialdysfunction, cardiovascular toobesity, severalparametersrelated control, riskof glyceamic roles inlipidprofile, fiber playsimportant post-prandial bloodsugarlevels(8).InT1D,dietary reductions infastingand associated withsignificant with T1DandT2D,ahigh-fiberdiet(40g/day)was inpatients type 2diabetes(T2D)(6,7).Furthermore, levelsinindividualswith cholesterol and onserum onBP and pulses,appearstohaveabeneficialeffect suchaswholegrains,fruits, sources, natural dietary blood 2 , andHbA1c9.0±2.0%. After clinicalandlaboratoryevaluation, Current recommendations for the dietary treatment treatment for the dietary recommendations Current pressure (BP) levels (4,5). Intake of fiber from (BP)levels (4,5). Intakeoffiberfrom pressure 1,3 1 , CigleaNascimento demonstrated a protective effect of effect demonstrated a protective original article original Conclusion: Subjects andmethods: 1 , Results:

We conclude Patients 47

Copyright© AE&M all rights reserved. Copyright© AE&M all rights reserved. 48 lifestyle. toasedentary level 1corresponded out duringatypicalday(13); based onactivitiescarried questionnaire, into four levels using a standardised wasgraded ofphysicalexercise absent). Thefrequency or alcoholintake(present smoker), aswascurrent status wasclassifieddichotomously (assmokerornon- classified byethnicityaswhiteornon-white.Smoking lifestyle. Patients were medication use, and current on past medical history, demographic data, interviewed evaluatedbyanendocrinologistand All patientswere Clinical evaluation (number 08-470). EthicsCommittee Research Alegre Clínicas dePorto bytheHospitalde wasapproved The studyprotocol consentforinclusioninthestudy.written informed provided 2011 toDecember2012,andallparticipants maintained,except forstatins. ongoing medicationswere All thecohort. excludedfrom were records dietary oedema),orinabilitytocompleteweighed pulmonary oracute infarction, myocardial (stroke, study enrolment eventsinthe6monthspreceding acute cardiovascular (NYHAclassIIIorIV), failure symptomatic heart failure, duration ofdiabetes>5years.Patientswithrenal age>18years; and studyenrolment; months preceding counsellingbyadietitianduringthe6 criteria: dietary selectedonthebasisof thefollowing life. Patientswere diagnosis, anddependenceoninsulintherapytosustain 40 yearsofage,ketonuriaorketonaemiaatthetime Brazil. T1Dwasdefinedasdiabeteswithonsetbefore Alegre, alarge teachinghospitalinPorto Alegre, Porto outpatient endocrinology clinic of Hospital de Clínicas de the consecutively from of patients with T1D recruited outonacohort studywascarried This cross-sectional Participants SUBJECTS ANDMETHODS with T1D. and BP levels in adults Association recommendations) withAmericanDiabetes fiber intake(inaccordance to evaluateapotentialassociationbetweendietary studywas thiscontext,theaimof present Within patients withT1Dhasyettobeestablisheddefinitively. (9). mortality fiber, especiallysolublefiber, againstCVDandall-cause Association ofhighfiberintake withbloodpressure indiabetes type1 The recruitment process took place from January January tookplacefrom process The recruitment in ofhypertension offiberinthepresence The role ophthalmologist. DR was detected by dilated-pupil at leasttwooccasionsduringa2-monthperiod(15). when theUAEwas>176mg/Lor199mg/minon 174 