Macronutrient intake and their association with risk factors of macro & micro-vascular diseases among Pakistani type 2 diabetic subjects

Abstract

Introduction: Intake of macronutrients by diabetic subjects has major implication on the development of diabetic complications as well as cardiovascular risk in general. The intake may vary substantially among populations depending on environmental, economic and socio-cultural factors. The degree of association of the intake with the above health outcomes may also vary among various population groups. The above issues, which are highly important in designing lifestyle modification programs (as a vital component of diabetes management and prevention) have not yet been adequately investigated among Pakistani population. Objective: The objective of the present study was to assess the intake levels of carbohydrate, protein and fat among newly registered type 2 diabetic subjects at a tertiary level hospital in Karachi, Pakistan and also to explore the association between the intake and the risk factors of micro- and macrovascular complications among the study subjects. Material and method: An observational analytical study was conducted on a retrospective cohort. First visit data of 9563 subjects were retrieved from the digital Hospital Management System of the Baqai Institute of Diabetology and Endocrinology (BIDE) in Karachi, Pakistan. In BIDE information related to macronutrient intake is collected following 24-hr recall method. Anthropometric (height and weight) and biochemical (FPG, RPG, HbA1c, lipid profile, and BP) measurements are done following standard protocol. For diagnosis of diabetes 2006 World Health Organization recommendations for the diagnostic criteria for diabetes and intermediate hyperglycaemia was used. Glycemic control using HbA1c was graded using diagnosed using the GRADE criteria. BMI was categorized following the criteria suggested for the Asian population. The criteria used for dyslipidemia was that was suggested by the American Association of Clinical Endocrinologists in 2012 and for blood pressure, guidelines by National Heart, Lung and Blood Institute (under U.S. Dept. of Health and Human Services) recommendations were followed. Univariate, bivariate and multivariate analyses were done as appropriate. Result: The mean (±SD) intakes of carbohydrate, protein and fat among the study subjects were found to be 230.6 ± 72.2, 68.1 ± 23.6 and 27.5 ± 26.3 respectively. In relative terms carbohydrate, protein and fat contributed to 65%, 19% and 16% of the calorie intake of these subjects. On group difference analysis daily carbohydrate intake varied significantly (p=0.011) between normal and over-weight groups. However it did not differ much among the various glycemic groups based on FPG, RPG or HbA1c criteria. Daily mean protein intake was also significantly (p=0.001) higher among the obese and over-weight as compared to normal weight group. However, it did not differ among the various glycemic groups. Daily mean fat intake was not significantly different between any two of the BMI or glycemic groups but it showed significant (p=0.04) association with HbA1c. On correlation analysis BMI showed no significant association with any of the intake levels; however, FPG was found to be significantly (p=0.05) correlated with age, diabetes duration, physical activity and Hba1c was significantly correlated with, fat intake and carbohydrate intake respectively. Remaining parameter of hyperglycemia (RPG) did not show any significant correlation with the intakes. On group difference analysis various groups of subjects with higher total cholesterol, higher LDL or lower HDL did not show any significant difference in the daily intake of any macronutrients. However, daily protein intake was found to be significantly higher (p<0.001) among hypertriglyceridemic and higher LDL-C group compared to normal group. Total cholesterol showed significant (p<0.001) positive correlation with age and duration of diabetes; triglyceride showed significant correlation (p<0.05) with age, duration of diabetes, carbohydrate intake and protein intake. Serum LDL-C showed similar positive correlation with age, duration of diabetes and carbohydrate intake. Among total subjects HDL-C was not found to be correlated with any other parameters but among females’ HDL-C group it showed significant (p<0.01) association with physical activity but HDL-C groups of men showed higher protein and fat intakes. Macronutrient intake did not differ between hypertensive and normotensive groups and blood pressure did not show any association with the intake levels of any macronutrient. On multivariate analysis (multiple regression) only BMI showed significant positive association with duration of diabetes, carbohydrate intake and protein intake. Conclusion: The present data leads to the following conclusion: • The prevalence of macro- and microvascular diseases risk factors are fairly high among the Pakistani diabetic patients who were outside any comprehensive care. Vast majority of them have uncontrolled diabetes, almost fifty percent have overweight, obesity and hypertension, and more than two-third had dyslipidemia. • The proportion of macronutrient intake among general diabetic subjects in Pakistan substantially differs from the generally recommended proportions applicable for diabetic subjects. In particular, the proportion of carbohydrate as a source total daily calorie is around 20% higher than the usually recommended proportion for diabetic patients.