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Adolescent type 1 diabetes: Eating and gastrointestinal function
Karolinska institutet, Stockholm, Sweden.ORCID iD: 0000-0002-5292-4913
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Adolescents with type 1 diabetes (T1DM) are given nutritional education, but the knowledge about their adherence to the food recommendations and associations between dietary intake and metabolic control is poor. Gastrointestinal symptoms are more prevalent in adults with T1DM than in healthy controls, which may be due to disturbed gastrointestinal motility. The meal content affects the gastric emptying rate and the postprandial glycaemia in healthy adults and adults with type 2 diabetes. Meal ingestion also elicits several postprandial hormonal changes of importance for gastrointestinal motility and glycaemia. Eating disorders are more prevalent in young females with T1DM than in healthy females, and are associated with poor metabolic control. The prevalence of eating disorders in adolescent boys with T1DM is not known.

 This thesis focuses on eating and gastrointestinal function in adolescents with T1DM. Three population-based, cross-sectional studies demonstrated that adolescents with T1DM consume healthy foods more often and have a more regular meal pattern than age- and sex-matched controls. Yet both boys and girls are heavier than controls. The intake of saturated fat is higher and the intake of fibre is lower than recommended in adolescents with T1DM. Patients with poor metabolic control consume more fat and less carbohydrates than patients with better metabolic control. Gastrointestinal symptoms are common in adolescents with T1DM, but the prevalence is not increased compared with controls. Gastrointestinal symptoms in patients are associated with female gender, daily cigarette smoking, long duration of diabetes, poor metabolic control during the past year, and an irregular meal pattern. Adolescent boys with T1DM are heavier and have higher drive for thinness than healthy boys, but do not differ from them in scales measuring psychopathology associated with eating disorders. 

 In a randomized, cross-over study, we found that a meal with a high fat and energy content reduces the initial (0–2 hours) postprandial glycaemic response and delays gastric emptying in adolescents with T1DM given a fixed prandial insulin dose compared with a low-fat meal. The glycaemic response is significantly associated with the gastric emptying rate. Both a high- and a low-fat meal increase the postprandial concentrations of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP-1) and suppress the postprandial ghrelin levels in adolescents with T1DM. The postprandial changes of these hormones are more pronounced after the high-fat meal. Insulin-like growth factor binding-protein (IGFBP) –1 concentrations decrease after insulin administration irrespective of meal ingestion. The GLP-1 response is negatively associated with the gastric emptying rate. The fasting ghrelin levels are negatively associated with the postprandial glycaemic response, and the fasting IGFBP-1 levels are positively associated with the fasting glucose levels.

 We conclude that nutritional education to adolescents with T1DM should focus more on energy intake and expenditure to prevent and treat weight gain. It should also focus on fat quality and fibre intake to reduce the risk of macrovascular complications and improve glycaemia. Gastrointestinal symptoms in adolescents with T1DM should be investigated and treated as in other people irrespective of having diabetes. However, adolescents with long duration of diabetes, poor metabolic control, and symptoms from the upper gut should have their gastric emptying rate examined during euglycaemia. There may be an increased risk for development of eating disorders in adolescent males with T1DM since they are heavier than healthy boys and have higher drive for thinness. This should be investigated in future, larger studies.

 For the first time, we showed that a fat-rich meal delays gastric emptying and reduces the initial glycaemic response in patients with T1DM. The action profile of the prandial insulin dose to a fat-rich meal may need to be postponed and prolonged compared with the profile to a low-fat meal to reach postprandial normoglycaemia. Circulating insulin levels affect postprandial GIP, GLP-1, and ghrelin, but not IGFBP-1, responses less than the meal content. The pronounced GIP-response to a fat- and energy-rich meal may promote adiposity, since GIP stimulates lipogenesis. Such an effect would be disadvantageous for adolescents with T1DM since they already have increased body fat mass and higher weights compared with healthy adolescents. Adolescents with T1DM may have subnormal postprandial ghrelin suppression, which may be due to their increased insulin resistance or elevated growth hormone levels. This needs to be investigated in future, controlled studies.

 

 

Place, publisher, year, edition, pages
Stockholm: Karolinska Institutet , 2009. , 166 p.
Keyword [en]
type 1 diabetes, adolescence, food habits, gastrointestinal symptoms, incretins, ghrelin, eating disorders, gastric emptying, postprandial glycaemia
National Category
Pediatrics
Research subject
Pediatrics
Identifiers
URN: urn:nbn:se:oru:diva-46180ISBN: 978-91-7409-285-1 (print)OAI: oai:DiVA.org:oru-46180DiVA: diva2:861854
Public defence
2009-03-06, Hörsalen, L8:00, CMM-huset, Karolinska Universitetssjukhuset, Solna, 09:30 (Swedish)
Opponent
Supervisors
Available from: 2015-10-20 Created: 2015-10-19 Last updated: 2017-10-17Bibliographically approved
List of papers
1. Food habits, energy and nutrient intake in adolescents with Type 1 diabetes mellitus
Open this publication in new window or tab >>Food habits, energy and nutrient intake in adolescents with Type 1 diabetes mellitus
2006 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 23, no 11, 1225-1232 p.Article in journal (Refereed) Published
Abstract [en]

