am j clin nutr 1979 anderson 2312 21

7/30/2019 Am J Clin Nutr 1979 Anderson 2312 21

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2312 The Am e ric an Jou rn a lo fC lin ic a l N u tr itio n 3 2: N OV EM BE R 1979 , pp .231 2-2321 . P r in te d in U .S .A

H igh -ca rbohyd ra te , h igh -fib e r d ie ts fo rin su lin -trea ted m en w ith d iabe tesmel l i tus1 2Jam es W . A nd erso n , M . D . a n d K y leen W a rd , R . D .

A BSTRACT T he ef fec ts o f h igh -ca rbo hydra te , h ig h p lan t f iber (HC F) d ie ts on g lucose andlip id m etabo lism of 20 lean m en rec eiv ing insu lin th erapy for d ia betes m ellitu s w ere evaluated o na m etabo lic w ard . A ll m en rec eiv ed con tro l d ie ts fo r an ave rag e of 7 d ay s fo l low ed by H CF d ietsfo r an av erage o f 16 day s. D iets w ere des ign ed to be w e igh t-m ain tain in g an d there w ere nosign ific an t al tera tio ns in b ody weight . T he dai ly do se of insu lin w a s low er for each pa tie n t on theHC F die t than on the con tro l d ie t. T he average in su l in d ose w as red uced from 26 3 units/d ay(m ean SEM ) on th e contro l d ie ts to 11 3 (P < 0 .00 1) o n th e H CF die ts. O n th e HC F die ts,in su l in the rap y co uld be d iscon tinu ed in n in e pa tien ts re ceiv ing 15 to 2 0 units/d ay an d in tw op atie n ts rec eiv ing 32 units/day . Fa sting an d 3 -hr pos tprand ial p lasm a glu co se values w e re low e r inm ost pa tie n ts on the H CF d iets th an on the contro l d ie ts de sp ite low e r insu lin d oses. Se rumcholeste ro l va lue s d rop ped from 206 10 m g /d l o n the con tro l d ie ts to 14 7 5 (P < 0 .00 1) on theHC F diet; a ve rage fas ting serum tr ig ly ce ride va lue s w ere no t sign ifican tly alte red o n the H C Fdie ts. Th ese s tud ies sugg es t tha t H C F d iets m ay be the d ie tary the rapy ofcho ice for ce rta in pa tie n tsw ith th e m aturity -o nse t ty pe o f d iab etes . Am . J . C lin . N u tr. 32: 23 12-2321 , 1 979 .

T he p ro portion of en ergy tha t sh ou ld b eprov id ed by e ithe r ca rb ohydrate o r fat ind ie ts fo r p atien ts w ith d iabe te s m e llitu s iscon trov ersia l (1 ) . T rad itio na l d ie ts (1 -5 ) havere str ic ted the in take o f carbo hyd ra te andsom e au tho ritie s (5 -7 ) m ain ta in tha t ca rbo -hy dra te -re stric tion is a v ery im po rtan t a spec to f the m anagem en t o f th e d iab etic sta te . R e-cen t recomm enda tions (8 - 1 1 ) sugg est tha t th ein take o f com p lex carbo hyd ra te can b e lib -e ra lized fo r m ost pa tien ts w ith d iab ete s . U n-fo rtu na tely , recomm end a tions fo r e ithe r ca r-boh ydra te-re str ictio n or fo r a gene rous in tak eo f ca rboh ydra te a re em pir ica l and a re n o tbased o n ca re fu l m e tabo lic stud ie s . W e areun aw are o f an y stu d ie s iii th e E ng lish lan -gu age lite ra tu re th a t dem onstra te con v inc -ing ly th at w eig h t m a in ta in ing d ie ts (eith e rlow in ca rboh ydra te o r h igh in ca rboh ydra te)lead to red uc tion s in insu lin req u irem en ts o flean ind iv idua ls w ith d iabe te s .H ig h-ca rb ohydrate d ie ts have b een advo-cated (12 -1 4) fo r the m anagem en t o f d iabe -tes , b u t con trad ic to ry re su lts h av e b eenreported ( 1 5 , 16). U sin g h igh -ca rb ohydrated ie ts , the redu ctio n in insu lin doses reportedby R ab in ow itch (13 ) and by K em pner Ct al .(14 ) w ere a lso accom pan ied by s ign if ican t

redu ctio ns in bo dy w e igh t. Tw o re lativ elylong -te rm stud ie s (15 , 16 ) have failed to d em -onstra te tha t d iets p rov id ing 60% or m ore o fca lo r ie s a s ca rboh ydra te w ere assoc ia ted w ithsign if ican t chan ges in in su lin doses (15 ) o r ing lucose m e tab o lism (16 ). T hus , d esp ite thefrequ en t recomm end atio ns (8 -1 4 ) tha t h igh -ca rb ohydrate d ie ts a re e ff icac io us in treatin gd iab ete s , th eir su pe rio rity ov er trad itio na ld iets has no t been c lea rly dem onstrated . Ad isad van tage o f ce r tain h igh -ca rbo hydra ted ie ts , e spec ia lly fo r p atien ts w ith d iab ete s( 1 7), is a re su ltan t inc rea se in fa sting se rumtrig lyce ride va lues (1 8 ) .

A dd itio n of p lan t f ibe rs to the d ie ts o fpa tien ts w ith d iab ete s is accom pan ied by sig -n ifican t red uc tions in po stp ran d ia l h yp erg ly -cem ia (1 9 , 20 ) . D ie ts con ta in in g gene ro usam oun ts o f p lan t fibe r a re a sso cia ted w ithsign if ican t red uc tions in th e quan tity o f g lu -co se exc re tion in the u rine (21 ). Th ese stud ies

1 F rom the M ed ica l an d D iete tic Se rv ic es, V e teransA dm inis tra t ion H o sp ita l an d D epa rtm en t of M ed icine,U n ive rsi ty of K entu cky Co lle ge o f M ed icin e, L ex ing ton ,Ken tu ck y .

2 Suppo rte d in par t b y G ran t I RO I A M 20889 -O lfrom the N a tio nal In sti tu te s of A rth rit is , M etabo lic an dD ig est ive D isea ses .