mg/Lor20-199mg/min;andmacroalbuminuric whentheUAEwas17- 20 μg/min;microalbuminuric (UAE)ratewas<17mg/Lor albumin excretion whentheurinary normoalbuminuric considered were Patients least twosamplesobtained6monthsapart). collection(at urine sampleor24-hourtimedurinary results ofarandomspot tothe classified according a fullphysicalexamination. therapy(14).Allpatientsunderwent antihypertensive mmHg ontwoseparateoccasions,orcurrent readings ≥140/90 wasdefinedasBP Hypertension sphygmomanometer (Omron usingadigital aftera10-minuterest, left arm, industrialized f of specific local manufacturers with data obtained from updated and/orsupplementedasnecessary were consumed or mg/day).Nutritionfacts forfrequently daily energy intake(%)andingrams amounts(g/day oftotal asthepercentage intakewasexpressed (Cybersoft, Phoenix,AZ,USA),version7.14(19). analised inNutriBase2007ClinicalNutritionManager 0.79 to1.26(18). acceptablewhenintherangeof intake wasconsidered intaketoestimatedprotein protein ratio ofreported (17).The records dayofdietary collected onthethird nitrogen, urea 24-hoururinary intake estimatedfrom intaketoprotein protein by comparingreported (17,18). standardised previously consecutive weekdaysandoneweekendday),as (twonon- by meansof3-dayweighedfoodrecords (11).Briefly,previously assessed habitswere dietary out as described Nutritional evaluation was carried Nutritional evaluation ofseverity). ofDR,regardless or presence (absence divided into two groups analysis, patients were DR’ (PDR). For purposes of DR’, or ‘proliferative DR’ (NPDR), ‘moderate NPDR’, ‘severe proliferative scale (16)as‘absenceof DR’, ‘mild non- Group severity usingtheGlobalDiabeticRetinopathyProject ophthalmoscopy, andindirect direct andgradedby Diabetic retinopathy (DR)wasassessed byan Diabetic retinopathy (DN)was ofdiabeticnephropathy The presence Sitting BPwasm The nutrient contents of dietary records were were records The nutrientcontentsofdietary wasevaluated records The adequacyofdietary oods. easured in triplicate,inthe easured Arch Metab. Endocrinol 2018;62/1 ® HEM-705CP). Arch Metab. Endocrinol 2018;62/1 (≥14g/1000 meeting/exceeding recommendations (<14g/1000kcal/day)orintake recommendations intakebelow Diabetes Associationrecommendations: relation to American the basisoffiberintake in U by meansofStudent’s byfiberintakestatus compared characteristics were range). Baseline (SD), n (%), ormedian(interquartile deviation as mean±standard presented Data are Statistical analyses assay (ADVIA1800 byanenzymaticultraviolet wasmeasured urea Urinary diluted sampleundertheinfluenceofexcessthrombin. therateoffibrinogenconversiontofibrinina measures bytheClaussclottingmethod,which determined 1800 quantitated bytheturbidimetric method (ADVIA (hs-CRP)was protein High-sensitivity C-reactive method (ADVIA1800 bythehomogeneous direct and HDLcholesterol methods (ADVIA1800 by enzymatic colorimetric measured were (Biodiagnostica enzymaticcolorimetric method -peroxidase by the Fasting plasma glucose was measured range 4.7-6.0%). (reference Germany) Darmstadt, 9100;Merck (Merck-Hitachi chromatography liquid byhigh-performance HbA1c wasmeasured evaluation Laboratory up to10%(21). Bvegetablescontaining containing upto5%andgroup Avegetables content (% ofgrams weight), withgroup