PRACE ORYGINALNE
Bartłomiej MATEJKO12 Sandra MROZIŃSKA1 Agata UCHMAN1 Marta KIAŁKA1-3 Magdalena SZOPA12 BeataKIEĆ-WILK12 Jerzy HOHENDORFF1 Tomasz KLUPA12
Comparison of dietary habits and lifestyle in patients with type 1 diabetes and patients with MODY diabetes
Porównanie nawyków żywieniowych i stylu życia pacjentów z cukrzycą typu 1 oraz pacjentów z cukrzycą typu MODY
’Department of MetabolicDiseases, Jagiellonian UniversityMedical College, Krakow, Poland
Head:
Maciej Matecki Prof. Ph. MD 2University Hospital, Krakow,Poland
’Department of Gynecologyand Obstetrics, Jagiellonian University MedicalCollege, Krakow, Poland
Head:
Robert JachProf.PhD. MD,Prof.UJ
Additional keywords:
diabetes type1 MODY dietaryhabits
Dodatkowe słowa kluczowe:
cukrzyca typu 1 MODY
zwyczaje żywieniowe
Diet is a key element of diabetes management, irrespective of the type of the disease. There is no doubt, however, that dietary requirements should differ depending on the type of diabetes. In this analysis, we aimed to assess dietary habits in patients with Maturity-Onset Diabetes of the Young (MODY) and Type 1 Diabetes (T1DM).
We surveyed a population of 186 patients of the Department of Meta
bolic Diseases in Cracow (Poland).
T1DM and MODY cohorts consisted of 96 (69% women) and 90 (62% wom
en) patients (p=0. 43), with a mean age of 26. 5±7. 7 and 38. 8±14. 8 years (p<0. 00), and a mean BMI of 23. 2±2. 6 and 23. 9±3. 9 kg/m2
We found several differences con
cerning eating habits in MODY ver
sus T1DM individuals. T1DM patients more frequently eat during night, felt the fear of gaining weight, drank sweet beverages or energy drinks.
There were no statistically significant differences between the two groups in the frequency of eating breakfast, eating a second breakfast, the fre
quency of eating fruits or vegetables, the number of meals ate during the day and some others.
Based on the results of the survey, we can conclude that dietary habits in T1DM patients and MODY patients are similar. The discrepancies we found can be attributed to differences in mode of treatment and age rather than to the nature of the disease itself.
Conflict of interest: Authorsnot declared conflict of interest
Addressfor correspondence:
TomaszKlupaMD, PhD
Department of Metabolic Diseases, Jagiellonian University
15 Kopernika Street, 31-501,Krakow, Poland tel. (48) 124248300, fax. (48) 12 4219786 e-mail: tomasz_klupa@yahoo.com
Cukrzyca wymaga nie tylko lecze
nia farmakologicznego, lecz także modyfikacji stylu życia m. in poprzez zwiększenie aktywności fizycznej oraz stosowanie odpowiednich reko
mendacji odnośnie żywienia. Dieta jest kluczową składową leczenia osób chorujących na cukrzycę, niezależnie od jej typu. Zarówno w cukrzycy typu 1 (T1DM), jak i cukrzycy typu MODY (Maturity-Onset Diabetes of the Young) można zaobserwować niedo
bór insuliny, brak insulinooporności oraz tendencji do przybierania na wa
dze. Rozróżnienie pomiędzy obiema formami cukrzycy stwarza możliwość zoptymalizowania leczenia farmako
logicznego oraz poprawy jakości ży
cia pacjentów.
Celem niniejszej pracy było po
równanie nawyków żywieniowych oraz stylu życia pacjentów z T1DM oraz pacjentów z cukrzycą typu MODY.
Badanie w postaci ankietowej zo
stało przeprowadzone łącznie u 186 pacjentów z T1DM oraz ze stwier
dzoną cukrzycą typu MODY (GCK i HNF1A-MODY). Wszyscy uczestnicy byli pacjentami Katedry i Kliniki Cho
rób Metabolicznych w Krakowie. Au
torski kwestionariusz składał się z 31 pytań dotyczących nawyków żywie
niowych oraz stylu życia pacjentów.
