Elsevier

Nutrition

Volume 14, Issues 11–12, November–December 1998, Pages 840-845
Nutrition

Original Articles
High-fat versus high-carbohydrate enteral formulae: effect on blood glucose, C-Peptide, and ketones in patients with type 2 diabetes treated with insulin or sulfonylurea

https://doi.org/10.1016/S0899-9007(98)00124-5Get rights and content

Abstract

Recently, two commercial enteral formulae for diabetic patients have been made available in Spain: a high-complex-carbohydrate, low-fat formulation (HCF) and a low-carbohydrate formulation (RCF). This study compares the effects of the two enteral nutritional formulae in patients with non–insulin-dependent diabetes mellitus (type 2 diabetes) treated with sulfonylurea or insulin. Fifty-two type 2 diabetes patients were randomly assigned to receive one of the two enteral formulae. Test enteral formula breakfast (250 cc) were consumed at approximately 0900 h after routine medications (insulin or oral agents) had been taken. Venous blood samples were obtained during fasting, before medication, and at 30 and 120 min after the start of the meal. The glycemic response of patients to the HCF was significantly greater than to RCF, but lower than in the sulfonyl type 2 diabetes treated groups. The incremental glucose response was within acceptable levels except in insulin treatment type 2 diabetes patients given HCF. Glucose, insulin, and C-peptide responses were higher in HCF than RCF groups. Two-factor analysis of variance on mean increments of blood glucose and C-peptide from basal levels to 30 min show the type of enteral nutrition as the main factor (P = 0.0010 and P = 0.0005, respectively). The RCF formula supplies 50.0% of energy as fat and 33.3% as carbohydrates, so it may be a ketogenic diet. It was found that both ketone bodies were higher after RCF than after HCF ingestion, but without statistical significance. We conclude that the partial replacement of complex digestible carbohydrates with monounsaturated fatty acids in the enteral formulae for supplementation of oral diet may improve glycemic control in patients with type 2 diabetes. The long-term effects of enteral diets high in monounsaturated fatty acids need further evaluation in patients with type 2 diabetes.

Introduction

Diabetes mellitus is a disorder of the metabolism caused by an absolute (type 1) or a relative (type 2) lack of insulin. It has been estimated that approximately 10% of hospitalized patients have diabetes.1 Eighty-five percent of these individuals have type 2 diabetes: non–insulin-dependent diabetes mellitus.

Diabetics are as likely to develop problems requiring nutritional support as are people who do not have diabetes. If diabetic patients are unable to ingest nutrients orally but the gastrointestinal tract is still functional, enteral feeding is the choice for nutritional support.2

Most standard enteral formulae are low in fiber, and fat and carbohydrates constitute the largest percentage of energy (45–92%).3 Two commercial enteral formulae specific for diabetic patients are now available in Spain: a high-complex-carbohydrate enteral formula (HCF), and a reduced carbohydrate modified formula (RCF).

The definition of an optimal diet for individuals with diabetes mellitus is the subject of considerable debate. There are two opposing views.4 The prevailing view is that diabetic patients should follow a low-fat diet5 such as HCF. However, the results of some studies (Table I) 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 have been considered by the American Diabetes Association (ADA), and the latest dietary recommendations16 allow monounsaturated fats and carbohydrates to constitute from 60 to 70% of the total caloric content of the diet, as in RCF.

Use of enteral nutritional supplementation in elderly nursing home patients with type 2 diabetes tends to exacerbate hyperglycemia and requires initiation or increase of insulin therapy.17 It would be of interest to use a supplemental enteral formula with the fewest possible side effects on metabolic control. In a previous study,18 we found that the glycemic response to a breakfast test was lower with RCF than with HCF. In this study, the effects of these two enteral diets are compared, not only on glycemic response, but also on insulin production and ketone suppression in type 2 diabetes treated with insulin or sulfonylureas.

Section snippets

Patients and methods

Fifty-two type 2 diabetes volunteers (64% females, ages 45–72 y, mean age 65 ± 7 y) with a good glycemic control (mean HbA1c 6.5 ± 0.9%) were selected for this study. None of the patients had a history of ketosis, brittle diabetes, or thyroidal, renal, or hepatic diseases. All had reported an insidious onset of diabetes with minimal symptoms, with the following means: type 2 diabetes duration 12 ± 5 y, body mass index 29.2 ± 2.7, triacylglycerols 151 ± 50 mg/dL, and total cholesterol 238 ± 39

Results

Age, duration of diabetes, insulin requirements, glycosylated hemoglobin concentrations, body mass index, and plasma levels of triacylglycerols and total cholesterol were similar in all groups.

The mean plasma levels in fasting and 30 and 120 min after ingestion of the two liquid formulae are shown in Table III and Figure 1, and the mean increments above basal levels in Table IV.

The mean glucose values were significantly higher for insulin-treated groups (HCF-i versus RCF-i) 120 min after the

Discussion

The best diet for diabetic patients has been a controversial issue for many years and the dietary recommendations to patients with diabetes mellitus have changed from the diets extremely rich in carbohydrates recommended by the ADA in 19865 to the 1994 ADA guidelines for individualizing the dietary prescription.16

The major emphasis of the ADA recommendations in 19865 was to reduce saturated fats to below 10% of the total energy intake and dietary cholesterol to below 300 mg/d with a view to

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