intwocategoriesonthebasisofcarbohydrate grouped , ,,andpineapple. were suchasapple,,,,, fruits ,and potatoes, (manioc),eddoes,, , ,),,, potatoes,sweet biscuits/crackers, flaxseed,sesameseeds,sunflower wholegrain grain foods (granola, wholemealbread, pulses(,,),whole- were by thecohort fiberconsumed ofdietary Themainsources records. described bypatientsintheir3-dayweighedfood basedonthe foods offiberwere sources (20). Dietary FiberinHumanNutrition Handbook ofDietary intheCRC todataprovided estimated according test. Patients were stratified into two groups on stratifiedintotwogroups test. Patientswere The total,soluble,andinsolublefibercontentwas ® Autoanalyzer, andfibrinogenwas Germany), ® ). Total and cholesterol serum ® Autoanalyzer, Germany). ® ® Autoanalyzer, Germany). Autoanalyzer, Germany), t -test andMann–Whitney ® ,

There were no significant differences betweenthelower nosignificantdifferences were There characteristics ofthesamplestratifiedbyfiberintake. ± 2.0% BMI was24.8 mean durationofdiabeteswas18.0±9.0years.Mean white.Themeanagewas40.0±10.0years,and were maleand88% Of the111patientsevaluated,56%were RESULTS SPSS 18.0(Chicago,IL,USA). out in carried and sodiumintake.Allanalyseswere model wasadjustedforage,totalcalorieintake,BMI values asthedependentvariables.Themultivariate with systolic(SBP)anddiastolic(DBP)bloodpressure modelwasconstructed kcal/day), alinearregression and higher fiber intake (≥ 14 g/1000 blood pressure kcal between-group differences were also found in terms alsofoundin terms were differences between-group adequateintakeoffiber.recommended Significant fat thandidpatientswho consumedlessthanthe intakes oftotalenergy, and , protein, Patients inthea describedin adequacy offiberintake, are Table 2. andtriglycerides). LDL cholesterol, HDLcholesterol, (totalcholesterol, DR, orlipidprofile ofDNor glucoselevels),presence (HbA1c orserum inglycaemiccontrol differences no between-group were (11.5%vs20.8%,p<0.001).There intake group thaninthelowerfiber the higherfiberintakegroup enzyme(ACE)inhibitorsin angiotensin-converting on therapy:fewerpatientswere antihypertensive regarding was found A similar, significant difference usedlower doses ofinsulin. higher fiberintakegroup (< 14g/1000kcal/day).Inaddition,patientsinthe recommended who consumedlessfiberperdaythan ± 9.2vs78.59.3mmHg,p=0.009)thanpatients vs 125.1±25.0mmHg,p=0.016)andDBP(73.0 (≥ 14g/1000kcal/day)hadlowerSBP(115.9±12.2 BP,Regarding patients in the higher fiber intake group ofhypertension. orpresence in waistcircumference differences nobetween-group were p =0.044).There (24.4±3.5vs26.24.8kg/m fiber intakegroup hadalowermeanBMIthandidthose inthelow group alcohol consumption.Patientsinthehighfiberintake ethnicity, durationofdiabetes,physicalactivitylevel, or ofage,gender, interms and higherfiberintakegroups Association ofhighfiberintake withbloodpressure indiabetes type1 Daily macronutrient intake values, according to intakevalues,according Daily macronutrient /day). To theassociationbetween determine . Table 1 describes the clinical and laboratory . Table 1describestheclinicalandlaboratory ± 3.85kg/m dequate fiber intake group hadhigher dequate fiberintakegroup 2 andmeanHbA1cwas9.0 49 2 ,

