|Year : 2022 | Volume
| Issue : 1 | Page : 38-45
Impact of a particular diet on the nutritional status and glycemic response of noninsulin-dependent diabetes mellitus patients – An analytical study
Yellesh Pothula1, S. S. B. Sharma2, A Krishnaiah3, Purna Singh Addanki4
1 Laboratories and Blood Bank, King Fahad Hofuf Hospital, Al Assah Eastern Provinces, Kingdom of Saudi Arabia
2 Department of Biochemistry, Bhaskar Medical College, Hyderabad, India
3 Sai Kiran Clinic, Secunderabad, India
4 Department of Physiology, Mamatha Medical College, Khammam, India
|Date of Submission||13-Sep-2021|
|Date of Decision||04-Oct-2021|
|Date of Acceptance||11-Nov-2021|
|Date of Web Publication||24-Jan-2022|
Purna Singh Addanki
Department of Physiology, Mamatha Medical College, Khammam, Telangana
Source of Support: None, Conflict of Interest: None
BACKGROUND: Diabetes mellitus is a heterogeneous primary disorder of carbohydrate metabolism with multiple etiological factors that generally involve absolute or relative insulin deficiency or insulin resistance or both. All causes of diabetes ultimately lead to hyperglycemia, which is the hall mark of this disease syndrome. Nutrition and diet play a critical role in the course of disease, in the controlling hyperglycemia in addition to drugs in diabetes mellitus patients.
OBJECTIVES: To assess nutritional status of noninsulin-dependent diabetes mellitus (NIDDM) patients and glycemic response to the given type of food as compared to normal individuals.
MATERIALS AND METHODS: Out of 40 cases of NIDDM patients, 15 normal subjects belonging to the same age and socioeconomic group were selected for the study on glycemic response to dextrose load and given test food (idly). In another six of NIDDM subjects, glycemic response to test food chapati was studied. In 13 cases of diabetes with hypertension, 12 cases of diabetes without hypertension, and 16 cases of normal subjects, a wide range of biochemical parameters like lipid profile, free fatty acid (FFA) levels, serum, and erythrocyte copper and malondialdehyde levels were estimated among them.
DISCUSSION: The results of the study showed that in NIDDM patients, body mass index is significantly lower than the normal, showing that obesity is not a predisposing condition in these subjects. The glycemic response to food (idly) is much higher than the response observed in normal subjects. The extent of suppression and FFA levels in the serum that was brought out by the food for glucose is lower than that observed in normal subjects.
CONCLUSION: High lipid profile values and low copper levels can favor the generation of lipid-derived free radicals, which further predispose to the vascular changes and hypertensive states observed in the NIDDM patients.
Keywords: Diet, noninsulin-dependent diabetes mellitus, nutrition
|How to cite this article:|
Pothula Y, Sharma SS, Krishnaiah A, Addanki PS. Impact of a particular diet on the nutritional status and glycemic response of noninsulin-dependent diabetes mellitus patients – An analytical study. Indian J Health Sci Biomed Res 2022;15:38-45
|How to cite this URL:|
Pothula Y, Sharma SS, Krishnaiah A, Addanki PS. Impact of a particular diet on the nutritional status and glycemic response of noninsulin-dependent diabetes mellitus patients – An analytical study. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 May 22];15:38-45. Available from: https://www.ijournalhs.org/text.asp?2022/15/1/38/336302
| Introduction|| |
Diabetes mellitus is a heterogeneous primary disorder of carbohydrate metabolism with multiple etiological factors that generally involve absolute or relative insulin deficiency or insulin resistance or both. All causes of diabetes ultimately lead to hyperglycemia, which is the hall mark of this disease syndrome. When it attains above the renal threshold level, it causes glucosuria, decline in glucose utilization, and poor glucose tolerance. Hyperglycemia and glucosuria enhance the fat and protein catabolism, hypercholesterolemia, and ketosis. These metabolic abnormalities during the long term can cause complications that can involve eyes, kidneys, nerves, and blood vessels, leading to clinical manifestations such as diabetic retinopathy, cataract, nephropathy, peripheral neuropathy, autonomic and sensory motor dysfunctions, atherosclerosis affecting cardiovascular system, and cerebra and renal blood vessels., Uncontrolled diabetes may even lead to severe ketoacidosis which may be fatal. Diabetes mellitus is a noncommunicable disease of foremost importance which occupies third place as the cause of death and rising rate of morbidity. Epidemiologically, diabetes mellitus is a major healthcare problem not only in developed countries but also in developing countries. Among the various racial groups, Indians, in particular, seem to be more prone to develop diabetes mellitus.