Większość formularzy została uzupeł
niona podczas rozmowy telefonicz
nej, pozostałe podczas kontrolnych wizyt u diabetologa. Wyniki kwestio
nariuszy zestawiono z danymi doty
czącymi opieki medycznej, takimi jak np. poziom hemoglobiny glikowanej.
Zmienne kategoryczne i porządkowe w obu grupach zostały porównane odpowiednio przy pomocy testu chi- -kwadrat Pearsona lub testu trendu Cochrane-Armitage. Do porównania cech ciągłych w dwóch grupach wy
korzystano test t-Studenta lub test U Mann-Whitney a.
Ankieta dotycząca nawyków ży
wieniowych została przeprowadzona wśród 96 (kobiety stanowiły 68, 7%)
Przegląd Lekarski 2017 /74/7 293
pacjentów z T1DM oraz 90 (kobiety stanowiły 62%) pa
cjentów z cukrzycą typu MODY. W opisanym badaniu osoby z T1DM częściej mieszkały w większych miastach niż pacjenci z cukrzycą typu MODY (p=0, 01). Pacjenci z T1DM częściej podjadali w nocy (p=0, 02) oraz częściej odczuwali strach przed przybraniem na wadze (p<0, 01) niż pacjenci chorujący na cukrzycę typu MODY. Większy odsetek pacjentów z T1 DM w porównaniu z osobami z cu
krzycą typu MODY spożywał napoje słodzone (p=0, 04), część z pacjentów deklarowała ich spożywanie w celu uniknięcia lub w związku z epizodami hipoglikemii. Nie zaobserwowano istotnych statystycznie różnic pomiędzy obiema grupami w ilości spożywanych posiłków w ciągu dnia, częstości spożywania napojów alkoholowych, pa
lenia papierów, częstości spożywania warzyw i owoców czy poczuciu zadowolenia ze swojego wyglądu.
Na podstawie wyników przeprowadzonej ankiety moż
na stwierdzić, iż pacjenci z T1DM oraz pacjenci z cukrzy
cą typu MODY posiadają wiele cech wspólnych, a obser
wowane różnice można wytłumaczyć raczej modelem leczenia i wiekiem niż naturą samej choroby.
Introduction
Diet isa keyelementofdiabetesma
nagement, irrespective of the type of the disease [1]. At the same time, nutritional recommendations areone of themostdif
ficult to follow.Thereisno doubt, however, thatdietary requirements should differ de
pendingon the type of diabetes [2]. In this analysis,weaimed to assessdietaryhabits in patientswith Maturity-Onset Diabetes of the Young (MODY)[3]and Type1 Diabetes (T1 DM). We chose thesetwo typesof dia
betesdue tothe following reasons:
1. Both forms of diabetesdealwithrelati
ve (MODY) orabsolute (T1DM) insulin deficiency.
2. Both forms of diabetes may affect young or relatively youngindividuals, in whom adherence to dietary guidelines may bemostproblematic.
3. Neither form of diabetes is typically as
sociated with insulin resistance or we ight gain, which maybe an important factor affecting dietary adherence and dietary habits. The tendency to gain weight may obviously appear in both forms of the disease as an iatrogenic effectof improperinsulin or oral treat
ment.
4. The clinical value of performing diffe rential diagnosis between T1DM and MODY and establishingmoleculardia
gnosisofmonogenicdiabetes lies both in the possibility of optimizationof phar macotherapy and improving quality of life. A more“flexible" approach to diet may be a significant component in the improvement ofquality oflife.
MODY is aheterogeneous group ofau
tosomal dominant forms of diabetes cha
racterized by pancreatic p-cell dysfunction and an early age of onset [4]. The dise ase results from a single mutation in one ofthe genes important for p-cell function and insulin production and/or secretion [3]. The gene mutations responsible for most MODY cases are foundin the genes HNF1A (encoding hepatic nuclear factor- la, MODY3), GCK (encoding glucokinase, MODY 2), and HNF4Aand HNF1B (enco
ding hepatic nuclear factor-4a and hepatic
nuclear factor-1 p, MODY 1 and MODY 5, respectively) [4, 5]. Our cohort of MODY pa
tientsis representedby GCKand HNF1A MODY-the twomost common types of this monogenic form ofdiabetes [5].