Copyright© AE&M all rights reserved. Copyright© AE&M all rights reserved. 50 LDL: low-densitylipoprotein; SBP: systolicbloodpressure. ACE: angiotensin-convertingenzyme; BMI: body mass index; DBP: diastolic blood pressure; HbA1c: glycatedhaemoglobin;HDL: high-density lipoprotein;hs-CRP: high-sensitivityC-reactiveprotein; Data expressedasmean±SD, median(IQR), orn(%). Table 1. inintakeoftransfatsorcholesterol. differences nobetween-group were mg/day; p=0.004).There of (2360.64±919,81vs1676.59688.01 hadasignificantlyhigherdailyintake fiber intakegroup patientsinthehigher polyunsaturated). Furthermore, of fat fractions (saturated, monounsaturated, and Association ofhighfiberintake withbloodpressure indiabetes type1 Urinary sodium excretion(mg/24h) Urinary Fibrinogen (mg/dL) hs-CRP (mg/L) Triglycerides (mg/dL) Cholesterol, LDL(mg/dL) Cholesterol, HDL(mg/dL) Cholesterol, total(mg/dL) Plasma glucose(mg/dL) HbA1c (%) Diabetic retinopathy(%) Diabetic nephropathy(%) Insulin dosage Under treatmentforhypertension DBP (mmHg) SBP (mmHg) Hypertension (%) Waist circumference(cm) Height (cm) Weight (kg) BMI (kg/m²) Alcohol intake(%) Physical activity: level1*(%) Duration ofdiabetes(years) Ethnicity (white) Sex (male) Age (years) N IU/kg bodyweight ACE inhibitor+betablockerdiuretic channelblocker Diuretic ACE inhibitor+diuretic ACE inhibitor Females Males Clinical and laboratory profileofpatientswithtype1DM,Clinical andlaboratory stratifiedbyadequacyoffiberintake(AmericanDiabetes Association)(1) † Below recommendedfiberintake Student’s (< 14g/1000kcal/day) t 408.1 (225-672) 241.33 ±160.0 test. 53.88 ±21.91 162.95 ±9.15 70.40 ±12.92 98.5 (49-207) 125.1 ±25.0 83.30 ±8.08 78.40 ±6.22 116.6 ±31.0 2.5 (0.1-7.3) 0.80 ±0.26 19.4 ±11.0 60.0 ±17.0 194.2 ±30 90.7 ±2.5 78.5 ±9.3 83.0 ±8.5 26.2 ±4.8 37 ±13 ‡ 12.5% 20.8% 58.3% 91.7% 29.2% chi-squaretest. *Level1: sedentary. 8.3% 4.2% 4.2% 40.9 54.5 54.2 10.7 20.8 24

intake group. Analysis of the main sources of dietary ofdietary Analysisofthemainsources intake group. inthebelow-adequatefiber did theircounterparts total,soluble,andinsolublefiberthan consumed more (≥14g/1000kcal) in thehighfiberintakegroup inoursample.Asexpected,patients type andsource, Table 3describesthedailyfiberintake,stratifiedby At or above recommendedfiber At orabove intake (≥14g/1000kcal/day) 364.3 (208-667.0) 88.1 (34.0-223.0) 193.0 ±107.0 47.80 ±19.34 169.21 ±9.21 69.02 ±10.73 111.5 ±35.0 115.9 ±12.2 79.54 ±9.44 86.51 ±9.14 2.1 (0.1-8.4) 59.5 ±16.3 0.67 ±0.25 187.3 ±37 24.4 ±3.5 17.6 ±8.6 90.0 ±1.8 72.9 ±9.2 83.3 ±9.8 40 ±11 83.9% 56.3% 12.6% 11.5% 32.2% 2.3% 0.0% 1.1% 56.2 46.0 12.6 38.2 9.7 87 Arch Metab. Endocrinol 2018;62/1 < 0.001 < 0.001 0.04 0.893 0.81 0.39 0.45 0.18 0.16 0.08 0.56 0.31 0.511 0.884 0.408 0.084 0.079 0.472 0.31 0.06 0.24 0.009 0.01 0.81 0.21 0.0 0.85 0.004 0.63 0.04 0.25 0.81 0.16 P - 59 4 1 4 1 0 1 8 6 5 2 1 0 6 5 0 6 2 3 0 3 1 † ‡ ‡ † ‡ ‡ † † † † † † † † † ‡ ‡ † † † † ‡ † † † † † Arch Metab. Endocrinol 2018;62/1 Data expressedasmean ±SDormedian(IQR).