Article Type : Case Report
Authors : Ogawa H, Bando H, Urasaki H, Nagahiro S, Urasaki H, Nakanishi M and Watanabe O
Keywords : Meal tolerance test (MTT); Type 2 diabetes (T2D); super low carbohydrate diet (LCD); Post-prandial blood glucose; Regression curve
Background: For diabetic research, recent topic includes meal tolerance test (MTT), carbohydrate amount and post-prandial glucose.
Case presentation: A Patient is 62-year-old male with type 2 diabetes (T2D). His glucose control was improved by super/standard low carbohydrate diet (LCD) from Sept 2021 to Apr 2022, with HbA1c 14.0% to 6.4%.
Results: The relationship between post-prandial blood glucose (45-min) and actual carbohydrate amount in breakfast was studied. The slope of the regression curve showed gradual flatter tendency during half year.
Discussion: These results suggest that post-prandial glucose would show lower level 45-min after breakfast associated with higher responsive secretion of insulin.
Diabetes has been crucial disease across the world,
and in discussion for long years. It seems to have several subgroups or
etiological mechanism from several points of view [1]. Diabetes is one of the
non-communicable diseases (NCVs) and shows complicated interrelationships with
dyslipidemia, atherosclerotic cardiovascular disease (ASCVD), hypertension and
other diseases [2]. In the light of prevalence and incidence of diabetes,
International Diabetes Federation (IDF) has announced successively epidemiological
reports [3]. According to several statistics, diagnosed DM and also undiagnosed
DM (UDM) in adults have increased in rapid stages [4]. Regarding
standardization of diabetes, American Diabetes Association (ADA) has proposed
the latest guideline in Jan 2022, which has been accepted for medical staffs
and patients worldwide as recommended Medical Care in Diabetes-2022 [5].
Concerning diabetic nutritional therapy, calorie
restriction (CR) was formerly rather usual treatment method. After that, low
carbohydrate diet (LCD) has become an adequate way for patients with diabetes
and obesity. LCD was applied to lots of cases with successful clinical efficacy
by Doctors of Atkins and Bernstein [6]. Dietary Intervention Randomized
Controlled Trial (DIRECT) Group has revealed clinical effect of LCD [7].
Successively, comparative studies of LCD and CR have reported from several
investigators [8]. On the other hand, authors and collaborators have firstly
started LCD in Japan, and continued clinical practice and research in the
fields of LCD, CR, and related issues [9]. Furthermore, we have established
Japan LCD Promotion Association (JLCDPA) and developed LCD medically and
socially [10]. In order to inform LCD to many people, three useful LCD ways
were presented [11].
These methods are super LCD, standard LCD and petite LCD, which include
carbohydrate content ratio as 12%, 26% and 40%, respectively [12].
For carbohydrate intake and post-prandial elevated blood glucose, authors have reported meal tolerance test (MTT) [13]. We have also proposed novel method of Carbo-70 using breakfast with 70g of carbohydrate [14]. In addition, we have reported a diabetic case with measurement of carbohydrate amount in the meal [15]. Among our continuous diabetic practice and research, we have investigated detail relationship with post-prandial blood glucose and intake of carbohydrate amount. In this article, general progress and some perspective would be described.
Figure
1: Clinical
progress of glucose variability and medication three consecutive periods are
indicated for post-prandial study. They are a: Oct-Dec 2021, b: Jan-Feb 2022,
c: Mar-May 2022.
Present history
The patient is 62-year male with type 2 diabetes
(T2D). About 5 years ago, his body weight was increased and then he was
diagnosed as T2D. After that, he has indicated to continue diabetic nutritional
therapy that is standard low carbohydrate diet (LCD) for his daily life. His
general condition was stable for a few years with HbA1c 6.0% - 6.3%. However,
his diabetic control was exacerbated in Sept 2021 associated with diabetic
symptoms and elevated HbA1c. Several causes for the exacerbation exist such as irregular
meal, exercise and life style. Consequently, he was advised to check actual
carbohydrate amount in the meal and post-prandial blood glucose.
Several exams
His physical examination revealed unremarkable
findings, which include consciousness, vital signs, chest, and abdomen.