In HNF1A MODY, pharmacologic tre atmentis usually inevitable; however, de
spite the frequently young ageof diabetes onset, there are alternativestoinsulin tre atment. Several reportsfromvarious popu lationssuggestedthat patients with HNF1A MODY were characterized by aspecifically prominent therapeutic response to sulpho- nylurea (includinga randomized controlled trial) [6]. In some cases, however, insulin therapy is eventually inevitable6. In GCK MODY, it is recommended to avoid insulin therapy andall other pharmacotherapy as their effectiveness has not yet been proven in this type of diabetes [7].
There are no specific dietary recom
mendations for patients with MODY. It is recommended that they follow the same diet aspatients with other formsof diabe tes. There are also very few publications regarding dietary intervention in individu als with MODY [8]. We have shown that in GCK MODY patients on a high-carbohy- dratediet,glucose levels weresignificantly higher and more hyperglycemic episodes occurred than in those on a low-carbo- hydratediet [8]. We concluded that a diet with a modestly limited carbohydrate con tent may improve glycemic control in GCK MODY patients. In contrastto MODY indi
viduals, patients with T1DM should follow strict rules as far as nutritional therapyis concerned [9]. Thecrucial issue of dietary management in T1DM ismonitoring carbo
hydrateintakeandbalancing carbohydrate intake and insulin levels, although dietary fat may also increase glucose levels and insulin requirements [9,10]. There is no do
ubtthat close adherence to carbohydrate intake recommendations is associated with better glycemic control [9]. Moreover, a mismatch between carbohydrate inta ke and insulin dosing can result not only in long-term butalso acute complications [9]. It should be notedthat evidence sug gests that people with diabetes do notfol
low recommended dietary guidelines [9].
In general, following recommendations for healthyeating may be the best method for preventing or treatingcomorbidconditions in T1DM [9].
Material and Methods
Wesurveyeda population of186 pa
tients of the Departmentof Metabolic Di
seases in Cracow (Poland). The survey was designedby ourselves andwascom
posed of 31 questions concerningdietary habits. All ofthe respondents expressed their consent to participate In thesurvey.
The study groupincluded96 patients suf fering from T1 DM treated with personal in sulin pumps and90 patientssufferingfrom MODY (GCK-and HNF1A-MODY). Most questionnaires (n=166) were completed via a telephone conversation. The rest of themwere completed during the patient’s routine visit to the diabetic clinic. In ad
dition, data concerning age, height, sex, body mass index (BMI),diabetes typeand duration, glycated hemoglobin (HbA1c), and other aspects of medical carewere collected. Categorical and ordinal varia
bles in two groups were compared using Pearson’s chi-squared test or the Co chran-Armitage testfortrend. Forcontinu ous datacomparison, we used Student's t-test or the Mann-Whitney U test when applicable. To assess influence of confo unding factor (age) in categorical or orde
red variables, we used multivariable logi
sticorordered logistic regression.Values are presented as mean±SD or median and percentage forcategorical variables.
Results
T1DM and MODY cohorts consisted of 96 (69% women) and 90 (62% wo men) patients (p=0.43), with a mean age of 26. 517.7 and 38. 8114. 8 years (p<0. 00), and a mean BMI of 23. 212.6 and 23. 913.9 kg/m2 (p=0. 25), respectively. In our study group, there were no cases withanorexia nervosa or bulimia nervosa. There was a statistically significant difference betwe enplaceof residence intwo groups. More T1DM patientslived in villagesor in towns
294 B. Matejko et al.
with more than100000 citizens whilemore MODY patients lived in towns with less than 100,000citizens (p=0.01).