AIMS: The aims were to describe the food habits of adolescents with Type 1 diabetes (Type 1 DM) and to compare them with healthy control subjects; to describe the distribution of energy-providing nutrients in patients and compare it with current recommendations and previous reports; and finally, to investigate associations between dietary intake and glycaemic control. METHODS: One hundred and seventy-four adolescents with Type 1 DM and 160 age- and sex-matched healthy control subjects completed a validated food frequency questionnaire, and 38 randomly chosen patients completed a prospective 4-day food record. RESULTS: Patients ate more regularly, and more often ate fruit and fruit juice, potatoes and root vegetables, meat, fish, egg, offal and sugar-free sweets than control subjects. Control subjects more often ate ordinary sweets and snacks. Patients chose coarse rye bread and dairy products with less fat to a greater extent than control subjects. Patients were heavier than control subjects. The intake of saturated fat was higher in patients compared with recommendations and, for boys with diabetes, the intake of protein was higher than recommended. Patients with poorer glycaemic control ate vegetables, fruit and fish less often than patients with better control. CONCLUSIONS: The food habits of adolescents with Type 1 DM were healthier than those of control subjects. The intake of energy-providing nutrients was in line with current recommendations and showed improvements compared with previous reports, with the exception of fibre intake. The association between dietary intake and glycaemic control needs further investigation in prospective studies.

Place, publisher, year, edition, pages
Oxon, United Kingdom: Wiley-Blackwell, 2006
Keyword
Adolescence, diet, glycaemic control, Type 1 diabetes
National Category
Medical and Health Sciences Pediatrics Endocrinology and Diabetes
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-12064 (URN)10.1111/j.1464-5491.2006.01971.x (DOI)000241367000012 ()17054600 (PubMedID)2-s2.0-33750175427 (Scopus ID)
Available from: 2010-10-05 Created: 2010-10-05 Last updated: 2017-12-12Bibliographically approved
2. Effects of fat supplementation on postprandial GIP, GLP-1, ghrelin and IGFBP-1 levels: a pilot study on adolescents with type 1 diabetes
Open this publication in new window or tab >>Effects of fat supplementation on postprandial GIP, GLP-1, ghrelin and IGFBP-1 levels: a pilot study on adolescents with type 1 diabetes
Show others...
2010 (English)In: Hormone Research in Paediatrics, ISSN 1663-2818, E-ISSN 1663-2826, Vol. 73, no 5, 355-62 p.Article in journal (Refereed) Published
Abstract [en]

Aims: To compare the responses of GIP, GLP-1, ghrelin and IGFBP-1 between meals with different fat and energy content in adolescents with type 1 diabetes (T1DM) and to relate them to gastric emptying and glycaemia.

Methods: On different days and in a random order, 7 adolescents with T1DM ingested a high- and low-fat meal (fat content: 38 and 2 g, energy content: 640 and 320 kcal, respectively). At normoglycaemia, the same prandial insulin dose was given at both meals and to all subjects. Postprandial blood samples were taken repeatedly over 4 hours. Gastric emptying was estimated by the paracetamol absorption method.

Results: The area under the curve (AUC) for GIP(0-240 min) and for GLP-1(0-120 min) was larger, but smaller for relative ghrelin(0-240 min), after the high-fat meal (p = 0.002, 0.030 and 0.043, respectively). IGFBP-1 decreased significantly, but not differently, after the meals. Larger GLP-1 secretion correlated with slower gastric emptying (p = 0.029) and higher fasting ghrelin levels correlated with lower postprandial glycaemia (p = 0.007).

Conclusion: In adolescents with T1DM, the postprandial responses of GIP, GLP-1 and ghrelin, but not that of IGFBP-1, depend more on meal size than on insulin.

Place, publisher, year, edition, pages
Basel, Switzerland: S. Karger, 2010
Keyword
Adolescence, gastric emptying, ghrelin, IGFBP-1, incretin hormones, type 1 diabetes
National Category
Medical and Health Sciences Nutrition and Dietetics
Identifiers
urn:nbn:se:oru:diva-44976 (URN)10.1159/000308168 (DOI)000277570100008 ()20389106 (PubMedID)2-s2.0-77954040563 (Scopus ID)
Available from: 2015-06-23 Created: 2015-06-23 Last updated: 2017-12-04Bibliographically approved
3. Gastrointestinal symptoms in adolescents with type 1 diabetes
Open this publication in new window or tab >>Gastrointestinal symptoms in adolescents with type 1 diabetes
2010 (English)In: Pediatric Diabetes, ISSN 1399-543X, E-ISSN 1399-5448, Vol. 11, no 4, 265-70 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To compare the prevalence of gastrointestinal (GI) symptoms in adolescents with and without type 1 diabetes (T1DM) and to relate the symptoms in patients to demographic, socioeconomic, diabetes-specific variables, and food habits.