Neurological examination was intact. As to his physique, his stature, body
weight and body mass index (BMI) showed 181cm, 88kg and 26.9 kg/m2,
respectively. The results of the biochemical test showed that Hb 16.2 g/dL, WBC
86 x 102 /?L, Plt 21.1 x 104 /?L, LDL 142 mg/dL, HDL 65
mg/dL, Triglyceride 100 mg/dL, AST 22 IU/L, ALT 28 IU/L, LDH 141 IU/L, GGT 25
IU/L, Cr 0.8 mg/dL, eGFR 89 mL/min/1.73m2, BUN 17 mg/dL, UA 3.9
mg/dL, CRP 0.02 mg/dL. For other basal examinations, ECG showed within normal
limits, and chest X-ray was negative. Pulse wave velocity (PWV) examination
revealed normal results. The ankle brachial index (ABI) was 1.19/1.19
(0.91-1.40) and cardio–ankle vascular index (CAVI) was 9.3/9.2 (7.8-9.4)
(right/left).
Clinical course
He was advised to continue super LCD for early period
and standard LCD for consecutive period (Figure 1). It means that carbohydrate
amount is set for 12% and 26% for calorie-ratio calculation, respectively. For
medication of oral hypoglycaemic agents (OHAs), he was indicated to continue
metformin 500mg and Canagliflozin 100mg. His HbA1c was decreased from 14.0% to
6.4% from Sept 2021 to April 2022. During this period, the relationship of
post-prandial blood glucose (45-min) and actual carbohydrate intake was
studied.
Current case has checked the relationship of post-prandial blood glucose and carbohydrate amount. In fact, he measured the blood glucose 45-min after breakfast one a week, and also calculated detail carbohydrate amount including in each breakfast. Among them, 4 different breakfast is shown associated with actual picture, carbohydrate amount and post-prandial blood glucose (Figure 2).
Figure
2: Breakfast
content with carbohydrate amount and post-prandial blood glucose.
It includes 4 different staple food of bread and rice. They include raisin bread, melon bread, plain bread and rice ball, associated with carbohydrate amount as 57.0g, 49.7g, 30.4g and 35.0g, respectively. Post-prandial blood glucose 45-min showed 182mg/dL, 164mg/dL, 152mg/dL and 156 mg/dL, respectively. This case has continued this research for several months. The results were divided into three periods, which were a) Oct-Dec 2021, b) Jan-Feb 2022 and c) Mar-May 2022. For three different periods, the correlation with post-prandial glucose and carbohydrate amount was investigated (Figure 3a-c). Among these figures, the degree of slope of the regression curve of a,b,c) is getting lower in order, which were 2.48, 1.26 and 0.55, respectively. Thus, the slope of c) became flatter than that of a).
Figure 3: Correlation between carbohydrate intake and
post-prandial blood glucose.
3a: Breakfast data once a week
during Oct-Dec 2021.
3b: Breakfast data once a week
during Jan-Feb 2022.
3c: Breakfast data once a week during Mar-May 2022.
In this report, super LCD and standard LCD were
provided to the patient, and his general diabetic condition was improved. This
case showed clinical efficacy of LCD (Figure 1). In recent decade, diabetic
diet therapy has been in focus, where LCD has been more prevalent [16]. LCD is
recognized for lowering blood glucose and body weight [17]. In addition to LCD,
authors have continued to report several diabetic matters with anti-diabetes
agents [18]. These include MTT, continuous blood glucose monitoring (CGM) and
glucagon-like peptide 1 receptor agonist (GLP-1RA) and others [19,20].
For his diabetic variability, blood glucose was
measured and monitored 45 minutes after breakfast. Simultaneously, carbohydrate
amount in the breakfast was calculated and the relationship between them was
analysed (Figure 2). Several MTT reports were found, in which beta-cell
function was studied using a standardized liquid diet [21]). Similar to MTT,
oral glucose tolerance test (OGTT) has been widely used [22]. We proposed a
method using 70g of carbohydrate food similar to 75g of glucose [23]. In fact,
we proposed a breakfast loading test using Japanese style breakfast with
carbohydrate 70g [24]. This method was used to examine the changes in blood
glucose, insulin, and c-peptide responses [25].
