Abstract
Diet therapy is one of the most important treatments for people with type 2 diabetes (T2D). However, dietary restrictions due to diet therapy may reduce quality of life (QOL). This cross-sectional study aimed to investigate the association between diabetes diet-related QOL and dietary fiber intake in 238 people with T2D. The Diabetes Diet-related Quality of Life–Revised version (DDRQOL-9-R) and the brief-type self-administered diet history questionnaire were used to evaluate diabetes diet-related QOL and nutritional intake, respectively. Higher scores of each DDRQOL-9-R subscale means greater satisfaction with diet, perceived merits of diet therapy, and lower burden of diet therapy, which indicates good QOL. The median scores for perceived merits of diet therapy, satisfaction with diet, and burden of diet therapy were 58.3 [41.7–75.0], 75.0 [66.7–91.7], and 66.7 [50.0–75.0] points, respectively. HbA1c levels in people with high perceived merits of diet therapy (7.3 [6.7–7.8] vs. 7.5 [7.1–8.2] %, p = 0.007) and people with high satisfaction with diet (7.3 [6.8–7.8] vs. 7.5 [7.1–8.4] %, p = 0.010) were lower than those without. Dietary fiber intake was higher in people with high perceived merits of diet therapy (11.6 [8.8–16.7] vs. 10.0 [7.9–13.8] g/day, p = 0.010), high satisfaction with diet (11.4 [8.8–16.1] vs. 9.7 [7.8–13.2] g/day, p = 0.007), and low burden of diet therapy (11.8 [8.7–16.5] vs. 9.7 [7.8–12.6] g/day, p = 0.004) than in those without. Dietary fiber intake was related to perceived merits of diet therapy (Odds ratio [OR]1.07 [95%CI: 1.00–1.15], p = 0.049), burden of diet therapy (OR 0.90 [95%CI: 0.82–0.98], p = 0.022), and satisfaction with diet (OR 1.18 [95%CI: 1.09–1.27], p < 0.001) after adjusting for covariates. Dietary fiber intake is associated with diabetes diet-related QOL in people with T2D.
THE PREVALENCE OF DIABETES is rapidly increasing globally [1]. Since diabetes is a chronic disease, it requires life-long treatment to maintain glycemic control [2]. The validity of diet therapy in diabetes is widely acknowledged; therefore, diet therapy is one of the most important treatments for people with diabetes [3]. On the other hand, maintaining the same quality of life (QOL) and longevity as people without diabetes is another goal of diabetes treatment. To achieve this goal and protect people with diabetes from the development and progression of diabetic microangiopathy and macroangiopathy, maintaining not only good glycemic control but also good blood pressure, serum lipid levels, and weight is important [4-6]. Diet, exercise, and drug therapy are crucial for maintaining good glycemic control [7-9]. In particular, dietary fiber intake affects glycemic control [10, 11]. Diet is a source of daily enjoyment; therefore, any diet restrictions enforced owing to diet therapy may reduce the QOL. High dietary fiber intake may contribute to high satisfaction with diet, promoting satiety [12], and contributes to glycemic control [10, 11]; thus, it may increase the perceived merits of diet therapy. However, it may be difficult for people with diabetes to learn and keep self-management behaviors [13]. Furthermore, the burden of adhering to dietary restrictions and conflict between diet as a source of enjoyment and the need for self-management behaviors influences the patients’ QOL [14, 15]. The diabetes diet-related quality of life revised-short form (DDRQOL-R-9) was developed [16] to measure the effect of diet therapy on QOL in people with type 2 diabetes (T2D). However, the relationship between diabetes diet-related QOL, including perceived merits of diet therapy, satisfaction with diet, and burden of diet therapy, and habitual dietary intake in people with T2D is not clear. Thus, this cross-sectional study aimed to investigate this association in people with T2D.
