Influence of Fat and Carbohydrate Proportions on the Metabolic Profile in Patients With Type 2 Diabetes: A Meta-Analysis

Satoru Kodama; Kazumi Saito; Shiro Tanaka; Miho Maki; Yoko Yachi; Mutsumi Sato; Ayumi Sugawara; Kumiko Totsuka; Hitoshi Shimano; Yasuo Ohashi; Nobuhiro Yamada; Hirohito Sone

doi:10.2337/dc08-1716

Reviews/Commentaries/ADA Statements

Influence of Fat and Carbohydrate Proportions on the Metabolic Profile in Patients With Type 2 Diabetes: A Meta-Analysis

Satoru Kodama, MD, PHD¹,
Kazumi Saito, MD, PHD¹,
Shiro Tanaka, PHD²,
Miho Maki, MS¹,
Yoko Yachi, RD¹,
Mutsumi Sato, RD¹,
Ayumi Sugawara, RD¹,
Kumiko Totsuka, RD¹,
Hitoshi Shimano, MD, PHD³,
Yasuo Ohashi, PHD²,
Nobuhiro Yamada, MD, PHD³ and
Hirohito Sone, MD, PHD, FACP¹

¹Department of Lifestyle Medicine and Applied Nutrition, Ochanomizu University, Tokyo, Japan;
²Department of Biostatistic, Epidemiology and Preventive Health Sciences, University of Tokyo, Tokyo, Japan;
³Endocrinology and Metabolism, University of Tsukuba, Tsukuba, Japan.

Corresponding author: Hirohito Sone, sone.hirohito{at}ocha.ac.jp

Diabetes Care 2009 May; 32(5): 959-965. https://doi.org/10.2337/dc08-1716

Article Figures & Tables

Tables

Table 1

Descriptive statistics of studies included in the meta-analysis

	Intervention period (weeks)	Dropout (%)	LFHC		HFLC		Age (years)	Men (%)	BMI	Using antihyperglycemia agents (%)	Diabetes duration (years)
	Intervention period (weeks)	Dropout (%)	n	C/F/P (%)	n	C/F/P (%)	Age (years)	Men (%)	BMI	Using antihyperglycemia agents (%)	Diabetes duration (years)
Campbell et al. (1994; ref. 13)	2	N/A	10	55/22/23	10	40/37/23	55	100	26.5	10	5
Chen et al. (1995; ref. 14)	6	N/A	9	55/30/15	9	40/45/15	49	67	27.5	N/A	N/A
Coulston et al. (1989; ref. 15)	6	0	8	60/20/20	8	40/40/20	66	63	25.5	75	N/A
Fuh et al. (1990; ref. 16)	2	N/A	11	60/20/20	11	40/40/20	58	100	25.8	100	N/A
Garg et al. (1992; ref. 17)	3	N/A	8	60/25/15	8	35/50/15	63	100	30	0	N/A
Garg et al. (1994; ref. 18)	6	0	42	55/30/15	42	40/45/15	58	79	28.1	100	N/A
Heilbronn et al. (1999a; ref. 19)	12	17	12	73/10/17	10	50/32/18	58	27	32.9	58	5
Heilbronn et al. (1999b; ref. 19)	12	15	12	73/10/17	13	50/32/18	58	20	33.1	52	6
Lovejoy et al. (2002a; ref. 20)	4	12	30	58/27/15	30	46/39/15	54	43	33	47	N/A
Lovejoy et al. (2002b; ref. 20)	4	12	30	58/27/15	30	46/39/15	54	43	33	47	N/A
Luscombe et al. (1999; ref. 21)	4	25	21	53/21/26	21	42/35/23	57	67	30.4	76	6
Miyashita et al. (2004; ref. 22)	4	N/A	11	63/10/27	11	40/35/25	52	73	27	0	N/A
Parillo et al. (1992; ref. 23)	2	0	10	60/20/20	10	40/40/20	53	70	26.7	50	8
Parillo et al. (1996a; ref. 24)	2	0	9	60/20/20	9	40/40/20	48	N/A	24.7	0	6
Parillo et al. (1996b; ref. 24)	2	0	9	60/20/20	9	40/40/20	50	N/A	24.6	100	8
Rodriguez-Villar et al. (2000; ref. 25)	6	25	12	55/30/15	12	45/40/15	N/A	N/A	27.9	N/A	6
Rodriguez-Villar et al. (2004; ref. 26)	6	15	22	55/30/15	22	45/40/15	61	54	28.3	N/A	N/A
Rusmussen et al. (1994; refs. 27, 28)	3	N/A	15	50/30/20	15	30/50/20	57	67	27	47	6
Sestoft et al. (1985; ref. 29)	1.4	N/A	8	50/30/20	8	42/36/22	48	50	22.7	0	5
Simpson et al. (1982; ref. 30)	4	N/A	10	60/22/18	10	35/47/18	58	N/A	26.2	80	6
Storm et al. (1997a; ref. 31)	3	0	15	50/30/20	15	40/45/15	53	53	29.7	73	6
Storm et al. (1997b; ref. 31)	3	0	15	50/30/20	15	40/45/15	53	53	29.7	73	6
Median	4	6	12	58/24/20	12	40/40/20	55	65	27.7	52	6
Minimum	1.4	0	8		8		48	20	22.7	0	5
Maximum	12	25	42		42		66	100	33.1	100	8