Hypertension and diabetes mellitus are commonly associated, and it is estimated that more than 50% of people with diabetes mellitus have hypertension. This combination adversely affects cardiac function due to various factors such as myocardial ischemia, microvascular derangement, and depressed left ventricular contractility. Dense interstitial connective tissue changes in the myocardium have been observed in hypertensive diabetic patients. Microscopic and histochemical analysis confirmed this observation that deposition fibrous tissue was significantly high in diabetic heart associated with hypertension compared to hypertension without diabetes mellitus. Diabetes mellitus is a major risk factor for atherogenesis and arterial disease, which result in the development of hypertension and coronary artery disease. The high lipid atmosphere observed in diabetes mellitus may favor more formation of lipid-derived free radical; in addition, low defense mechanism against free radical may also contribute for high lipid peroxides.
A recent survey has shown an equally high prevalence in the urban population of India; considering the long-term nature of the illness and the consequences of the improperly treated diabetes, it is important that all those involved with healthcare delivery be familiar with the disease and its management. The diabetic state may vary in its expression from being totally asymptomatic to being rapidly lethal, and this range is largely related to the degree of defect in insulin production and/or insulin action, knowledge about the metabolic, etiological, and biochemical aspects of diabetes mellitus, and influence of nutritional status, and diet on the course of the disease has brought out that chronic hyperglycemia and dyslipidemia are responsible for many important fatal complications of disease., There is not much experimental work or clinical observation to show that glycemic response for given food is different in diabetes mellitus patients from the normal, except for the fibers present in diet, which has an attenuating effect on glucose absorption.
The present study is aimed to find out the lipid profile, malondialdehyde (MDA) levels, intra- and extra-cellular copper levels among the diabetes mellitus patients. This study is also performed to evaluate the association of those parameters with the development of vascular changes among the patients with diabetes mellitus. For this purpose, the above parameters were studied in two groups of NIDDM patients; one group having hypertension and another group with normotension. Similarly, nutrition and diet play a critical role in the course of disease, in the controlling hyperglycemia in addition to drugs in diabetes mellitus patients.
| Materials and Methods|| |
The subjects for the present analytical study are noninsulin diabetes mellitus (n = 40) patients and normal volunteers (n = 15) belonging to adult age group. In one group of diabetes mellitus patients, the study on glycemic responses to glucose and food was carried out. Another group of diabetes mellitus patients were subdivided into two groups; one without hypertension and other group with hypertension. Fasting and postprandial blood sugar, lipid profile, and serum and erythrocyte levels of copper and MDA were estimated among the two groups of patients. Data pertaining to general history and clinical history were collected from all the subjects. The Ethical Clearance was obtained from Institutional Ethical Clearance Committee, Bhaskar Medical College, Hyderabad, Telangana via Ref no 2019/02712/43 DATED 21-08-2019.
The test food selected for the patients was idly (made of rice and black gram dhal) and chapati (made out wheat flour). The number of normal subjects included for glucose load is five and glycemic response to idly is carried out in ten. However, in normal subjects, glycemic response to wheat could not be studied. The number of diabetes mellitus subjects for glucose load was 10 with idly and with heat six cases. Based upon the composition of idly and wheat before and after their cooling and based on their calorific value given in the Annual Report of National Institution of Nutrition (NIN) (1991–1992), it was calculated that 150 g of idly and 200 g of chapati contained equal calorific value and carbohydrate content (dextrose) has been found to be 75 g [Table 1]a and [Table 1]b.
The test food was given that supplies 75 g of carbohydrate, 200 g of chapati will be containing approximately 105 g of wheat flour as 67 g wheat flour contains 50/67 × 105 = 78 g of carbohydrate. Similarly, 150 g of raw rice contains 50 g of carbohydrate and pulses may contribute approximately 20 g of carbohydrate, and thus, 150 g of idly will supply approximately 75 g of carbohydrate and the total calorific value is also same.
The study was conducted in the following manner: (1) glycemic response to standard oral glucose load test by giving 75 g of dextrose was carried out both in normal subjects and diabetes, and the blood samples were drawn every ½ h up to 2 h. (2) Wherever it was possible in the same subjects, glycemic response to either test dose of idly or chapati was carried out in a similar manner after an interval of 1 or 2 weeks and the food was given in place of dextrose and the blood samples were drawn, for a period of 2 h. Some of the cases were only tested with either of the food item alone. In all the blood samples, blood sugar was estimated. In addition, free fatty acid (FFA) levels were also estimated from the fasting and postprandial serum samples obtained. (3) For the second type study, i.e., diabetes mellitus with and without hypertension, following investigations were done; (a) fasting and postprandial blood sugar; (b) in the serum obtained from fasting blood, following lipid parameters estimated: (i) serum total cholesterol; (ii) triglyceride; (iii) HDL-cholesterol; (iv) VLDL and LDLL; and (v) FFAs, fasting and postprandial; (c) in the serum and erythrocytes, copper and MDA levels were estimated.