We found several differences concer ning eating habits in MODY versus T1DM individuals. One of them concerned night
time eating habits. In the portion of the surveyconcerning how often patientsate during the nighttime, available respon
ses ranged from neverto everyday. Most MODY patients did noteat during thenight at all (81%), while this habitwas quite fre
quently observed in T1 DM patients(44. 8%
reported snacking during the night from less than once a week to 3-4 times per week) (p=0.02). After controlling for age, there was no difference between the two groups in respect of nighttime eating habits (with never eating at night asthe reference in anordinal scale) (p=0.10). Our dataalso suggestthat MODY patients atetheirlast meal ofthe day earlier before going sle
ep than T1DM patients (p=0. 01) (answer options in questionnaire form).
Anotherfinding was that patients with T1DM more oftenfelt the fear ofgaining weight (48%) than patients with MODY (25%) (p<0. 01) (answer options: yes/no).
This was still significant after adjustingfor age as a possible confounder (p<0. 01).
Patients with T1DM more frequently fol
lowed a calorie-restricted diet for weight loss (29% vs. 20%, p=0. 04), however this relationship disappeared when adjusted for patient age (p=0. 30).
Finally, we found that patients with T1DM more frequently drank sweet be
verages or energy drinks (61% vs. 45%, p=0.04), however this relationshipwas in fluenced by patient age; afteradjusting for that variable,the significance disappeared (p=0.97).
There were no statistically significant differencesbetweenthe two groups in the frequencyof eating breakfast, eating a se cond breakfast, the frequency of eating fruits or vegetables, thenumberofmeals ate during the day, the frequency of fe
elinghunger, the frequency of overeating, thefrequencyof consumptionof alcoholic beverages, smoking, or a sense of satis
faction with their appearance (all answer options in questionnaire form). There was only a tendency that T1DM patients were more physically active (answer options were light, average, or extensive physical activity, p=0. 08), however in the question regarding the amountoftime spent exer
cising during the week, there was no dif ferencebetweenthe two groups(p=0. 97).
Discussion
Theresultsof our study showsomedif ferences in dietary habits between MODY and T1DM patients, however one sho
uld interpret them with caution. Thethree statistically significant findings concerned nighttime eating habits, drinking sweet beverages, and the fear of uncontrolled weightgain. All those discrepancies could be attributed todifferencesin the modeof treatment anddifferences in age. All T1 DM individuals weretreated with insulin while most MODY patients were treated either withdiet or oral agents (Tab. I). Treatment with insulin per se increases the risk of nocturnal hypoglycemia [11,12], which mayexplain nighttime eating habits among T1 DM patients as a form of precaution or hypoglycemia treatment. Drinking sweet beverages (or taking other forms of high glycemic index carbohydrates) is a stan
dard form of actionduring or inprevention of hypoglycemia in insulin-treated individu
als[13, 14]. Patients treated with diet alone are generally not prone to hypoglycemia.
In patients treated with oral antydiabetic drugs, hypoglycemia risk is generally much lowerwhen compared toinsulin-managed individuals [15].
Finally, fear of weight gain may be war
ranted in insulin-treated patients, since ia trogenicexogenous hyperinsulinemiamay indeed lead to uncontrolled weight gain [16, 17].
To our surprise, no other differences in dietary habits were foundbetween MODY and T1DM patients. One could expect, forinstance, that the need for precise es
timation ofprandial insulin dose in T1DM patients may result in atendency towards a smaller number of meals compared to
MODY patients, where, atleast in non-in- sulin treated individuals, no additional ac tionbefore the meal is required.
It is worth noting that our study was the first oneto assess the dietary habits in alarge population ofpatients with mo
nogenic diabetes (MODY). The present report also has several limitations. It was anobservational study; therefore,causality could notbe identified andthecumulative effect ofanalyzed variables could not be evaluated. The impact of potential confo- unders should alsobementioned. We did not use dietary interview, which could have given us more detailed insight into eating behaviors and whether patients were me etingnutritionalstandards. Finally, we must acknowledge that the questionnaire used in this research was not validated.
Conclusion
Based onthe results of thesurvey, we can conclude that dietary habits in T1DM patients and MODY patientsare similar. The discrepancies we found can be attributed to differences in mode of treatment and age ra ther thanto the nature of thedisease itself.