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H IGH -CARBO HY DRA TE , H IG H -F IB ER D IET S IN D IABET IC M EN 2313

sug gest th a t p lan t fib e rs m ay h av e a ro le inthe d ie tary m anagem en t o f pa tien ts w ith d i-abetes .

C om bin ing a g ene rou s in take o f p lan t fi-be rs w ith a h igh -carbo hyd ra te d ie t m igh t beo f d istin ct b ene fit in th e m anagem en t o f ce r-tam p atien ts w ith d iab e tes . Th e usefu lness o fh igh -ca rb ohydrate , h igh p lan t f ibe r d ie ts(H CF ) in treatin g p atien ts w ith d iabe te s h asno t been eva lua ted ca re fu lly . In a p relim ina rystud y (22 ), w e ob served tha t H CF die ts w ereaccom pan ied b y low er fa sting p la sm a g lucoseva lues an d insu lin o r su lfony lu rea doses thanobserved on con tro l d ie ts . In te rp re ta tio n ofth is study is d iff icu lt, h ow ev e r, because o f th efo llow ing fac to rs: on ly eig h t o fth e 1 3 pa tien tsw ere o n insu lin , f ive pa tien ts w ere obese , andm os t pa tien ts lo st w eig h t on th e H CF d iet.T o eva lua te fu rth er the po ten tial th e rapeu ticu tility o f HC F d iets , w e h av e ex tended th esestud ies . Tw en ty lean m en w ho w ere receiv inginsu lin the rap y w ere p laced o n w e igh t-m a in -tam ing H CF die ts fo r app rox im a te ly 16 day sa fte r 1 w eek o f observa tion on a con tro l d ie ton a m e tabo lic w ard .Me th o d sPat ien ts

A ll p atien ts h ad d iab ete s m elli tus w ith m ultip le fast-ing p lasm a glu cose va lue s ab ove 200 m g/d l and w ereh osp ita liz ed o n a m etabo lic w ard fo r th ese stud ies . In -su lin therapy h ad been ins titu ted b ecause of sym ptom a tich yp erg lyc em ia an d m ost p atie n ts had re ceived dai lyin je ctio ns sin ce th e tim e of d iagn os is o f the ir d iabe tes(Table 1) . A ll pat ien ts w ere lean and non e ex ce eded1 13% o f their es tim ated des ira b le b ody w e igh t (23) .Die t s

A ll pa tien ts w e re fed w eig h t-m ain ta in in g con tro l d ie ts

fo r an av erage o f 7 days (ra nge o f 4 to I I day s) afteradm issio n to the m etabo lic w ard . T he se d iets pro v id edapp rox im ate ly 4 3% o fca lories a s ca rbo hydra te (Table 2)an d w e re sim ilar to d iets tra d itiona lly u sed to trea tpat ien ts w ith d iabe tes . Th en ea ch pa tie n t w a s fed anH C F die t that w as des ign ed to m ain ta in the ir w eig h t atthe sam e leve l fo r th e du rat ion of th e stu dy . Th ese HC Fdie ts (T ab le 2) pro v id ed ap pro x im ately 70% of calo rie sas carboh yd rate , 2 1 % as pro tein , and on ly 9% as fat . N osuc rose w as added to either o f th ese d ie ts and th e sim plecarboh yd rate refers to m ono sac ch arid es, d isac cha rid es,and tr isa cch arid es co n ta ined in m ilk , g ra in pro duc ts,v eg etab les , an d fru its . Th e p lan t fib er w a s prov ided b y:

TABLE 1D iabe tic m en

P atien t A ge Dura tion of.diabe te sw eigh t % of

.de s i ra b l e.H CF d iet durat ion

Sr days1 68 6 96 152 56 7 97 153 42 14 94 134 60 16 96 145 55 4 91 196 53 1 99 187 49 1 109 148 57 9 110 219 75 20 111 13

10 56 1 113 1711 32 3 112 1612 55 1 99 1613 49 10 70 1514 45 19 109 l6 (24 )1 5 69 1 109 1816 62 8 1 03 16 (33)fl17 70 5 112 1618 42 4 84 1619 53 8 85 1620 38 15 82 16

M ean 54 8 99 16SEM 3 1 33 0 .4

a D ata fo r l6days w e re an alyz ed (Table s3and 4 ).N um bers in p aren th ese s are to ta l duratio n o f H CF d iet .

TABLE 2C om pos itio n o f d iets a

C o n tro l d ie t HC F d ie tg /da s % kca l g /d ay 5 kca !

P ro tein 92 20 98 21C arb ohydra te . to ta l 191 43 314 70

S im p le 79 91Comp l ex 1 12 223

F at, to ta l 74 37 18 9Satura t ed 26 5Monosa tura t ed 39 5Po lyu nsa turated fa tty ac ids 9 8

Chole ste ro l 0 .48 0 .0 65P lan t fiber , to ta l 26 65

Inso lub le 16 53So lub le 10 12a V alu es are g iven fo r rep resen ta tiv e 1 800-k cal d ie ts. b T ota l ca rbo hyd rate re fers to ava ilab le ca rbo hyd rate and

does no t in clu de p lan t f ibe r (2 4).