The conditions of test were carried out in the morning after a night fast. Any drugs that might influence the result were withdrawn for 3 days. After overnight fasting, the ideal time in the morning was 9 A.M.; from the cubital vein, 6 ml of blood was collected into bottle containing fluoride oxalate anticoagulant and 5 ml for RBC into bottle containing heparin anticoagulant to estimate copper and MDA levels in the RBC. Similarly, another 3 ml of blood was drawn for lipid profile without anticoagulant allowed to clot and after retraction of clot serum was separated by centrifugation at 2500 rpm for 10 min.
The patient was advised to have a test meal after the fasting sample was collected and samples were drawn every ½ h for a period of 2 h. For estimation of copper, MDA and postprandial FFA, the sample was collected after 2 h of test meal. The specific tests were performed as per the methods described below. For MADA and copper estimation in erythrocytes, a hemolysate was prepared by separating the plasma after washing RBC three times with normal saline. Hemolysis of the RBC's was done by adding distilled water, 4 times the volume of water to 1 volume of RBC preparation. This was centrifuged and cellular sediment removed and clear supernatant was used for estimation.
- Estimation of blood glucose level was done by ortho-toluidine method, where the aromatic amines (ortho-toluidine) react quantitatively with the aldehyde group of aldohexoses in hot acetic acid solution to give colored derivatives glycosylating and a Schiff base
- Estimation of total cholesterol was done by Henly method, where the cholesterol in acetic acid solution gives purple color when treated with ferric chloride and sulfuric acid
- Estimation of HDL cholesterol was done by Burstein method, where the cholesterol present in the various components of lipoproteins, such as chylomicrons LDL, VLDL, and HDL, precipitated by polyanions in the presence of metal ions to keep the HDL in solution. The estimation of cholesterol content of clear supernatant gives HDL cholesterol value
- Estimation of triglycerides was done by enzymatic method using commercial kit, where the triglycerides form serum were hydrolyzed by lipase and the glycerol that is liberated and enzymatically reacted to give a highly colored formazan
- Estimation of serum free fatty acid was done by Falholt method, where the serum was extracted with a chloroform-heptane-methanol mixture in the presence of a phosphate buffer to eliminate interference form phospholipids and the extract shaken with a high-density copper reagent at pH 8.1. The copper soap remains in the upper organic layer form which an aliquot was removed and the copper content determined colorimetric ally with diphenyl carbazide
- Estimation of copper in the serum and erythrocytes was done by Eden and Green, Ventura and King methods, where the copper was released from protein by hydrochloric acid. Proteins were precipitated by trichloroacetic acid, then copper was extracted into the mixture of amyl alcohol-ether mixture, where the golden yellow color developed by the sodium dithiol carbonate and sodium pyrophosphate was used for preventing the interference of iron with the mixture.
- Estimation of serum and erythrocytes MDA levels was done by Nadiger and Sheriff methods, where lipid peroxides in the tissue homogenates and extracellular fluid (seed) under the thiobarbuturic acid reaction break down to form MDA, which complexes with thriobarbuturic acid. The resulting MDA-TAB chromogens can be measured calorimetrically at 530 nm.
Data were analyzed using Statistical Package for the Social Sciences (SPSS) for Windows, Version 24, SPSS Inc. by International Business Machines Corporation (IBM), Chicago, Illinois, USA. Student's t-test has been used to assess the significance between the groups. A P < 0.05 is considered significant.
| Results|| |
The case history of the patient shows that, out of the 40 cases of NIDDM patients included in the study: (a) family history of diabetes mellitus present in 14 cases (35%); (b) history of viral infection present in 17 cases (42%); (c) history of alcoholism and smoking 28 cases (70%); (d) most of them belong to low socioeconomic groups.
Assessment of nutritional status as measured by body mass index (BMI) which was obtained by using the formula height in meters/(weight)2 in kg showed that the BMI of normal individuals had value of 25, which agree with a reported value for normal persons in India. In diabetes mellitus patients, the value was 22, which was significantly different from the normal, showing that nutritional status of diabetes mellitus patients included in the study was lower than the normal [Table 2]a and [Table 2]b.
