The association of substituting carbohydrates with total fat and different types of fatty acids with mortality and weight change among diabetes patients.
Substitution of carbohydrates with fat in a diet for type 2 diabetes patients is still debated.



This study aimed to investigate the association between dietary carbohydrate intake and isocaloric substitution with (i) total fat, (ii) saturated fatty acids (SFA), (iii) mono-unsaturated fatty acids (MUFA) and (iv) poly-unsaturated fatty acids (PUFA) with all-cause and cardiovascular (CVD) mortality risk and 5-year weight change in patients with type 2 diabetes.



The study included 6192 patients with type 2 diabetes from 15 cohorts of the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at recruitment with country-specific food-frequency questionnaires. Cox and linear regression were used to estimate the associations with (CVD) mortality and weight change, adjusting for confounders and using different methods to adjust for energy intake.



After a mean follow-up of 9.2 y ± SD 2.3 y, 791 (13%) participants had died, of which 268 (4%) due to CVD. Substituting 10 g or 5 energy% of carbohydrates by total fat was associated with a higher all-cause mortality risk (HR 1.07 [1.02-1.13]), or SFAs (HR 1.25 [1.11-1.40]) and a lower risk when replaced by MUFAs (HR 0.89 [0.77-1.02]). When carbohydrates were substituted with SFAs (HR 1.22 [1.00-1.49]) or PUFAs (HR 1.29 [1.02-1.63]) CVD mortality risk increased. The 5-year weight was lower when carbohydrates were substituted with total fat or MUFAs. These results were consistent over different energy adjustment methods.



In diabetes patients, substitution of carbohydrates with SFAs was associated with a higher (CVD) mortality risk and substitution by total fat was associated with a higher all-cause mortality risk. Substitution of carbohydrates with MUFAs may be associated with lower mortality risk and weight reduction. Instead of promoting replacement of carbohydrates by total fat, dietary guideline should continue focusing on replacement by fat-subtypes; especially SFAs by MUFAs.
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: M.J.E.Campmans-Kuijpers@Umcutrecht.nl.
Marjo J
MJ
Campmans-Kuijpers
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Ivonne
I
Sluijs
Department of Food Sciences and Nutrition, University of Bonn, Bonn, Germany.
Ute
U
Nöthlings
International Agency for Research on Cancer (IARC-WHO), Lyon, France.
Heinz
H
Freisling
Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark.
Kim
K
Overvad
Department of Epidemiology, German Institute of Human Nutrition, Potsdam-Rehbrücke, Germany.
Heiner
H
Boeing
Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute - ISPO, Florence, Italy.
Giovanna
G
Masala
Department of Clinical and Experimental Medicine, Federico II University Medical School, Naples, Italy.
Salvatore
S
Panico
Cancer Registry and Histopathology Unit, "Civic - M.P-Arezzo" Hospital, ASP Ragusa, Italy.
Rosario
R
Tumino
Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
Sabina
S
Sieri
Institutionen för odontologi, Umeå university, Umeå, Sweden.
Ingegerd
I
Johansson
Intitutionen för medicin, Göteborgs universitet, Göteborg, Sweden.
Anna
A
Winkvist
Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
Verena A
VA
Katzke
Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
Tilman
T
Kuehn
Department of Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden.
Peter M
PM
Nilsson
Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark.
Jytte
J
Halkjær
Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark.
Anne
A
Tjønneland
National Institute for Public Health and the Environment, Centre for Nutrition, Prevention and Health Services, Bilthoven, The Netherlands.
Annemieke M
AM
Spijkerman
Public Health Division of Gipuzkoa, Instituto BIO-Donostia, San Sebastian, Spain.
Larraitz
L
Arriola
Unit of Cancer Epidemiology, AO Citta' della Salute e della Scienza-University of Turin and Center for Cancer Prevention, Turin, Italy; Human Genetics Foundation, Turin, Italy.
Carlotta
C
Sacerdote
Navarre Public Health Institute, Pamplona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), Madrid, Spain.
Aurelio
A
Barricarte
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Anne M
AM
May
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Joline W
JW
Beulens
D001835:Body Weight; D002318:Cardiovascular Diseases / Q000178:diet therapy / Q000209:etiology / Q000401:mortality; D003924:Diabetes Mellitus, Type 2 / Q000178:diet therapy* / Q000401:mortality*; D004032:Diet; D004040:Dietary Carbohydrates / Q000008:administration & dosage*; D004041:Dietary Fats / Q000008:administration & dosage*; D005227:Fatty Acids / Q000008:administration & dosage / Q000009:adverse effects; D005229:Fatty Acids, Monounsaturated / Q000008:administration & dosage; D005231:Fatty Acids, Unsaturated / Q000008:administration & dosage*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015596:Nutrition Assessment; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011795:Surveys and Questionnaires
D004040:Dietary Carbohydrates; D004041:Dietary Fats; D005227:Fatty Acids; D005229:Fatty Acids, Monounsaturated; D005231:Fatty Acids, Unsaturated
Body weight; Carbohydrates; Fatty acids; Mortality risk; Substitution; Type 2 diabetes