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I PLASM A G LUCOSEE

Ia, .500 -

0

II,.1515CON TRO L D IET H CF D IET

30)- F --c 20 -U)I- 1 0 -

0-

H760 .4 ]

I,,.320 .41W E IG HT I7 40 .3 -4

INS UL IN DO SE

Iw 1

2314 AN DERSON AN D W A RD

FIG . 1 . G luco se m etabo lism on con tro l an d H CF die ts. V alues be tw een a r rows a re m ea n SEM for the last 6day s on ea ch d iet . R ep rod uced w ith p erm is sion from A nd erson (2 8).

w hole gra in o r gra in cere als an d bread s, 40% ; sta rch yveg etab le s, such as beans, corn , o r pea s, 20% ; o th erveg etab le s, 3 1 % ; and fru its, 9% . The nu trie n t, c alo rie ,and fiber con ten ts of each d iet w ere ca lcu lated fromtab les p ublished e lsew h ere (24) . S o lu b le f ibe rs refer tow ater so lub le fib ers such a s pec tin s and gum s wh ileinso lub le fib ers re fer to fibers su ch a s ce llu lose an d lign inw hich are no t w ater so lu b le .Procedures

Pa tien ts w e re w eig hed da ily . E ach d ay bloo d w asdraw n be fore break fas t a fter an 1 1-h r fa st fo r p lasm aglu cose and serum cho les tero l a nd trig ly ceride values ; a t3 hr a fter the no on m ea l, b lo od w as draw n daily forp lasm a gluco se v alu es in 12 pat ien ts. B lo od gluco se andlip id va lue s on the co ntro l d ie ts w ere av eraged andcom pa red w ith va lue s fo r the la st 5 day s on th e HC Fdie ts. T he deg ree of g lyco su ria w as est im ated fo ur tim esd aily by m ea sur ing urin e g luco se con cen trat ion s be forem ea ls an d at 9 :00 PM . U rinary g luco se excretio n ove r

20 0 -

each 24 -hr p eriod w as m easured in eigh t p atie n ts . G lu-cose, cho les tero l, an d trig lyce rid es w ere m easu red asprev io usly d esc rib ed (2 2). S tatis tica l com parisons w e rem ad e us ing the paired t test .

Resu l tsG lu co se m eta b o lism on co n tro l d ie ts

The respon se o f pa tien t 1 5 is dem onstra tedin F ig u re 1 . O n the con tro l d ie t, th e insu lindose w as in crea sed to m ain tain fa stingp la sm a g lu co se va lues sligh tly ab ove 150 m g/d l. F o r the la st 6 d ay s o n the con tro l d iet, theinsu lin d ose w as m a in tain ed at 32 un its /dayan d the fa sting p la sm a g lucose va lues an d 24 -h r u rin e g lucose exc retio n w ere re la tive lyco nstan t. A s in d icated in F igu re 1 to 3 , w e

-1 2 -6 0 6 2 18DAYS


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H IGH -CARBO HY DRATE , H IGH -F IBER D IETS IN D IA BETIC M EN 2315

obse rved n o sign if ican t alte ratio ns in in su lindo ses, p lasm a g lucose va lues, o r u rin e g lucoseva lu es in 12 pa tien ts m ain tain ed fo r 7 to 1 1day s on con tro l d ie ts .G lu co se m e ta b o lism o n H CF d iets

Patien ts w ere d iv ided in to th ree g ro ups(T ab le 3 ) acco rd in g to th eir in su lin do ses oncon tro l d iets . T h e 1 st g ro up w as trea ted w ith15 to 2 0 un its o f in su lin p er day on th e co n tro ld iets an d insu lin the rap y w as d iscon tin ued inn ine o f th ese 1 0 pa tien ts . B ecause o f pe rson alp rob lem s, pa tien t 4 had to leav e the ho sp ita la fte r 14 d ay s on the H CF die t; w e hadp lan ned to d isco n tinu e in su lin the rapy on thenex t day . Th e respon se o f e igh t pa tien ts inth e f irs t g ro up is p re sen ted in F igu re 2 . T hesee igh t p a tien ts w ere m a in ta ined fo r a t least 6day s on the con tro l d ie ts be fo re in itia ting th eH CF die ts . P a tien ts 2 and 7 are exc lud edfrom F ig ure 2 because they w ere on the co n-

tro l d ie ts fo r le ss than 6 d ay s. O n con tro ld iets , p la sm a g lucose va lues and insu lin dosesw ere fa irly cons tan t. A fte r in itiatin g H CFd iets , the re w as a red uc tion in fa stin g p la sm ag lucose v alu es and a sligh t inc rea se in po st-p rand ia l g lucose va lue3 as the insu lin dosesw ere reduced . D uring th e 2n d w eek of theH CF die ts , fa sting p la sm a g lucose v alu esw ere sim ilar to those on the con tro l d ie ts , andp ostp rand ia l p lasm a g lu co se va lues w erelow er th an con tro l va lues d esp ite sign ifican tlylow er in su lin doses. A s presen ted in Tab le 3 ,m ost p atien ts had low er fa stin g an d po stp ran -d ial g lucose v a lu es during the las t 5 days o fth e H CF die ts th an on th e con tro l d iets de -sp ite m arked ly low er do ses o f in su lin . T hein su lin dose w as reduced approx im a tely 2u n its eve ry o the r day and insu lin the rapy w asd isco n tinu ed afte r an ave rage of 14 day s inth ese pa tien ts .

T he 2nd g ro up o f pa tien ts (T ab le 3 ) w as

TABLE 3Insu lin doses and plasm a g lucose va lues on con tro l an d H CF die ts

PatientInsulin

P lasm a g lu co se Fa sting Postp ran d ial

C on tro l HC F C on tro l HC F C on tro l HC Funit/d ay mg/d i

1 15 0 165 128 142 14 02 15 0 157 148 163 11 13 15 0 14 9 14 44 15 2 19 2 17 05 15 0 138 122 133 13 06 17 0 87 135 14 6 12 87 17 0 124 101 13 5 11 88 18 0 239 155 178 1119 20 0 136 152

10 20 0 107 11 4Group( l0) 17

10. 20 .2c

14 914

137 15 07 7

12 35

11 22 5 146 132 2 23 16 212 28 15 150 239 2 38 35 013 2 9 15 21 1 17 6 278 30 414 32 18(8) 216 15 9 182 16 815 32 0 165 15 116 32 14(0) 1 58 13917 34 20 198 17 7 123 13 5

G roup (7) 302

123C

17 811

16 8 20914 26

22 443

18 40 35 16 9 13 919 46 43 213 19 8 322 22 120 57 48 159 16 3

Group (3 ) 485

424

18 017

16 717

Total(20) 263 Il 3C 16 49152 189

7 1817 223

a G roup va lu es are tabu la ted a s m ean SEM . ii M ean of va l ue s fo r la st 5 day s on each d iet . P versusco ntro l < 0 .001 .