Materials and Methods
Study participants
To investigate and clarify the natural history of people with diabetes, a prospective cohort study, namely KAMOGAWA-DM cohort study, was conducted from 2014 [9]. In this cross-sectional study, we recruited outpatients of the Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine (KPUM) Hospital, Kyoto, Japan, who completed the DDRQOL-R-9 between March 2021 and October 2021. We excluded people without T2D and data on the brief-type self-administered diet history questionnaire (BDHQ). The KPUM ethics committee approved this study (No. RBMR-E-466-6). This study was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants.
Data collection
Data on the duration of diabetes, family history of diabetes, smoking status, and exercise habit were collected through a standardized questionnaire. At the time of enrolment, people who smoked cigarettes or another tobacco product were considered smokers, and those who engaged in any type of exercise for one or more times a week were considered to be physically active. Venous blood was collected after overnight fasting for the assessment of triglyceride, plasma glucose, glycosylated hemoglobin (HbA1c), high-density lipoprotein cholesterol, and creatinine (Cr) levels. Estimated glomerular filtration rate (eGFR) was estimated as 194 × age–0.287 × Cr–1.094 (if women, ×0.739) (mL/min/1.73 m2) according to the Japanese Society of Nephrology [17]. Body mass index (BMI) was calculated by dividing body weight (in kilograms) by height squared (in meters). Blood pressure was measured automatically with the participants in a seated position after 5 min of rest in a quiet room using a HEM-906 device (OMRON, Kyoto, Japan). Additionally, data on use of medications for diabetes and hypertension, were collected from patients’ records. Renal failure, ideal body weight (IBW) and hypertension were defined as eGFR <30 mL/min/1.73 m2 [18] and 22 × height squared (m2) [19], and blood pressure ≥140/90 mmHg and the use of antihypertensive drugs [20]. Obesity was defined as BMI ≥25 kg/m2.
Data of the Diabetes Diet-Related Quality of Life revised-short form
Diabetes diet-related QOL were evaluated using the DDRQOL-R-9 [16]. The DDRQOL-R-9 evaluates three subscales of “satisfaction with diet,” “perceived merits of diet therapy,” and “burden of diet therapy” with three questions. The score is rated on a 5-point Likert type scale, with scores ranging from 1 (very strongly agree) to 5 (very strongly disagree). The scores for “satisfaction with diet” and “perceived merits of diet therapy” were reversed, and the sum of the scores for each scale was calculated as total scores of 100 points as follows: (the raw score for that sample – the minimum possible raw score for that subscale)/(the maximum possible raw score for that subscale – the minimum possible raw score for that subscale) × 100. The minimum possible raw score for that subscale was 3 in this DDRQOL-R-9. Higher scores of each subscale means greater satisfaction with diet, perceived merits of diet therapy, and lower burden of diet therapy, indicating a good diet-related QOL. The DDRQOL-R-9 showed good internal consistency with the original version of DDRQOL-R and Cronbach’s alpha coefficients of 0.86, 0.86, and 0.82 for “burden of diet therapy,” “satisfaction with diet,” and “perceived merits of diet therapy,” respectively [16].
Data of habitual diet intake
We evaluated the participants’ habitual food and nutrient intake during the previous month using the BDHQ. The validity and details of the BDHQ, including fiber intake, have been previously published [21, 22]. Pearson correlation coefficients between semi-weighed dietary records and BDHQ are as follows: dietary fiber intake (men: r = 0.51, women: r = 0.56), soluble fiber intake (men: r = 0.45, women: r = 0.54), and insoluble fiber intake (men: r = 0.48, women: r = 0.56) [22]. Using the BDHQ, energy intake was assessed in kcal/day, fiber intake, soluble fiber intake, insoluble fiber intake, fat intake, carbohydrate intake, protein intake, and alcohol intake were assessed in g/day. Moreover, energy (kcal/IBW/day), fat (g/IBW/day), carbohydrate (g/IBW/day), protein (g/IBW/day) intakes were calculated by dividing each intake by IBW.