The studies on glycemic response to dextrose, and test food item idly, which was given in the quantities of same calorific value, and carbohydrate content of test dose of dextrose, showed that the glycemic response to dextrose in the normal group was in normal pattern, showing a peak response of blood glucose at the end of 1 h; all blood glucose values were within the normal limits [Table 3]a and [Table 3]b. The total area under curve (AUC in sq.cm) was obtained by plotting glucose value at ½ h.
Interval obtained till the end of 2 h in the graph [sheet 1], [sheet 2], [sheet 3], [sheet 4] and area was measured. In normal individuals, total area of glycemic response to glucose was 3612 sq.cm and with idly 2 was 732 sq.cm, giving a glycemic index (GI) of 0.75. In case of diabetes mellitus patients, as expected fasting blood sugar values were high, the peak response was at 1 h and was persistently elevated even at the end of 2 h. Diabetes mellitus patients, when given idly, also showed similar pattern but have peak value at the end of 1½ h. The area under curve (AUC) for glucose was 8807 sq.cm, whereas for idly was 7551 sq.cm, showing a GI of 0.857.
The value on FFA estimated in fasting and postprandial samples collected at the end of 2 h in normal showed that both dextrose and idly could suppress the serum levels of FFA levels, and the extent of suppression is proportional to glycemic response. Higher the area, the more was the suppression as dextrose caused a higher glycemic response, compared to idly. In case of diabetes mellitus patients, there was an increase in fasting FFA levels, and the amount of fall in FFA levels after dextrose load or idly was however much less than what was observed in normal. The extent of this FFA level fall in both the types of carbohydrate challenges was also the same because of the glycemic status.
The response to idly in diabetes mellitus was almost same to that of dextrose load as shown in [Table 3]b. Studies on lipid profile include estimation of triglycerides, total cholesterol, HDL-cholesterol, and fasting and postprandial levels of FFFA; values for these estimated in normal persons were within the reported normal limits. In case of diabetes mellitus patients without hypertension, the triglycerides levels and fasting FFA were high, whereas total cholesterol and cholesterol content LDL fraction though elevated were not statistically significant. Similarly, in diabetes mellitus with hypertension, the triglyceride FFA levels were much more elevated. Cholesterol and LDL-cholesterol were same as that of diabetes mellitus without hypertension. The plasma lipid and their interrelationship in normal and diabetes patients are given in [Table 4]. [Table 4] shows that in diabetes mellitus patients, there was relative increase of triglyceride as compared to total cholesterol, and there was relative increase of LDL-cholesterol as compared to HDL-cholesterol. Moreover, there was relative decrease of HDL-cholesterol as compared to triglyceride levels.
Copper levels in the serum and erythrocytes were same having a value of 159.92 ug/dl and 156.30 u g/dl in erythrocytes. In diabetes mellitus patients without hypertension, values were same as normal; however, in diabetes mellitus patients with hypertension, both serum and erythrocytes were very much low. However, MDA levels in normal serum 3.6 umol/dl in erythrocytes 11.78 umol/dl. However, in diabetes mellitus with and without hypertension, the serum levels of MDA significantly elevated. In erythrocytes of diabetes mellitus patients without hypertension, though the mean levels are higher side, the difference was no significantly, whereas in diabetes mellitus patients with hypertension, values were very much elevated, which was statistically significant [Table 5].
|Table 5: Total copper and malondialdehyde levels in normal and diabetes mellitus patients|
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| Discussion|| |
A recent survey conducted by Medical Research Council-UK revealed that the incidence of coronary artery disease (CAD) is 30% more in diabetes mellitus patients. An important predisposing condition associated with coronary artery disease is hypertension. More than the drugs, dietary planning for NIDDM patients is very important in correcting the disturbances in carbohydrate and lipid metabolism. Diabetic diet should be so planned as to maintain the ideal body weight with normoglycemia and normolipidemic and providing adequate energy and essential nutrients. In terms of dietary advice to diabetes mellitus patients, there is at present evidence for recommending high carbohydrate diet containing high proportion of complex polysaccharide and fibers, low fat, and low GI foods, which will facilitate maintenance of ideal body weight (BMI 25) and reduce blood glucose level. Maintenance of optimal glycemic control has been shown to reverse the diabetic dyslipidemia.