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20 0 FA ST ING G LUCOSE

I 50-5 0 5 10 15

2316 A N DERSON A N D W A RD

E

wU)00

,(U)1

0

z0

CONTRO L HFC D IET

DAYS

N :8

FIG . 2 . G lucose m etabo lism on contro l an d H CF diets . V a lue s rep resen t m ean SEM fo r eigh t m en rec eiv ing15 to 20 un its/day of insu lin (see Tab le 3) .

treated w ith 22 to 34 un its o f in su lin pe r dayo n the con tro l d ie ts . O n the H CF die ts , th erew as a g radu al reduc tion in in su lin d oses toan ave rag e of 12 un its /d ay . M o st o f th esep atien ts h ad low er p la sm a g lucose va lues andle ss g lycosu ria on the HCF die ts . P a tien t 12is an ex cep tio n an d h is d iab etic co n tro l w asw orsened w hen h is do se w as reduced to 15un its /day ; h ow ev e r, on 18 un its /d ay , h is fas t-ing and postp rand ia l g lucose va lu es w erelow er o n the H CF die t than o n the co n tro ld ie t. S im ila r ly , pa tien t 1 3 sh ow ed an im -prov em en t in g lu co se m etabo lism on theH CF d iet, bu t w hen h is d ose w as low ered to15 un its /d ay , h is pos tp rand ia l g lu co se va luesw ere d istinc tly h igh er than con tro l v alu es.T he d iet o f p atien t 1 4 w as co n tinu ed to 24days and h is in su lin w as redu ced to 8 u n its /day . T en w eek s a fte r d ischa rge , he w as ab leto d is co n tinu e in su lin the rapy and has go nefo r 1 3 m onth s as an ou tp atien t o n n o insu lin

w hile fo llow in g a m ain ten an ce HC F die t (2 5 ) .P a tien t 16 w as m a in ta ined o n th e H CF die tfo r 33 days and h is in su lin w as d iscon tinued .A fter d ischa rg e from the h osp ita l, h e hasm a in ta ined sa tisfacto ry fas ting p la sm a g lu -co se v a lu es fo r 2 m on ths on the m a in tenanced ie t (25 ) . In th is g rou p o f sev en p a tien ts onth e H CF die t, the in su lin dose cou ld be low -e red approx im a tely 2 un its eve ry o the r d ay .

Th e 3rd g rou p o f pa tien ts (T ab le 3 ) re -q u ired 40 to 57 un its o f in su lin p e r day tom anag e the ir d iabe te s . O n th e H CF die t,th e re w as a sligh t reduc tion in insu lin d oses;ave rag e p lasm a g lucose va lues and urine g lu -cose v a lu es w ere low er o n th e HC F d iet th anva lues o n the co n tro l d iets .

T he re sp onses o f sev en pa tien ts from th e2nd and 3rd group s a re p re sen ted in F ig u re3 . D iabe tic con tro l w as no t d iff icu lt in th eseseven p atien ts , an d they d id no t h av e w id esw ing s in th eir p lasm a g lu co se va lues. Th ree


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T o ev a lua te the po ten tial bene ficia l effec ts

DAYS

H IGH -CARBO HY DRA TE , H IG H -FIBER D IET S IN D IA BETIC M EN 2317

F IG . 3 . G luco se m etabo lism on contro l and HC F diets . V a lues rep resen t m ean SEM fo r sev en m en rece iv in g2 2 to 40 units/d ay o f insu lin (se e tex t and Table 3).

pa tien ts (13 , 19 , and 20) w ere exc lud ed fromF ig ure 3 because th e asses sm en t o f d iabe ticco n tro l w as m o re d ifficu lt b ecause o f w idesw ings o f th e ir p la sm a g lucose va lues. T heseven pa tien ts p re sen ted in F igu re 3 w erem a in ta ined o n rela tive ly constan t in su lindoses fo r at least 7 d ay s du rin g the con tro lpe rio d . T he re w as no ev id en ce th at the ir in -su lin requ irem en ts w ere red uced by the con-tro l d ie t an d fa sting p la sm a g lu co se va luesw ere re la tive ly cons tan t fo r the la st 5 days o nthe con tro l d ie t. D u rin g the 1st w eek of theH CF d ie t, fa stin g p lasm a g lucose v alu es w erelow er an d av erage in su lin do ses co u ld beredu ced . A fter an av erage of 16 d ay s on theHC F d ie t, th e insu lin do se w as redu ced froman ave rage of3 l to 1 6 un its /day (P < 0 .001) .F astin g p la sm a g lu co se va lues w ere sim ilardu ring the la st w eek on th e H CF die ts tova lues du rin g the 1st w eek on the con tro ld iets .

A s a g ro up , the se 20 pa tien ts show ed asign if ican t reduc tion in the ir in su lin do ses (P< 0 .0 01) on the H CF d ie ts a s com pared tothe con tro l d iets (T ab le 3 ). T hese redu ctio nsin insu lin d oses w ere accom pan ied by s lig h tredu ctio ns in fa sting and postp rand ia l g lu -co se va lues in these pa tien ts .Bo d y w e ig h ts

T he av erage w e ig h t change (T ab le 4 ) w as

E

U)I-2

U)0

no t sta tis tic a lly s ign if ican t. S om e pa tien ts lo stw e igh t du rin g the 1 st w eek on th e H CF die tsbecause they w ere un ab le to ea t th e la rgese rv ings o f veg etab le s p rov id ed ; w ith m in ord ie ta ry m od ifica tion s an d pa tien t adap ta tion ,m o st pa tien ts w ere ab le to ea t a ll o fth e ir fo odby the 2n d w eek . O the rw ise , th e d iets w erew ell to lera ted an d p atien ts h ad m in im a l gas-tro in te stin al com pla in ts . M o st p a tien ts n o tedtha t stoo ls w ere bu lk ier and they ex pe lledm o re g as w h ile on the H CF die ts , b u t non eof these pa tien ts deve lo ped d ia rrhea.Serum lip id re sp on se s

T he H CF die ts w ere accom pan ied b y re -d uc tions in fa sting se rum cho le ste ro l va luesin a ll pa tien ts and th e red uc tions ave rag ed 59m g/d l. T h e decreases in se rum cho le ste ro lva lues w ere cons isten t in all th ree g rou ps(T ab le 4 ). A v erage fa sting se rum trig lyce rid eva lues w ere s im ila r on the HCF die ts tova lues on the con tro l d ie ts . In som e pa tien ts ,how ev er , th ere w as a sligh t in c rea se in fa stingse rum trig lyceride v alu es. S eria l chang es infa stin g se rum cho le ste ro l, trig lyce ride , an dpo stp ran d ia l tr ig ly ce ride va lues w ill b e re -po rted e lsew here .