† Table 2. associatedwithhigher lower SBPandDBP levels were that intake, BMIandsodiumintake.Analysisrevealed adjustedforage,totalenergy kcal). Themodelswere between BPlevelsandhigherfiberintake(≥14g/1000 toevaluatepotentialassociations constructed were p =0.02;andr-0.215,0.02respectively). intake withBPlevels(r=-0.219,p0.021;r-0.221, between totalfiber, solublefiber, andinsolublefiber , andwholegrains. A+B), vegetables(groups of totalfiberintakefrom interms differences nosignificant between-group were (7.8vs1.6g/day;p<0.001).There fiber intakegroup pulsesthandidpatientsinthebelow-adequate from amountoftotalfiber consumedagreater intake group pulses.Patientsinthehighfiber the intakeoffiberfrom in difference revealed asignificantbetween-group fiber Sodium (mg/day) Cholesterol, (mg/day) dietary Fat, trans(g/day) Fat, polyunsaturated Fat, monounsaturated Fat, saturated Fat, total Protein Carbohydrate Total energyintake(kcal/bodyweight/day) Total energyintake(KJ) Total energyintake(kcal/day) n % oftotalenergyintake g/day % oftotalenergyintake g/day % oftotalenergyintake g/day % oftotalenergyintake g/day % oftotalenergyintake g/day % oftotalenergyintake g/day Linear regression models(TableLinear regression 4andTable 5) inverse correlations we observed Furthermore, Daily nutrientintakeofpatientswithtype1DM, stratifiedbyadequacyoffiberintake(AmericanDiabetes Association)(1) t test. §Mann-WhitneyU. Below recommendedfiberintake (< 14g/1000kcal/day) 1676.59 ±688.01 12.0 (1.98-23.65) 7.0 (1.73-12.78) 1632.8 ±502.0 224.7 ±171.9 0.2 (0.0-2.58) 201.7 ±71.0 57.6 ±22.8 74.9 ±27.1 24.09 ±7.3 31.6 ±8.3 18.4 ±3.5 49.5 ±7.6 21.0 ±9.8 21.0 ±8.6 17.8 ±9.0 9.5 ±3.1 9.5 ±2.3 6821.76 24 was 19.8 ± 7.2 g/day (5.8 ± 2.4 g from solubleand was 19.8±7.2g/day(5.82.4gfrom themeantotal fiberintake levels. Inthispatientgroup, and insolublefiberwasnegativelyassociatedwithBP between fibertypeandBP. intakeofsoluble Increased an association we observed BMI). Furthermore, factors (age,totalenergy intake,sodiumand significant afteradjustment forpotential confounding SBP andDBPlevels.Theseassociationsremained (≥14g/1000kcal)exhibitedlower recommendations intake met or exceeded American Diabetes Association levels inpatientswithT1D.Patientswhosedailyfiber fiberintakeandlowerBP dietary between increased studydemonstrated an association The present DISCUSSION independentoftheadjustments. respectively), fiber intake(beta-11.11,p=0.01and-6.21,0.005 Association ofhighfiberintake withbloodpressure indiabetes type1 At or above recommendedfiber At orabove intake (≥14g/1000kcal/day) 2360.64 ±919.81 19.0 (2.7-66.1) 231.3 ±109.0 2164.0 ±626 7.7 (1.8-27.3) 269.6 ±86.5 0.3 (0.0-4.0) 27.6 ±12.2 27.0 ±12.6 24.2 ±10.5 77.5 ±34.5 98.1 ±33.0 31.24 ±8.0 11.1 ±3.5 10.0 ±3.1 31.7 ±9.4 18.3 ±3.6 50.2 ±8.6 9045.52 87 0.770 0.519 0.026 0.004 0.818 0.627 0.021 0.031 0.648 0.007 0.952 0.009 0.742 0.002 0.899 0.001 0.001 0.001 0.001 P - § § § † † † † † † † † † † † † † † † † 51

Copyright© AE&M all rights reserved. Copyright© AE&M all rights reserved. 52 BMI: bodymassindex. intake, BMI, andsodiumintake fiber intake(≥14gfiber/1000kcal). Modeladjustedforage, totalenergy Table 4. e flaxseed, quinoa, amaranth, sunflowerseeds. d c squash/marrow (cooked). (cooked), (cooked), courgette (cooked), heartsofpalm, , peppers, runner beans, b , . b a Data expressedasmean±SDormedian(IQR). (1) Diabetes Association) patients with type 1 DM, stratified by adequacy of fiber intake (American Table 3. 2,108 patientswithT1Daged15to60yearsandfound patients withT1D.Schoenakerandcols.