DietaryDietary FibreFibre inin DiabetesDiabetes

JimJim MannMann Professor in & Medicine Director, Edgar National Centre for Diabetes Research University of Otago Dietary fibre (nonstarch polysaccharides) in Diabetes

Modern history of high /high fibre diets

Himsworth 1935: High CHO diet increased insulin sensitivity (Clin Sci 2: 67-94)

Kempner et al 1958: Rice diet (Postgrad Med 24:359)

Stone & Connor 1963: High CHO diet & serum lipids in diabetes (Diabetes 12: 127-132)

Trowell 1975: Little diabetes in East Africa & high fibre diets (Diabetes 24: 762-765)

Kiehm et al 1976: Uncontrolled experiments in type 2 patients, insulin treated. (Am J Clin Nutr 29:895-899) Simpson R et al, 1979: High carbohydrate diets & maturity-onset diabetics (BMJ 1: 1753-1756)

Simpson R et al, 1979: High carbohydrate diets & insulin- dependent diabetics (BMJ 2: 523-525)

HIGH CHO LOW CHO

60% CHO 40% CHO * 25% Fat (P:0,1:1) 38% Fat (P:0,1:3)

*Cereal containing foods *Very low free (“wholegrain”) Tuberous vegetables Very low free sugars Twenty-four-hour Plasma Concentrations Mean (± SE of mean) total serum cholesterol & triglyceride & lipoprotein cholesterol concentrations with the two diets Low - High - Significance carbohydrate carbohydrate diet diet Serum 1.20 ± 0.13 1.09 ± 0.08 NS triglycerides (mmol/l) Total cholesterol 4.9 ± 0.2 4.4 ± 0.2 P < 0.001 (mmol/l

HDL cholesterol 1.6 ± 0.1 1.6 ± 0.1 NS (mmol/l LDL cholesterol 3.2 ± 0.2 2.4 ± 0.3 P< 0.02 (mmol/l)

VLDL cholesterol 0.2 ± 0.1 0.5 ± 0.2 NS (mmol/l) JJeennkkiinnss,, DD..JJ..AA..,, TT..MM..SS.. WWoolleevveerr,, TT..DD..RR.. HHoocckkaaddaayy,, AA..RR.. LLeeeeddss,, RR.. HHaawwoorrtthh,, SS.. BBaaccoonn,, EE..CC.. AApplliinngg aanndd JJ.. DDiillaawwaarrii

Treatment of diabetes with guar gum: reduction of urinary glucose loss in diabetes.

Lancet 2: 779, 1977 Simpson HCR et al, 1981

A high carbohydrate leguminous fibre diet improves all aspects of diabetic control. Lancet 1: 1-5

Diet Carbohydrate Fat (%) Protein (%) Fibre (%) (g/24h)

HL 61 18 21 96.6

LC 40 39 21 17.6 PPllaassmmaa gglluuccoossee vvaalluueess dduurriinngg 2244hh pprroofifilleess ooff ttyyppee 11 ppaattiieennttss oonn HHLL && LLCC ddiieettss MMeeaassuurreess ooff ddiiaabbeettiicc ccoonnttrrooll oonn ttyyppee 22 ppaattiieennttss Index LC HL P Blood glucose (mmol/l) Basal 6.7 ± 1.5 5.7 ± 1.4 0.001 Preprandial 7.3 ± 2.1 6.2 ± 1.5 <0.01 2 h postprandial 9.1 ± 2.3 8.1 ± 1.6 <0.05 Daily 7.9 ± 1.8 6.9 ± 1.1 <0.01 Mean postprandial 9.0 ± 1.9 7.6 ± 1.2 <0.001 24 h urine glucose (mmol) 31 ± 51 2 ± 3 0.05

HbA1c 9.6 ± 2.3 8.6 ± 1.6 <0.02 Simpson HCR et al, 1982

Digestible carbohydrate - an independent effect on diabetic control in type 2 diabetic patients? Diabetologia 23: 235-239

Diet CHO (%) FAT (%) Protein (%) Total dietary fibre (g/24h)

High CHO 60 22 18 16

Low CHO 35 47 18 14 PPllaassmmaa gglluuccoossee lleevveellss dduurriinngg hhiigghh CCHHOO aanndd llooww CCHHOO 2244 hhrr pprroofifilleess PPllaassmmaa cchhoolleesstteerrooll aanndd lliippoopprrootteeiinn cchhoolleesstteerrooll ssuubbffrraaccttiioonnss oonn llooww aanndd hhiigghh CCHHOO ddiieettss Fasting samples Chol (mmol/l) Low CHO High CHO p Total 4.55 ± 0.51 4.55 ± 0.58 NS LDL 2.73 ± 0.61 2.79 ± 0.57 NS VLDL 0.77 ± 0.30 0.67 ± 0.38 NS HDL 1.26 ± 0.35 1.08 ± 0.20 <0.05 HDL/LDL(%) 47.4 ± 12.6 39.9 ± 9.2 <0.01 Rivellese, Riccardi, Giacco et al, 1980 Table 1 - Composition of a 2200 kcal Diet

Diet A B C g/day %Kcal g/day %Kcal g/day %Kcal Protein 98 17 98 17 121 21 Fat total 76 30 74 30 93 37 saturated 17 18 26 monounsaturated 50 47 54 polyunsaturated 9 9 13 Cholesterol < .250 < .250 < .250

Carbohydrate 42 total 318 53 321 53 252 simple 111 112 108 complex 207 209 144

Plant fibre (total) 16 54 20 Blood glucose levels after each dietary period Riccardi, Rivellese et al, 1984

Separate influence of dietary carbohydrate and fibre on the metabolic control in diabetes

Low CHO/low fibre High CHO/low fibre High CHO/high fibre Protein 21% 17% 17%

CHO

Total 252g 42% 318g 53% 321g 53%

Simple 108g 111g 112g

Complex 144g 207g 209g

Fibre 20g 16g 54g Blood glucose control at the end of each dietary period Composition of major lipoprotein classes at end of each dietary period Relative risk of by different levels of cereal fibre intake and glycaemic load IInncciiddeennccee ooff ddiiaabbeetteess dduurriinngg ffoollllooww--uupp Louheranta, Uusitupa et al

High-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk: the Finnish DPS.

Diabetologia, 2006 Hazard Ratios for Diabetes by Fibre and Fat Intake TTooeelllleerr,, HHeeiittkkaammpp eett aall Eurodiab Study, 1998, 2000 etc

Relation of fibre intake to HbA1c, ketoacidosis, hypoglycaemia, cholesterol,

Total fibre Intake Severe ketoacidosis Severe hypoglycaemia (g/day) OR

11.4 1 1

15.6 0.76 0.82

20.1 0.65 0.84

27.4 0.48 0.80 Hermansen, Rasmussen and colleagues

Karlstrom, Vessby and colleagues

Rizkalla, Slama and colleagues

Vuksan, Sievenpiper and colleagues

Wolever and colleagues

Karamaros and colleagues

Katsilambros and colleagues