Discussion


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2318 AN DERSON AN D W A RD

TA BLE 4Body w eig h ts and fa stin g serum lip id v alu es o n con tro l an d HC F diets

Pa t i e n t

Weigh t Se rum lipids

C on tro l HC F

C ho le s te ro l T rig lyc er id es

Con t ro l HC F C o n tro l H C Flb mg /d l

I 139.8 135.9 212 13 6 74 612 136.1 133.6 172 12 8 72 733 141.2 142.2 137 13 2 11 9 1324 168 .7 1 68 .8 2 06 151 139 1485 144 .0 1 44 .0 141 130 156 1696 147.6 148.7 269 200 10 9 1077 170.1 169.2 206 149 14 1 1098 159.6 161.1 156 133 Ill 1179 156.3 159.4 227 135 135 134

10 159.3 157.1 246 188 231 2 6311 182.8 180.5 226 132 156 14012 144 .0 14 2 .0 2 12 132 74 7813 104 .2 10 4 .5 1 81 141 77 5514 145.5 144.4 228 158 126 8515 176.8 174.2 333 201 314 31 616 163.8 161.3 183 152 122 12917 166.4 165.8 215 147 176 17518 132.0 135.3 168 132 93 8219 139.5 137.9 208 142 90 9620 131.4 130.6 185 130 105 90

Mean 150 .4 14 9 .8 20 6 14 7 131 128SEM 4 .2 4 .1 1 0 5 1 3 1 5

a M ean of valu e s for las t 5 d a ys o n ea ch diet . P v ersus co n tro l < 0 .0 01 .

of H CF d iets in in su lin -trea ted , lean m en w efed co n tro l d ie ts fo r approx im a tely 7 daysfo llow ed by H CF die ts fo r an av erage of 16d ay s. T he H CF die ts w ere accom pan ied by asig n if ican t low ering of insu lin doses andsligh tly low er p lasm a g lucose va lues than o b-se rv ed on con tro l d iets . O ur cu rren t stu d ie sdo no t an sw er fou r im portan t q uestions . 1)W ou ld 3 w eeks o f treatm en t in the hosp ita lw ith con tro l d iets b e accom pan ied by sim ilarredu ctio ns in in su lin doses? 2) W ould h ig h -f ibe r d ie ts con ta in ing the sam e quan tity o fca rboh ydra te a s th e con tro l d ie ts be accom -p an ied b y s im ila r red uc tions in insu lin do ses?3) W ould h igh -carboh yd ra te d ie ts th a t a relow in p lan t f ib e r be accom pan ied by sim ilarreduc tion s in insu lin d oses? 4 ) A fte r a reduc -tio n in insu lin doses o n the H CF die ts , w ou ldin su lin do ses in crease if p a tien ts w ere re-s tar ted on the co n tro l d ie ts? W e are cu rren tlyexam in ing th ese question s; how ev er , da ta a reava ilab le to answ er in pa rt th ese q uestion s.

W hen co n tro l d ie ts w ere fed to 12 of th esep atien ts fo r 7 to 1 1 days (m ean of 8 d ays) w eobse rved n o a lte ra tion s in insu lin do ses.(F igs. 1 to 3 ) . A fter 8 days o n th e HCF die ts ,

how eve r, in su lin doses w ere sig n ifican tlylow er (F ig s. 1 to 3 ). W e h av e fed conv en tiona ld iabe tic d iets to pa tien ts ho sp ita lized fo r p ro -lo nged p e riod s w ithou t o bse rv ing sig n if ican ta lte ra tion s in insu lin doses (J . W . A nd erson ,u npub lish ed o bse rv atio ns) . F u rthe rm ore , w ea re aw are o f no reports in the Eng lish lan -g uage lite ratu re tha t dem on stra te tha t w e igh t-m ain tain ing d ie ts a re accom pan ied b y sig -n ifican t reduc tion s in in su lin do ses in leanind iv idu als w ith d iabe te s .

Th e in fluence of la rg e am oun ts o f d ieta ryf ibe r on g lu co se m e tabo lism in these s tud ie sis unc lea r. In m ea l-feed ing expe rim en ts , h ig h -f ibe r m ea ls w ere accom pan ied by sign ifi-can tly low er pos tp ran d ia l g lu co se va lues thanob se rved a fte r f ib e r-free m ea ls (19 ) . Tw ogrou ps h ave inv es tiga ted the in flu en ce offeed ing m odera te to la rge am oun ts o f p lan tfib er fo r 5 , 7 , o r 10 day s (20 , 2 1 ) . J en k ins e ta l. (21 ) o bse rv ed th at w hen 25 g of gua r gumw ere add ed to the d ie t o f six lean , in su lin -trea ted ind iv idu als fo r a pe rio d o f 5 to 7 d ay s,u r ine g lu co se v alu es w ere redu ced to app ro x-im a tely h a lf o f v alu es on the con tro l d ie t.In su lin do ses , h ow eve r, w ere m ain tain ed con -


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H IGH -CARBO H YD RA TE , H IGH -F IBER D IETS IN D IA BETIC M EN 2319

stan t du rin g these stud ies . S im ila rly , M irandaand H orw itz (2 0 ) fed h igh -f ibe r d ie ts to eig h tlean , in su lin - trea ted p atien ts fo r 10 d ay s;p ostp rand ia l g luco se va lues w ere sign if ican tlylow er bu t fa sting p la sm a g lu cose v alu es w eren o t changed and insu lin d oses w ere m a in -tam ed con stan t. In con tras t to these stud ies ,o u r HC F die ts w ere accom pan ied by ap rom pt reduc tion in fas ting p la sm a g lucosev alu es (F igs. 1 to 3 ) and in su lin doses had tob e redu ced w ith in the firs t 3 to 5 days top reven t hy pog lycem ia in m o st p a tien ts . T h us,it s eem s un like ly th at th e p lan t f ibe r con ten to f o u r HCF die ts is the m ajo r facto r in de ter-m in ing the reduc tion in insu lin d oses o f ou rp atien ts . H ow ev er , the add itive o r sy ne rg isticro le tha t p lan t f ibe rs m ay have in ind uc ingth ese ch anges in g lu co se m etabo lism canno tbe fu lly asses sed at th is tim e.