C/F/P, proportion of carbohydrate/fat/protein to total energy of the prescribed diet; N/A, not assessed.

Table 2

Overall percent changes resulting from LFHC versus HFLC diet on metabolic profiles and data on publication bias and their likely effect on the estimates

	A1C	FPG	2-h glucose	Fasting insulin	2-h fasting insulin	Total cholesterol	Triglycerides	HDL cholesterol	LDL cholesterol
Trials (n)	10	22	10	22	9	20	22	20	16
Overall percent change	−1.5	0.3	10.3	8.4	12.8	1.6	13.4	−5.6	0.1
95% CI	−5.3 to 2.3	−2.8 to 3.4	6.7–13.9	1.3–15.6	5.2–20.4	−1.3 to 4.5	7.1–19.8	−8.4 to −2.9	−3.8 to 4.1
P	0.70	0.87	<0.001	0.02	<0.001	0.27	<0.001	<0.001	0.94
Publication bias
Begg's	0.80	0.82	0.25	0.30	0.40	0.85	0.48	0.75	0.86
Egger's	0.47	0.30	0.12	0.13	0.16	0.26	0.75	0.08	0.92
Trim and fill
Fill^*								7
Adjusted^†								−7.6
95% CI								−10.2 to −5.0

↵*Studies (n) added by the trim-and-fill method.
↵†Percent change after adjustment for publication bias by the trim-and-fill method. Begg's, Begg's adjusted rank correlation test; Egger's, Egger's regression asymmetry test.

Table 3

Stratified analysis to examine the effects of characteristics of studies and patients on each metabolic profile