EATINGHABITS QUESTIONNAIRE Introduction
Thank youforagreeing to participate in our survey. This questionnaire is designed to assess theeating habitsof people suf
fering from diabetes mellitus and compare them to patients withdifferent types of dia
betes. Itshouldtake 5-10 minutesto com plete thisform.
1. Please, select your sex.
a)female b)male 2. Place of residence:
a) Thecountry
b) Atownof <100, 000residents c) Acity of >100, 000 residents 3. Age: ...
4. Height: ...
5. Body weight: ...
6. How often do yousnack between me
als?
a)everyday b)3-4 timesa week c) 1-2timesa week
Table I
Study group characteristics.
Charakterystyka grupy.
1 P-value for comparison between MODY and T1DM patients Variable
T1DM PATIENTS
MODY PATIENTS
P-value*
GCK-MODY HNF1A-MODY
N % N % N %
Gender F/M (%F) 66/30 68. 7 29/18 61. 7 27/16 62. 8 0. 4342
Treatment option: diet, oral, insulin (%) 96 - insulin on
personal pump 100 28/5/4 76/13/11 8/17/9 23/50/27 0. 0000
Variable Mean SD Mean SD Mean SD P-value*
HbA1c[%] 7. 5 1. 1 6. 4 0. 8 6. 8 1. 5 0. 0000
BMI [kg/m=] 23. 2 2. 6 23. 7 3. 8 24. 2 4. 1 0. 2447
Age at examination [yr] 26. 1 7. 7 37. 4 15. 1 40. 0 14. 6 0. 0000
Age at diabetes diagnosis [yr] 11. 8 5. 8 27. 5 13. 2 24. 4 10. 4 0. 0000
Diabetes duration [yr] 15. 1 7. 3 10. 1 7. 6 16. 4 12. 1 0. 0030
Przegląd Lekarski 2017 /74/7 295
d) Less than once a week e) Never
7. Do you snack or eatmeals at night?
a) everyday b)3-4times a week c) 1-2 times a week d)Less than once a week e) Never
8. Howoften do you feel hungry?
a)everyday b)3-4times a week c) 1 -2times aweek d) Less thanonce a week e) Never
9. Howoften do you overeat?
a) everyday b)3-4 timesa week c) 1-2 times a week d) Less thanonce aweek e) Never
11. Doyou have a fear of gaining weight?
a) yes b) no
12. Do you sometimes provoke vomiting after meals?
a)yes b) no
13. Do you suffer from anorexia?
a)yes b) no
14. Do you feel uncontrollable attacks of hunger?
a)yes b) no
15. Do you eat breakfast?
a)yes b) no
16. Do you eat a second breakfast?
a) yes b) no
17. In your opinion, areyou:
a) too thin b) slim c) normal d) overweight e) obese
18. Have you ever been on a restricted diet?
a) yes b)no
19. Have you ever tried to gainweight?
a) yes b)no
20. Do you like your appearance?
a) yes b)no
21. Describeyour physicalactivity:
a)light b) average c) extensive
22. Howoften doyou eat vegetables?
a) 4 times a day or more
b) 2-3 times a day c) once a day
d)several timesa week e)several timesamonth 23. Howoften do you eat fruit?
a) 4times aday or more b)2-3 timesa day c) once a day
d)several times aweek e)several times a month
24. Do you consume sweetened drinks like Coca-Cola,Sprite, Fanta or energy drinks?
a)yes b) no 25. If yes, how often?
a)everyday
b)several times a week c) several times amonth
26. How many hours before bedtime do you eat your last meal?
a) more than 4 hours b)3-4 hours c) 2-3 hours d) less than2 hours
27. Howmany mealsdo you eat daily?
a)3orless b)4-5 c) more than 5
28. How often do youengage in physical activity weekly?
a) less than1 hour b)1-2hours c) more than 2 hours
29. Which meal is yourlargest meal?
a) breakfast b) lunch c) dinner
30. How oftendo you drinkalcohol?
a)2-3 times a week
b)lessthan2-3 times a week c) more than 2-3 timesa week 31. Do yousmoke?
a) yes b) no c) in thepast
Thank youfor completingthisquestion naire.
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