Th e h ig h -ca rboh ydra te and low -fa t con ten to f o u r HCF d iet m ay p lay the p redom inan tro le in th e reduc tion in in su lin d oses tha t w eobse rv ed . O u r stud ies (1 8 ) and those o f B run -ze ll e t al. (2 6 ) dem on stra ted th a t d iets con -tam in g 75 to 85% of calo rie s a s ca rboh ydra tew ith 10% or le ss o fca lo r ie s a s fa t w ere accom -pan ied by d istin ct im prov em en t in g lucosem e tabo lism in p a tien ts w ith m ild d iab e te s .T he fo rm ula d iets o f B ru nzell e t a l. (26 )con tain ed no p lan t fibe rs and ou r so lid d ie tsw ere low in p lan t f ibe r . F u rthe rm ore, w e havefed 10 insu lin -treated in d iv id ua ls w ith 7 0%carb ohydrate d ie ts tha t w ere e ithe r low orh igh in p lan t fib er con ten t fo r 1 0 days in ana lte rn atin g sequ en ce (27 , 28 ). Th e changes inin su lin d oses and fastin g p la sm a g lucose va l-u es w ere sim ila r on the low -fibe r d ie ts toth ose o bse rv ed on the h igh -fib e r d ie t. T hu s,from the ava ilab le da ta w e be lieve tha t theh igh -carbo hyd ra te con ten t o f the HC F d ie tsp lay s th e p redom inan t ro le in low ering fas t-in g p la sm a g lu co se v alu es an d insu lin d oseso n these d ie ts .

W hen pa tien ts resum e ea ting conven tio na ld iets (s im ila r to our con tro l d ie ts) a fte r 2 o r3 w eeks o n HCF die ts the ir in su lin d osesu sua lly re tu rn to va lues sim ilar to those ob -se rved on the con tro l d iets . W e have p lacedn ine p atien ts on w eig h t-m a in ta in ing co n tro l-ty pe d iets a f ter th e H CF die ts ; th ree p atien tsw ere o bse rv ed fo r 1 0 to 1 7 days on the m e t-abo lic w ard and si x pa tien ts w ere fo llow edc lose ly as ou tp atien ts fo r a m in im um of 3

m onth s. In su lin doses w ere ad ju sted to m a in -tam fasting p la sm a g luco se va lues o f app ro x-im ate ly 1 50 m g/d l. F o r th e th ree pa tien tstreated in th e h osp ital in su lin do ses w ere : 2 9 ,17 , and 15 un its /day o n the co n tro l d iets ; 15 ,0 , and 0 un its /d ay o n the H CF die ts ; and 3 0 ,15 , and 15 on th e seco nd pe riod of con tro ld ie ts . In su lin d oses fo r the n ine p atien ts w ere :23 4 un its /d ay (m ean SEM ) on th econ tro l d ie ts , 8 4 un its /day on th e H CFdie ts , and 27 3 afte r an ave rage o f 3 m on thson the con tro l- type d ie ts a s ou tpa tien ts . F u r-the r stu d ie s a re req u ired to com pare th e lo ng-te rm effects o f H CF -type d iets (2 5 ) w ith con -tro l-ty pe d ie ts . N eve rthe less , ou r p re lim ina ryob serva tion s sug gest th at tho se pa tien ts w hofo llow HCF -typ e d ie ts a t h om e are ab le tom a in ta in low er in su lin do ses than o n con tro ld ie ts w h ereas tho se pa tien ts w ho resum e con -tro l-ty pe d ie ts h av e sim ila r in su lin d oses totho se o bse rv ed in th e hosp ital o n the con tro ld iets .

Tw o prev iou s s tud ie s h av e fa iled to dem -on stra te a redu ctio n in in su lin do ses (15 ) o rim provem en t in g luco se m etabo lism (1 6)w hen pa tien ts w ere fed d ie ts co n ta in ing 60 or62% of ca lo r ies a s carbo hyd ra te . P resum ab lythe p lan t fib e r con ten t o f th ese d ie ts w as lowsince the au tho rs d id no t m en tion p lan t fib e rand d id no t a ttem pt to p rov ide a g en e rou sin take o f p lan t f ibe r. T he ir d iets w ere a lsolow er in to ta l ca rboh ydra te and h ig he r in fa tthan ou r HC F die ts . T h eir fa ilu re to d em on-stra te a favorab le re spon se to h ig h ca rb ohy -d ra te d ie ts m igh t be re lated to th e low er fib e rco n ten t o f th eir d ie ts o r to the low er ca rbo -hyd ra te and h ighe r fa t con ten ts o f the ir d ie ts .W e have obse rved tha t th e re sp onse o f g lu -co se m e tabo lism to 6 0% carbo hyd ra te , h ig h -f ibe r d ie ts (2 5 ) is m uch slow er than the re -sp onse repo rted he re w ith 70% carbohydra ted ie ts (J . W . A nde rson , u npub lish ed obse rva -t ions) .

