title: Isocaloric substitution of carbohydrates with protein: the association with weight change and mortality among patients with type 2 diabetes.
abstract: BACKGROUND
  The health impact of dietary replacement of carbohydrates with protein for patients with type 2 diabetes is still debated. This study aimed to investigate the association between dietary substitution of carbohydrates with (animal and plant) protein and 5-year weight change, and all-cause and cardiovascular (CVD) mortality risk in patients with type 2 diabetes.
  
  
  METHODS
  The study included 6,107 diabetes patients from 15 European cohorts. Patients with type 1 diabetes were excluded. At recruitment, validated country-specific food-frequency questionnaires were used to estimate dietary intake. Multivariable adjusted linear regression was used to examine the associations between dietary carbohydrate substitution with protein and 5-year weight change, and Cox regression to estimate hazard ratios (HRs) for (CVD) mortality.
  
  
  RESULTS
  Annual weight loss of patients with type 2 diabetes was 0.17 (SD 1.24) kg. After a mean follow-up of 9.2 (SD 2.3)y, 787 (13%) participants had died, of which 266 (4%) deaths were due to CVD. Substitution of 10 gram dietary carbohydrate with total (ß = 187 [75;299]g) and animal (ß = 196 [137;254]g) protein was associated with mean 5-year weight gain. Substitution for plant protein was not significantly associated with weight change (β = 82 [-421;584]g). Substitution with plant protein was associated with lower all-cause mortality risk (HR = 0.79 [0.64;0.97]), whereas substitution with total or animal protein was not associated with (CVD) mortality risk.
  
  
  CONCLUSIONS
  In diabetes patients, substitution with plant protein was beneficial with respect to weight change and all-cause mortality as opposed to substitution with animal protein. Therefore, future research is needed whether dietary guidelines should not actively promote substitution of carbohydrates by total protein, but rather focus on substitution of carbohydrates with plant protein.
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR 6.131, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. M.J.E.Campmans-Kuijpers@umcutrecht.nl.
authors.forename: Marjo Je
authors.initials: MJ
authors.lastname: Campmans-Kuijpers
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR 6.131, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. I.Sluijs-2@umcutrecht.nl.
authors.forename: Ivonne
authors.initials: I
authors.lastname: Sluijs
authors.affiliation: Department of Nutrition and Food Sciences, University of Bonn, Bonn, Germany. noethlings@uni-bonn.de.
authors.forename: Ute
authors.initials: U
authors.lastname: Nöthlings
authors.affiliation: International Agency for Research on Cancer (IARC-WHO), Lyon, France. FreislingH@iarc.fr.
authors.forename: Heinz
authors.initials: H
authors.lastname: Freisling
authors.affiliation: Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark. ko@soci.au.dk.
authors.forename: Kim
authors.initials: K
authors.lastname: Overvad
authors.affiliation: Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, Tromsø, Norway. Elisabete.Weiderpass.Vainio@ki.se.
authors.forename: Elisabete
authors.initials: E
authors.lastname: Weiderpass
authors.affiliation: Institut Gustave-Roussy, Villejuif, France. guy.fagherazzi@gustaveroussy.fr.
authors.forename: Guy
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authors.lastname: Fagherazzi
authors.affiliation: Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany. t.kuehn@dkfz.de.
authors.forename: Tilman
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authors.affiliation: Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany. v.katzke@dkfz.de.
authors.forename: Verena A
authors.initials: VA
authors.lastname: Katzke
authors.affiliation: Dipartimento Di Medicina Clinica E Chirurgia Federico II University, Naples, Italy. amattiel@unina.it.
authors.forename: Amalia
authors.initials: A
authors.lastname: Mattiello
authors.affiliation: Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden. emily.sonestedt@med.lu.se.
authors.forename: Emily
authors.initials: E
authors.lastname: Sonestedt
authors.affiliation: Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute - ISPO, Florence, Italy. g.masala@ispo.toscana.it.
authors.forename: Giovanna
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authors.affiliation: Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milano, Italy. claudia.agnoli@istitutotumori.mi.it.
authors.forename: Claudia
authors.initials: C
authors.lastname: Agnoli
authors.affiliation: Cancer Registry and Histopathology Unit, "Civic - M.P.Arezzo" Hospital, ASP, Ragusa, Italy. rosario.tumino@asp.rg.it.
authors.forename: Rosario
authors.initials: R
authors.lastname: Tumino
authors.affiliation: National Institute for Public Health and the Environment, Centre for Nutrition, Prevention and Health Services, PO Box 1, 3720, BA, Bilthoven, The Netherlands. Annemieke.Spijkerman@rivm.nl.
authors.forename: Annemieke M W
authors.initials: AM
authors.lastname: Spijkerman
authors.affiliation: Jefe Del Servicio De Epidemiologia, Prevencion Y Promocion De La Salud, Instituto de Salud Pública, Leyre 15, 31003, Pamplona, Spain. abarricg@cfnavarra.es.
authors.forename: Aurelio
authors.initials: A
authors.lastname: Barricarte
authors.affiliation: Unit of Cancer Epidemiology - CERMS, Department of Medical Sciences, University of Turin and Città della Salute e della Scienza Hospital, Turin, Italy. fulvio.ricceri@gmail.com.
authors.forename: Fulvio
authors.initials: F
authors.lastname: Ricceri
authors.affiliation: Public Health Division of Gipuzkoa, BioDonostia Research Institute, Health Department of Basque Region, San Sebastian, Spain. s-chamosa@ej-gv.es.
authors.forename: Saioa
authors.initials: S
authors.lastname: Chamosa
authors.affiliation: Institutionen för odontologi, Umeå university, Umeå, Sweden. ingegerd.johansson@odont.umu.se.
authors.forename: Ingegerd
authors.initials: I
authors.lastname: Johansson
authors.affiliation: Institutionen för medicin, Göteborgs universitet, Göteborg, Sweden. anna.winkvist@nutrition.gu.se.
authors.forename: Anna
authors.initials: A
authors.lastname: Winkvist
authors.affiliation: Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark. annet@cancer.dk.
authors.forename: Anne
authors.initials: A
authors.lastname: Tjønneland
authors.affiliation: Division of human nutrition, WU Agrotechnology & Food Sciences, P.O. Box 8129, 6700, EV, Wageningen, The Netherlands. Diewertje.sluik@wur.nl.
authors.forename: Diewertje
authors.initials: D
authors.lastname: Sluik
authors.affiliation: Department of Epidemiology, German Institute of Human Nutrition, Potsdam-Rehbrücke, Germany. boeing@dife.de.
authors.forename: Heiner
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authors.lastname: Boeing
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR 6.131, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. J.Beulens@umcutrecht.nl.
authors.forename: Joline W J
authors.initials: JW
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mesh_terms: D015331:Cohort Studies; D003924:Diabetes Mellitus, Type 2 / Q000178:diet therapy* / Q000378:metabolism / Q000401:mortality*; D004038:Diet, Reducing / Q000379:methods / Q000639:trends; D004040:Dietary Carbohydrates / Q000008:administration & dosage* / Q000009:adverse effects; D004044:Dietary Proteins / Q000008:administration & dosage / Q000009:adverse effects; D002149:Energy Intake / Q000502:physiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D014674:Plant Proteins, Dietary / Q000008:administration & dosage*; D011446:Prospective Studies; D012307:Risk Factors; D015430:Weight Gain / Q000502:physiology; D015431:Weight Loss / Q000502:physiology
chemical_list: D004040:Dietary Carbohydrates; D004044:Dietary Proteins; D014674:Plant Proteins, Dietary