Method: In a population-based, cross-sectional setting, 173 adolescents with T1DM and 160 matched controls completed a questionnaire. Moreover, 13 patients and 1 control were excluded due to having a GI disorder.

Results: Moreover, 75% of patients and 77% of controls reported at least one GI symptom (ns). More girls than boys reported symptoms. Reflux episodes were more prevalent in patients with poorer socioeconomic status. Poor appetite, loss of weight, an uncomfortable feeling of fullness, swallowing difficulties, and nausea were more prevalent in patients smoking daily compared with patients not smoking daily. Vomiting was more prevalent in patients with duration of diabetes >7 yr, and patients with reflux episodes had higher glycated hemoglobin (HbA1c). Belching and early satiety were more prevalent in patients with an irregular meal pattern.

Conclusions: GI symptoms in adolescents are common, but the prevalence is not increased in those with T1DM. GI symptoms in adolescents with T1DM are associated with female sex, poorer socioeconomic status, daily cigarette smoking, longer duration of diabetes, poorer metabolic control, and an irregular meal pattern.

Place, publisher, year, edition, pages
Hoboken, USA: John Wiley & Sons, 2010
Keyword
Adolescent, diabetes mellitus, food habits, GI, type 1
National Category
Medical and Health Sciences Gastroenterology and Hepatology
Identifiers
urn:nbn:se:oru:diva-44974 (URN)10.1111/j.1399-5448.2010.00664.x (DOI)20618744 (PubMedID)2-s2.0-77954485881 (Scopus ID)
Available from: 2015-06-23 Created: 2015-06-23 Last updated: 2017-12-04Bibliographically approved
4. Effects of fat supplementation on glycaemic response and gastric emptying in adolescents with Type 1 diabetes
Open this publication in new window or tab >>Effects of fat supplementation on glycaemic response and gastric emptying in adolescents with Type 1 diabetes
2008 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 25, no 9, 1030-1035 p.Article in journal (Refereed) Published
Abstract [en]

AIMS: To compare the glycaemic response to meals with different fat content in adolescents with Type 1 diabetes mellitus (T1DM) and to investigate associations with gastric emptying.

METHODS: In this randomized, cross-over study, paired results were obtained from seven adolescents with T1DM who ingested on different days two meals with the same carbohydrate and protein content, but different fat and energy content (2 and 38 g fat, 320 and 640 kcal, respectively). Paracetamol was mixed into the meals and gastric emptying was estimated by the paracetamol absorption method. All subjects were normoglycaemic and given 7 IU insulin aspart at commencement of ingestion. Postprandial blood samples were taken during 4 h.

RESULTS: The areas under the curves for plasma glucose and serum paracetamol concentrations were larger after the low-fat than after the high-fat meal during the first 2 h (P = 0.047 and P = 0.041, respectively). The difference between meals in time-to-peak in glucose and paracetamol concentrations did not reach statistical significance (high-fat vs. low-fat meal: 210 min (120-240) vs. 120 min (50-240), P = 0.080 and 120 min (75-180) vs. 60 min (60-120), P = 0.051, respectively). Changes in glucose concentrations correlated with simultaneous changes in paracetamol concentrations (P < 0.001).

CONCLUSIONS: For the first time, we have shown that the initial glycaemic response is reduced after a meal with higher compared with a meal with lower fat content in adolescents with T1DM given a rapid-acting insulin analogue preprandially. The type and dose of preprandial insulin may need adjustment to the fat content of the meal to reach postprandial normoglycaemia.

Place, publisher, year, edition, pages
Oxford: Blackwell, 2008
Keyword
adolescents, dietary fat, gastric emptying, postprandial glycaemic response, Type 1 diabetes
National Category
Medical and Health Sciences Endocrinology and Diabetes Clinical Medicine
Research subject
Internal Medicine
Identifiers
urn:nbn:se:oru:diva-6949 (URN)10.1111/j.1464-5491.2008.02530.x (DOI)19183308 (PubMedID)
Available from: 2009-05-27 Created: 2009-05-27 Last updated: 2017-10-18Bibliographically approved
5. Higher drive for thinness in adolescent males with insulin-dependent diabetes mellitus compared with healthy controls
Open this publication in new window or tab >>Higher drive for thinness in adolescent males with insulin-dependent diabetes mellitus compared with healthy controls
2003 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 92, 114-117 p.Article in journal (Refereed) Published
Place, publisher, year, edition, pages
Oslo, Norway: Taylor & Francis, 2003
Keyword
diabetes mellitus, ätstörning, ungdomar, pojkar
National Category
Medical and Health Sciences Pediatrics
Research subject
Pediatrics
Identifiers
urn:nbn:se:oru:diva-46125 (URN)000181612300021 ()12650311 (PubMedID)2-s2.0-0347927478 (Scopus ID)
Available from: 2015-10-15 Created: 2015-10-15 Last updated: 2017-12-01Bibliographically approved

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