T h e m ech an ism s fo r im prov em en t o f g lu -cose m e tabo lism on h igh -ca rb ohydrate d ietsh av e no t been c la rif ied . Ex tens ive stu d ie s inno rm al ind iv idu als have dem onstra ted th a th ig h -fa t d iets im pa ir g luco se to le ran ce w hileh ig h -ca rboh ydra te d ie ts im p rov e g lucose m e-tabo lism (26 , 2 9 , 30 ). W e igh t-m a in ta in in g ,h ig h -ca rboh ydra te, low -fat d ie ts a re accom -pan ied b y low er p lasm a insu lin va lues and bylow er p la sm a insu lin respon ses to o ra l g lucose


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2320 A ND ER SO N A ND W ARD

adm in istratio n in lean ind iv idu als (2 6 , 29 ).T hese ob serva tion s co up led w ith ou t p re sen tstu dy sug gest tha t h igh -carbo hyd ra te , low -fa td ie ts m ay inc rease the sens itiv ity o f va rio ustissu es to insu lin .

The d ram a tic low erin g o f se rum cho les -te ro l va lues tha t w e obse rved is p ro bab lyre la ted to th e low er ch o le ste ro l an d fa t co n -ten t as w e ll a s the h ig h -fib er co n ten t o f th esed ie ts . S o lub le f ibe rs h ave d istin ct hy pocho les -te ro lem ic effec ts in m an (3 1 , 32 ) . S upp lem en -ta tion o f the d ie t w ith pec tin o r gua r gum(3 1) is accom pan ied by sign ifican t red uc tionsin serum cho le ste ro l v alu es . Th e ava ilab leda ta (32 ) sug gest th a t so lub le p lan t f ibe rs m aylow er serum cho le ste ro l va lues b y d ec reasin gb ile sa lt ab so rp tion .

T he changes in serum trig ly ceride con cen -tra tion s o f the H CF d iets cann o t read ily beexp la ined . W hen w e fed h igh -carbo hyd ra te ,low er f ibe r d iets to pa tien ts w ith ch em ica ld iabe te s , se rum trig ly ce ride v alu es inc rea sedby an av erage of 55% (18 ). T hese d ie ts , h ow -eve r, co n ta ined less than ha lf as m u ch sim plecarbo hyd ra te a s o ur p re sen t d ie ts . T he re fo re ,the changes in fastin g serum trig ly ce rides cu r-ren tly no ted cann o t be re lated to a re str ic tionof sim p le ca rb ohydrate s since the HC F die tsco n ta ined m o re sim p le ca rb oh ydrate th an th eco n tro l d ie ts (T ab le 2 ) o r th e h igh -ca rb ohy -d ra te, low -fibe r d iets (1 8 ). O ur p rev ious o b-serva tion s (32 , 3 3 ) sug gest tha t the in co rp o-ra tion of large am oun ts o f p lan t f ibe rs in toth e H CF d iets has p rev en ted th is hy pe rtr i-g lycendem ia an d re su lted in the stab ility o fave rag e fa stin g se rum trig lyceride v a lues.F u rthe r stu d ie s are requ ired to de lineate th ein flu en ce of p lan t fib ers on fa stin g serumtrig lyce rid e va lues.

O u r stu d ie s sug gest tha t H CF die ts m ay b eth e the rap y o f cho ice fo r ce rta in pa tien ts w ithth e m a tu rity -on set type of d iabe tes . Th esestud ie s do no t reveal h ow m uch ca rb ohydrateo r how m uch p lan t fib e r is requ ired to in ducethese bene fic ia l e ffects o n ca rboh ydra te an dlip id m e tab o lism . W h ile these d ie ts con tain -ing 70% carb ohydrate and 65 g o f p lan t f ibe ra re pa la tab le an d can easily b e p repa red in am e tabo lic k itchen , p atien ts have d iff icu ltydu p licatin g these d iets a t hom e . T he re fo re ,a fte r pa tien ts h av e dem onstrated a favorab lere sp onse to th ese d ie ts in the ho sp ita l w einstruc t them in m a in tenance d iets co n ta in ing

55 to 6 0% carbo hyd ra te and 40 to 50 g ofp lan t f ibe r fo r hom e use (25 ) . T en pa tien tshave fo llow ed these m a in tenance d ie ts a thom e and have m a in ta ined stab le insu lindo ses, b lo od g lucose , an d lip id v alu es fo r upto 3 yea rs af te r d ischa rge from th e h osp ital(25 ). F u rthe r stu d ie s a re requ ired to d ocu-m en t th e lo ng-te rm effects o fth e se H CF d ietson g lu co se an d lip id m e tabo lism of pa tien tsw ith d iabe te s .

T he auth ors ap prec iate th e as sistanc e of Tae G .K iehm , M .D ., a nd Ba rba ra R eiser.

Refe r en ces1. TRUSWELL , A . S ., B . J. THO M A S AN D A . M . B ROW N .

Su rvey of d ie tary p olic y and m anag em ent in B rit ishd iabe tic clin ics . B rit. M ed . J. 4 : 7 , 197 5 .

2. DAUGHADAY , W . H . D ietary treatm en t o f adu ltsw ith d iabe tes m e llitu s. J. Am . M ed. A ssoc . 167 : 859 ,1 9 5 8 .

3. ALLAN , F . N . D ie tetic trea tm ent of d iab ete s. M ed .C lin . N orth A m . 44: 423 , 19 60 .

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5. PERK INS , J . R ., T . E . T . WEST , P . H . SONKSEN , C.Lowv AN D C. ILES . T he e ffe ct o f energy an d carb o-hy dra te re stric tio n in pa tie n ts w ith chro n ic d iab etesm ellitu s. D iabe to log ia 1 3 : 607 , 197 7 .

6. WALL , J. R ., D . A . PYKE AN D W . G . O AK LEY . E ffe ctof c arb ohydra te re str ic tion in o bese d iabe tic s: re la-tio nsh ip of con tro l to w eig h t los s. B ri t. M ed . J. 1 :577 , 19 73 .

7. HADDEN , D . R ., D . A . D . MONTGOMER Y , R . J.SHELLY , E . R . TR IMBLE , J . A . WEAV ER , E . A . WILSONAN D K . D . B UC HANON . M aturity onset d iabete s m e l-l i tus : re spo nse to in tens ive d ieta ry m anag em ent . B rit .M ed . J. 3 :27 6 , 19 75 .