Tattersall and Fajans have speculated that prolonged intake of fiber depleted refined food induced the development of diabetes in an individual. They were the first to propound the dietary fiber hypothesis of the etiology of diabetes. Anderson et al. have concluded that in diabetes, the high fiber intake is definitely advantageous on several counts that is by lowering nutrient digestion and absorption, decreasing postprandial glucose, increasing tissue insulin sensitivity, increasing insulin receptors, decreasing counterregulatory hormone release (such as glucagon), and moderating hepatic glucose output. Several studies have conclusively demonstrated that plant fibers can reduce postprandial glucose peak and moderate insulin concentration in NIDDM patients, when administered with meals. Certain Indian condiments such as fenugreek seeds which are rich in fiber with high viscosity have been shown to reduce significantly fasting blood glucose and improve GTT in Type I diabetic patients. Fiber constitutes the area of plant cells that are indigestible by the human. It is both water soluble and insoluble. The water-soluble forms are more hypocholesterolemic, and also in blunting the glycemic peak, than the partially soluble fibers, while the water-insoluble ones have no hypocholerol emic action. In an overall perspective, it is seen that nondigestible fiber (including polysaccharides and lignin) is potent in moderating the development of obesity, hypercholesterolemia, heart diseases, diverticular diseases and cancer of the colon heart diseases, and diverticular diseases and cancer of the colon. Based upon these reported observations, the present study was carried out on NIDDM patients attending the teaching hospital of this institute regarding specific factors in clinical history of the patient, BMI, glycemic response to commonly consumed food item (idly) versus dextrose load, lipid profile, MDA, and copper levels in serum and erythrocytes, and the results are presented. The results of study show family history of diabetes (35%) and high incidence viral infection. The BMI of the patients is significantly lower than normal showing that obesity is not an important condition associated with these patients. The observation on glycemic response to food is rather interesting. Glycemic response was studied using isocaloric and isocarbohydrate food item idly weighing 150 g in normal and NIDDM patients and the response was compared with glycemic response to 75 g of oral dextrose load for a period of 2 h. In normal, the GI for idly is 0.75, which shows that due to fiber content and complex carbohydrate content, the response is less than glucose load. This value of GI of idly somewhat less than what is reported by NIN. The variation may be due to subjects selected and the exact test amount give may be higher than what has been given in the present study. The normal subjects selected for this study belong to the same socioeconomic status of the patients. When the same test was conducted, in NIDDM, the glycemic response to idly was 87 and with chapati was 59. The area of response for glucose load was much higher than normal; similarly, for food items, however, if the total area of response to glucose load or food item when it is corrected for expected, BMI of 25, it will be much higher. These observations show that the rate of absorption and transport of glucose from intestine may also have a contribution in the hyperglycemia of diabetes mellitus, and the observation idly containing rice and black gram dhal could cause almost similar rise in blood glucose like dextrose showing that, we must be cautious in extrapolating GI of food items calculated in a small segment of normal and prescribing diet for diabetes mellitus. On the other hand, more and more studies needed on the glycemic response to food in diabetes mellitus patients.
Regarding the results on lipid profile MDA and copper levels, with reference to diabetes with and without hypertension, the present study shows that severity of hyperlipidemia is more in diabetes mellitus with hypertension and especially hypertriglyceridemia. There is significant elevation in triglyceride and cholesterol levels in diabetes mellitus with hypertension, serum MDA levels are elevated in both groups of diabetes mellitus as compared to the normal, but erythrocyte MDA levels are much significantly elevated in diabetes mellitus with hypertension as compared diabetes mellitus without hypertension and normal subjects. Similarly, the serum copper and erythrocyte copper levels were same in diabetes mellitus patients without hypertension as that of normal, but these values were much lowered in diabetes mellitus having hypertension. The important observations made in this study are that BMI in NIDDM patients is lower than normal, the glycemic response to food item idly is much higher than what is observed in normal subjects, serum and erythrocyte copper levels are low, and MDA levels are significantly elevated in diabetes with hypertension. From this observation, it can be concluded that in the control of hyperglycemia by dietary means in NIDDM, more studies are needed in the diabetic patients to arrive at a meaningful conclusion regarding the validity of a particular food item. Apart from metabolic disturbances of carbohydrates, intestinal rate of absorption of carbohydrates may be also contribute to the condition of diabetes mellitus. Similarly, hypertriglyceridemia and increase in free radical generation may be contributing to the hypertensive state in diabetes mellitus, and this may be due to decrease in copper-dependent defense mechanism as evidenced by decrease in serum and erythrocyte copper level.
| Conclusion|| |
The results of this study suggest that diabetes with hypertension has higher triglyceride cholesterol and FFA levels and also higher serum and erythrocyte MDA levels. Serum and erythrocyte copper levels which play defense role against free radical formation are lowered. High lipid profile and low copper levels may favor generation lipid-derived free radicals and predispose for vascular changes and hypertension in NIDDM.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]