	FPG		Fasting insulin		Triglycerides		Total cholesterol		HDL cholesterol		LDL cholesterol
	N	Percent change (95% CI)	N	Percent change (95% CI)	N	Percent change (95% CI)	N	Percent change (95% CI)	N	Percent change (95% CI)	N	Percent change (95% CI)
Study with washout period or baseline data
Neither^*	10	0.9 (−4.6 to 6.3)	10	9.0 (−1.7 to 19.7)	10	18.2 (7.3–29.1)	9	0.7 (−4.2 to 5.5)	9	−6.8 (−10.3 to −3.2)	5	−0.7 (−8 to 6.6)
Others^†	12	0.0 (−3.8 to 3.7)	12	8.0 (−1.6 to 17.6)		11.0 (3.2–18.8)	11	2.2 (−1.5 to 5.8)	11	−4.0 (−8.2 to 0.3)	11	0.5 (−4.2 to 5.1)
Period <4 weeks	10	1.3 (−2.9 to 5.5)	10	15.2 (3.1–27.3)	10	15.8 (4.9–26.6)	10	1.7 (−3 to 6.4)	10	−7.3 (−10.9 to −3.6)	6	0.8 (−7.5 to 9.1)
Period ≥4 weeks	12	−1 (−5.5 to 3.6)	12	4.9 (−3.9 to 13.7)	12	12.2 (4.4–20)	10	1.6 (−2.1 to 5.3)	10	−3.6 (−7.7 to 0.6)	10	0.0 (−4.5 to 4.4)
<50% of subjects female	13	0.4 (−3.3 to 4.1)	13	6.2 (−3.4 to 15.9)	13	13.7 (5.8–21.6)	11	2 (−1.8 to 5.9)	11	−3.4 (−8.1 to 1.2)	10	0.6 (−4.6 to 5.8)
≥50% of subjects female	5	1.6 (−4.6 to 7.8)	5	11.5 (−0.1 to 23.2)	5	15.1 (2.8–27.3)	5	1.8 (−3.8 to 7.4)	5	−7.4 (−11 to −3.7)	4	−0.5 (−7 to 6.1)
Mean age <55 years	10	−0.2 (−4.1 to 3.7)	10	17.2 (6.7–27.8)^‡	10	12.7 (4.6–20.8)	8	1.2 (−3.9 to 6.2)	8	−5.8 (−9.2 to −2.4)	4	−0.6 (−7.5 to 6.3)
Mean age ≥55 years	11	1.2 (−3.9 to 6.4)	11	1.7 (−8.2 to 11.7)^‡	11	15.1 (4.5–25.7)	11	1.9 (−1.7 to 5.5)	11	−5.6 (−10.3 to −0.8)	11	0.7 (−4.2 to 5.5)
BMI <28.0 kg/m²	12	1.9 (−2.8 to 6.6)	12	18.2 (7.6–28.8)^‡	12	12.5 (4.6–20.4)	10	1.2 (−3.5 to 5.8)	10	−7.8 (−11.6 to −4.1)	6	−0.9 (−8.6 to 6.9)
BMI ≥28.0 kg/m²	10	−1 (−5.1 to 3.1)	10	0.3 (−9.4 to 9.9)^‡	10	15.1 (4.6–25.7)	10	1.9 (−1.8 to 5.6)	10	−3.1 (−7.1 to 0.9)	10	0.5 (−4.1 to 5)
Taking hypoglycemic agents	18	−0.6 (−4.1 to 2.9)	18	4.4 (−3.8 to 12.7)^§	18	15.4 (6.9–23.8)	17	1.5 (−1.5 to 4.6)	17	−3.1 (−6.6 to 0.4)	15	0.1 (−3.8 to 4.1)
Not taking hypoglycemic agents	4	2.9 (−3.3 to 9.1)	4	20.7 (6.3–35.1)^§	4	10.9 (1.4–20.5)	3	2.6 (−6.7 to 11.8)	3	−9.4 (−13.7 to −5.1)	1	0 (−31.8 to 31.8)
C/F ratio in LFHC ≥3	8	0.5 (−5.5 to 6.5)	8	17.1 (5.7–28.6)^§	8	9.3 (−0.9 to 19.4)	7	−0.1 (−5.4 to 5.1)	7	−4.6 (−10.9 to 1.6)	4	−3.1 (−11.4 to 5.2)
C/F ratio in LFHC <3	14	0.2 (−3.4 to 3.8)	14	2.9 (−6.2 to 12.1)^§	14	16 (8–24.1)	13	2.4 (−1.1 to 5.9)	13	−5.9 (−8.9 to −2.8)	12	1.1 (−3.4 to 5.5)
C/F ratio in HFLC ≤1	12	0.2 (−3.8 to 4.2)	12	8.1 (−4 to 20.2)	12	18.7 (8.3–29.1)	11	1.2 (−2.7 to 5)	11	−4.2 (−9.1 to 0.6)	8	−0.6 (−6.4 to 5.2)
C/F ratio in HFLC >1	10	0.4 (−4.5 to 5.2)	10	8.6 (−0.2 to 17.5)	10	10.4 (2.4–18.3)	9	2.2 (−2.2 to 6.6)	9	−6.3 (−9.6 to −3)	8	0.8 (−4.5 to 6.1)
MUFA diet in HFLC diet	11	1.9 (−3.9 to 7.7)	11	5.2 (−4.9 to 15.2)	11	21.0 (10.2–31.7)^§	10	3.1 (−1.1 to 7.2)	10	−4.3 (−9.4 to 0.8)	7	2.8 (−3.4 to 8.9)
No MUFA diet in HFLC diet	11	−0.4 (−4.0 to 3.3)	11	11.8 (1.7–22)	11	9.4 (1.6–17.2)^§	10	0.2 (−3.8 to 4.3)	10	−6.2 (−9.4 to −3)	9	−1.6 (−6.7 to 3.4)
WL diet in LFHC and HFLC diets	4	−2.1 (−9.6 to 5.5)	4	12.5 (−1 to 25.9)	4	4.0 (−7.1 to 15.2)^‡	3	1.3 (−6 to 8.5)	3	−3.9 (−12.4 to 4.6)	3	1.9 (−7.4 to 11.2)
No WL diet in LFHC and HFLC diets	18	0.7 (−2.7 to 4.1)	18	6.9 (−1.5 to 15.3)	18	17.9 (10.2–25.5)^‡	17	1.7 (−1.5 to 4.9)	17	−5.8 (−8.7 to −3)	13	−0.2 (−4.6 to 4.1)

↵*Studies having neither a washout period nor baseline data.
↵†Parallel study design or cross-sectional design studies that have a washout period and/or baseline data.
↵‡P < 0.01;
↵§P < 0.05. WL diet, energy intake restricted for weight loss.