(9)evaluated disease(CVD) in intheriskof cardiovascular role and peach). papaya, , clementine, orange, grape,mango, (banana,, pulses (beans,lentils,peas)andfruit were fiber associated with significant differences dietary of insolublefiber).Themainsources 14.0 ±5.3gfrom Association ofhighfiberintake withbloodpressure indiabetes type1 : apple, banana, clementine, grape, mango, orange, papaya, peach, pineapple. Whole grains: granola, wholemealbread, wholegrainbiscuits/crackers, wholemealflour, , Bvegetables: aubergine(cooked), beets(cooked), , (cooked), A vegetables: , , cress, , , , mustardgreens, , rocket, Tubers: potatoes, sweetpotatoes, cassava(manioc), eddoes, taro. Pulses: beans, lentils, peas. Sodium intake(mg/day) BMI (kg/m²) (kcal/day) Total energyintake Age (years) ≥ 14gfiber/1000kcal Variables sources(g/day) Dietary Fiber (g/day) n Fiber frompulses grains Fiber fromwhole Fiber fromtubers vegetables (A+B) Fiber from Fiber fromfruit Insoluble Soluble Total The type of dietary fiber appears to play an important fiberappearstoplayanimportant The typeofdietary Linearregressionanalysis: systolicbloodpressureandadequate Daily fiberintake, sourcesin typesoffiberandtheirmaindietary d a

b c e recommended 1.6 (0.0–5.8) 1.5 (0.0–6.5) 0.5 (0.0–2.2) 1.2 (0.0–3.5) 1.2 (0.0–3.5) (< 14g/1000 fiber intake 10.4 ±2.0 kcal/day) 7.6 ±2.0 3.2 ±1.6 Below 24 - 0.004 -11.11 0.032 0.03 0.03 β †

t test. § Mann–Whitney U. recommended 7.8 (0.0-26.0) 2.3 (0.0-12.4) 2.8 (0.0-47.2) 2.7 (0.0-10.2) (≥ 14g/1000 0.5 (0.0-3.5) fiber intake At or above At orabove 15.8 ±4.5 22.9 ±7.4 kcal/day) 6.5 ±2.2 87 0.031 0.930 0.200 0.810 0.010

P < 0.001 < 0.001 < 0.001 < 0.001 0.292 0.791 0.208 0.010 P - § § § § § † † † cholesterol, or LDL cholesterol. orLDLcholesterol. cholesterol, HDL levelsoftotalcholesterol, kcal/day) andserum fiberintake (≥14g/1000 association betweenincreased andfound nosignificant CVD, suchaslipidprofile, study,present weevaluatedparametersassociatedwith inCVDrisk.Inthe day experienceda16%reduction that thosewhoconsumedatleast5gofsolublefiberper BMI: bodymassindex. intake, BMI, andsodiumintake fiber intake(≥14gfiber/1000kcal). Modeladjustedforage, totalenergy Table 5. that increased intake of thesefoodswasassociated that increased in thedietandincidenceof diabetes(25),andfound andvegetables between quantityandvariety offruits intheDASH . thanrecommended of dairy andvegetablesfewerportions consume lessfruits foundto were highest BPlevels(i.e.,thetoptertile) withthe andpatientsinthesubgroup by BPtertiles, stratified BP of225patientswithT2D.Patientswere cols. (24) with thosewhodidnotfollowthediet.DePaulaand reductions inBPascompared diet showedsignificant diabetic) individuals.ThosewhofollowedtheDASH (butnon- andnormotensive diet inhypertensive (DASH) toStopHypertension Approaches Dietary daily intake of sodium for diabetics (22). recommended althoughwithoutexceedingthe fiber intakegroup, inthelower sodiumthantheircounterparts more alsoconsumed Patients inthehigherfiberintakegroup (ACEinhibitors). diabetes (insulin)andhypertension of diabetes,andinferiorusemedicationstotreat alsohadlowerBMI,superiormetabolic control group intake,patientsinthehigherfiberintake macronutrient day). Interestingly, energy and despitethisincreased (<14g/1000kcal/ the lowerfiberconsumptiongroup andfat)intakethanpatientsin (carbohydrate, protein, found tohavehigherenergy and macronutrient (≥14g/1000kcal/day) wasalso fiber intakegroup Sodium intake(mg/day) BMI (kg/m²) (kcal/day) Total energyintake Age (years) ≥ 14gfiber/1000kcal Variables A prospective studyevaluatedthe association A prospective ofthe Sacks andcols.(23)evaluatedtheeffect In thissampleofpatientswithT1D,thehigher Linear regression analysis: diastolic bloodpressure and adequate