8. B IERMAN , E . L ., M . J. ALBR INK , R . A . ARKY , W . E .CONNER , S. DAYTON , N . SPR ITZ AND D . STE INBERG .P rin cip les of n u tr itio n and d ieta ry recomm endation sfor p atien ts w ith d iab ete s m e llitus: 197 1 . Diabetes2 0 : 63 3 , 19 79 .

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1 1. A Gu ide for P rofess ion als: T he E ffe ctiv e A pp lic atio no f Ex change L ists of M eal P lann ing . N ew Yo rk :A m e ric an D iab etes A ssoc iat ion and A m eric an D ie -te tic A sso cia tion , 197 7 .

12 . S ING H , I. Low -fat d ie t a nd the rap eu tic do ses o fin su lin in d iabe tes m ellitu s. L ancet 1 : 422 , 19 75 .

13 . RAB INOWITCH , I . M . E ffects of the h igh ca rbo hy -d rate -low calorie d ie t up on carbo hydra te to leran cein d iab ete s m e llitus. C an . M ed. A sso c. J. 33 : 1 36 ,1 9 3 5 .

14 . KEMPN ER , W ., R . L . PESCHEL AND C. SC HLAY ER .E ffe ct o f rice d iet on d iab ete s m ellitu s asso cia ted


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w ith v ascu la r d ise ase . Po stg rad . M ed. 24 : 359 , 1 95 8 .15 . STONE , D . B ., AN D W . E . C ONNOR . T he pro lo nge d

e ffec ts o f a low chole ste ro l , h igh c arb oh ydrate d ieton the serum lip id s in d iabet ic pat ien ts. D iabe tes 1 2 :1 27 , 1 96 3.

16 . WEINS I ER , R . L ., A . SE EM A N AN D G. HERRERA . High -an d low -c arb ohydra te d ie ts in d iab ete s m e llitu s.A nn . In ternal M ed . 80 : 3 32 , 1 97 4 .

1 7 . BRUN ZELL , J. D ., D . POR TE , JR . A ND E . L . B I ERMAN .Reversib le ab no rm alit ies in po sthepar in lip o ly tic ac-tivity durin g the late ph ase of rele ase in d iab ete sm e llitus. M etabo lism 24 : 1 123 , 197 5 .

1 8. ANDERSON , J . W . E ffec t o f carboh yd rate restric t ionan d hig h c arb ohydra te d iets on m en w ith ch em ica ld iabe tes . Am . J . C lin . N utr. 30 : 4 02 , 197 7 .

19 . JENK INS , D . J. A ., A . R . LEED S A ND M . A . GAS SULL .Unabsorb ab le c arb oh ydrate s and diabetes: d e-creased pos tprand ial hy pe rg ly caem ia. L ancet 2 : 17 2 ,1 9 7 6 .

20 . MIRANDA , P . M ., AN D D . L . HO RW ITZ . H igh-fibe rdiets in the trea tm ent o f d iab etes m e llitus. A nn .In te rna l M ed . 88 : 4 82 , 19 78 .

21 . JENK INS , D . J. A ., T . M . S . W OLEV ER AND T . D . R .HOCKADAY . T re atm ent of d iabe tes w ith gua r g um .L an cet 2 : 77 9 , 19 77 .

22 . K I EHM , T . G ., J . W . ANDER SON AND K. WARD .B en efic ia l e ffec ts of a h igh carb oh ydrate , h igh fib erd ie t on hyp erg lyc em ic d iabetic m en . A m . J . C lin .N u tr. 29 : 895 , 19 76 .

23 . N ew weigh t s tan dards for m en and w om en . M e tro -po l itan L ife In s. S tatis . B ull. 40 :1 , 19 59 .

24 . ANDERSON , J. W ., W . CH EN AN D K. W ARD . C om -

pos itio n of fo ods com monly used in d iets fo r p ersonsw ith d iab etes . D iabe tes C a re 1 :293 , 197 8 .

25 . ANDERSON , J. W ., AN D K . W ARD . L ong-term effec tsofh igh ca rbo hyd rate , h ig h f ibe r d iets on g lucose andlip id m e tabo lism . A p relim in ary rep ort on p atien tsw ith d iabe tes. D iabe tes C a re 1 : 7 7 , 1 978 .

26 . BRUNZELL , J. D ., R . L . LERN ER AND W . R . HA z-ZARD . Im prov ed g lu cose to lera n ce w ith h igh ca rbo -hy dra te feed ing in m ild d iabe tes. N ew E ng I. J . M ed.28 4: 52 1 , 197 1 .

27 . ANDERSON , J. W . T rig lyc erid e low e rin g e ffec ts ofh ig h carb oh ydrate , h igh fib er d iets . C hin R es. 26 :7 l9A , 1 978 .

28 . ANDERSON , J. W . H ig h carbo hydra te , h igh fiber d ietsfo r pa tien ts w ith d iab ete s. IV In tern atio na l S ym po -sium on Ear ly D iabe tes , ed ite d by R . A . C am erin i-D av alo s and B . H anover . N ew Yo rk : P len um , 1 979 .

29 . ANDERSON , J. W ., R . H . HERM AN AND D. ZAK IM .Effect of h ig h g lucose an d hig h su cro se d iets o ngluco se to le ran ce of no rm al m en . Am . J . C lin . N u tr.25 : 6 00 , 1 97 3 .

3 0 . H IM SW O RTH , H . P . T he physio lo g ic al ac tiva tio n ofinsu lin . C lin . Sc i. 1 : 1 , 193 3 .

31 . JENK INS , D . J . A ., A . R . LEED S AN D C. NEWTON .Effects of p ectin , gu ar gum and w heat fiber o nse rum -choleste ro l . L ance t 1 :1 1 16 , 19 75 .

32 . ANDERSON , J. W ., AND C HEN , W . L . P lan t fiber :C arb ohydra te and lip id m e tab o lism . Am . J . C lin .N u tr. 32 : 3 46 , 1 97 9 .

33 . ANDERSON , J. W . H igh polysa cch aride d iet s tud iesin p atien ts w ith d iab etes an d va scu lar d isea se . C ere alFoods W o rld 22 : 12 , 1 97 7 .

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