In this case, the difference in blood glucose increase
with respect to carbohydrate intake was examined for three consecutive periods
(Figure 3a-c). The results showed that the slope of the regression curve of 3c)
became flatter than that of 3a). This result supposed that insulin secretion
responsive to glucose loading may be increased. When insert x= 50 (gram of
carbohydrate amount), the result of y becomes, 204, 191, 168 mg/dL,
respectively. In contrast, by inserting x=20 to Figure 3b and 3c, y will become
153 and 152 mg/dL, respectively, which is almost same. From this estimated
calculation, it may be supposed that LCD continuation would bring improved
insulin secretion for >30-50g of carbohydrate. It is rather usual that
healthy person and diabetic patients have breakfast with carbohydrate amount
about 40-80g per meal. The case has continued standard LCD for several months,
and then the pancreas may be in rest for a while leading to improved insulin
response. Consequently, continuing LCD may have beneficial effects of
increasing insulin secretion and also improving the ability of self-remedy
situation by oneself.
This case has investigated the relationship between
post-prandial blood glucose and carbohydrate amount in the breakfast.
Carbohydrate is usually included in staple food, such as bread, rice and
noodles [26]. According to the textbook
of Harper’s biochemistry, it has been reported that 1g of carbohydrate taken
per os will increase blood glucose 1mg for healthy subjects, 3mg for T2D
patient and 5mg/dL T1D patient [27].
Some limitations are present in this case report. The
relationship with post-prandial glucose and carbohydrate intake would be
important, which is the theme of this presentation. However, such results do
not necessarily show the precise glucose value like computer or the electric
experiments. The reason includes the ingestion and absorption of glucose in the
intestine. Further studies will be required for MTT research. In summary, this
article presented the combined research of LCD and MTT in diabetic patient. The
results would become at least some meaningful reference for diabetic detail
research in the future.
Current investigation was conducted along the
Declaration of Helsinki that was previously revised in 2013 for the WMA
Fortaleza General Assembly. In addition, several commentaries were added by the
ethical guidelines for medical research. They are notified by the Ministry of
Education, Culture, Sports, Science and Technology [MEXT], Japan and Ministry of
Health, Labour and Welfare [MHLW], Japan. This study in detail was explained to
the patient. Authors have obtained the written document agreements from the
patient. Current study was discussed in the professional ethical committee. The
committee involves several professionals including president, director,
doctors, nurses, pharmacists, dieticians, and a professional legal specialty.?
The authors declare no conflict of interest.
Funding
There was no funding received for this paper.
3. Aschner
P, Karuranga S, James S, Simmons D, Basit A, Shaw JE, et al. International
Diabetes Federation's Diabetes Epidemiological Guide Writing Group. The
International Diabetes Federation's guide for diabetes epidemiological studies.
Diabetes Res Clin Pract. 2021.
5. American
Diabetes Association. Introduction: Standards of Medical Care in Diabetes—2022
Diabetes Care 2022.
6. Atkins
RC. Dr. Atkins' New diet revolution. Harper. 2009.
7. Shai
I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, et al. Dietary
Intervention Randomized Controlled Trial (DIRECT) Group. Weight loss with a
low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008; 359:
229-241.
9. Ebe
K, Ebe Y, Yokota S, Matsumoto T, Hashimoto M, Sakai Y, et al. Low Carbohydrate
diet (LCD) treated for three cases as diabetic diet therapy. Kyoto Medical
Association J 2004; 51: 125-129.
17. ADA
Professional Practice Committee. 5. Facilitating behaviour change and
well-being to improve health outcomes: Standards of Medical Care in
Diabetes-2022. Diabetes Care. 2022.
27.
Bender DA, Mayers PA.
Carbohydrates of Physiological Significance. Rodwell VW, Bender DA, botham KM,
Kennelly PJ, Weil PA (eds). Harper's Illustrated Biochemistry, 31edition.
Lange. 2018. McGraw-Hill Education.