analyzed the impact of fiber intakeon the -0.001 0.005 -6.21 -0.18 -6.21 0.14 β

Arch Metab. Endocrinol 2018;62/1 0.005 0.310 0.550 0.009 0.040 0.005 P Arch Metab. Endocrinol 2018;62/1 ( Fundings andacknowledgements: thisstudywasfundedbyFipe themanuscript. lection, andreviewed manuscript; T. C.R.designedthestudy, contributedtodatacol themanuscript; T.and reviewed the S.helpeddraftandreview manuscript; F. R. B. and C. N. contributed to data collection follows: M.V. the B.contributedtodatacollectionandwrote as Individual contributions:theauthors’contributionswere patients withT1D. onBPlevels in typesandsources) fiber (ofdifferent effects ofdietary thebeneficial trials shouldconfirm studies, includingrandomized clinical T1D. Future associated withlowerSBPandDBPinpatients toclinicalpractice. highly relevant intake onBPlevelinpatientswithT1D,ourstudyis offiber lack ofstudiesdemonstratingspecificeffects giventhe Nevertheless, would havebeenperformed. BPmonitoring In anidealsetting,24-hourambulatory tosubmittheirfoodrecords. when patientsreturned duringthefirst studyvisitand BP wasonlymeasured of fiberintakeonBPlevels. beneficial effects mechanisms involvedintheproposed neededtoelucidate the Additionalstudiesare stress. onvasodilatation andonoxidative a favorableeffect well assodium,wesuggestthatfiberintakemayhave energy,consumed more as includingallmacronutrients of patients with higher fiber intakealso that the group (27,29). Basedonthesefindingsandourobservation BPlevels vasodilation andconsequentlywithreduced endothelial canbeassociatedwithimproved reduction lipidslevels(29)andthis serum appears toimprove fiberintake satiety andweightloss(28).Dietary as evidencedin role in addition,ithasanimportant CVD and (27), metabolic syndrome, insomepathologiessuchas effect and preventive aprotective both solubleandinsolublefibersexert However, that iswellestablishedintheliterature lower BPlevelshavenotyetbeenelucidated(26). may beassociatedwithBPlevelsinpatientsT1D. componentthat dietary important wasaparticularly fruit beans/pulses andfrom thatfiberfrom we observed study, Inthepresent (30%, 22%,and39%,respectively). reductions intheriskofT2D associated withsignificant andvegetableswas vegetables alone,andbothfruits alone, consumptionoffruits increased Furthermore, with alowerriskofdevelopinganydiabetes(21%). Fundo de Incentivo à Pesquisa do Hospital de Clínicas de Porto Fundo de Incentivo à Pesquisa do Hospital de Clínicas de Porto In conclusion, increased totalfiberintakeis In conclusion,increased study isthat A potentiallimitationofthepresent fibersleadto The mechanismsbywhichdietary - 4. 3. 2. 1. REFERENCES was reported. relevant tothisarticle nopotentialconflictofinterest Disclosure: dePessoalNívelSuperior ção deAperfeiçoamento pergs grantandF. ofaCapes( R.B.wastherecipient do RioGrandeSul Alegre 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5.

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