Statistical analyses
Data are shown as a median [interquartile range] or frequencies of potential confounding variables. Since the subdomains of DDRQOL-R-9 showed unmorally distributed, the analysis was conducted by dividing the participants into two groups based on whether their scores were higher or lower than the median value for each subdomain of DDRQOL-R-9. The differences in continuous variables were assessed using Mann-Whitney U test. The differences in categorical variables were assessed using chi-square test. To investigate the association between diabetes diet-related QOL and fiber intake, logistic regression analysis was used, adjusting for potential cofounders; age, physical activity, smoking status, HbA1c and Cr levels, presence of hypertension, use of oral hypoglycemic drug, use of glucagon-like peptide 1 receptor agonist, use of insulin, and energy intake [23-38]. Statistical analyses were conducted using EZR (Saitama Medical Center, Jichi Medical University, Japan) [29] and JMP (version 13.2; SAS Institute Inc., United States). Statistical significance was defined as p < 0.05.
Results
Among the 335 participants, 97 participants—73 participants without T2D and 24 participants who did not complete the questionnaires—were excluded. Thus, as shown in Fig. 1, the final study population included 238 participants (148 men and 90 women).
Table 1 represents the study participants’ clinical characteristics. The median age and BMI were 69 [63–74] years and 23.5 [21.4–26.2] kg/m2, respectively. The median scores for perceived merits of diet therapy, satisfaction with diet, and burden of diet therapy were 58.3 [41.7–75.0], 75.0 [66.7–91.7], and 66.7 [50.0–75.0] points, respectively.
Table 1
Clinical characteristics of study participants
|
All N = 238 |
| Age (years) |
69 [63–74] |
| Sex (men/women) |
148/90 |
| Duration of diabetes (years) |
18 [12–24.8] |
| Family history of diabetes (–/+) |
152/86 |
| Height (cm) |
163.0 [156.0–169.0] |
| Body weight (kg) |
62.7 [55–70.5] |
| Body mass index (kg/m2) |
23.5 [21.4–26.2] |
| Obesity (–/+) |
157/81 |
| HbA1c (mmol/mol) |
57.4 [51.9–64.0] |
| HbA1c (%) |
7.4 [6.9–8.0] |
| Creatinine (μmol/L) |
73.4 [60.1–89.3] |
| eGFR (mL/min/1.73 m2) |
64.1 [53.7–75.7] |
| Renal failure (–/+) |
228/9 (no data 1) |
| Triglycerides (mmol/L) |
1.3 [0.8–1.8] |
| HDL cholesterol (mmol/L) |
1.4 [1.2–1.8] |
| Systolic blood pressure (mmHg) |
137.0 [126.0–148.8] |
| Diastolic blood pressure (mmHg) |
78.5 [71.0–85.0] |
| Antihypertensive drugs (–/+) |
103/135 |
| Hypertension (–/+) |
91/147 |
| Oral hypoglycemic drug (–/+) |
16/222 |
| GLP-1 receptor agonist (–/+) |
179/59 |
| Insulin (–/+) |
168/70 |
| Smoking (–/+) |
207/31 |
| Exercise (–/+) |
129/109 |
| Perceived merits of diet therapy |
58.3 [41.7–75.0] |
| Burden of diet therapy |
66.7 [50.0–75.0] |
| Satisfaction with diet |
75.0 [66.7–91.7] |
Data were expressed as median [interquartile range] or number. eGFR, estimated glomerular filtration rate; HDL, high-density lipoprotein.
Table 2 presented the data on dietary intake. The median energy and dietary fiber intakes were 28.1 [22.3–34.8] kcal/IBW/day and 10.7 [8.5–15.2] g/day, respectively.
Table 2
Habitual diet intake of study participants
|
All N = 238 |
| Total energy intake (kcal/day) |
1,637.6 [1,364.3–2,105.2] |
| Energy intake (kcal/IBW/day) |
28.1 [22.3–34.8] |
| Total protein intake (g/day) |
67.5 [55.3–87.0] |
| Protein intake (g/IBW/day) |
1.2 [0.9–1.5] |
| Protein intake per energy intake (%) |
16.3 [14.2–18.9] |
| Animal protein intake (g/day) |
41.3 [29.8–56.2] |
| Animal protein intake (g/IBW/day) |
0.7 [0.5–0.9] |
| Vegetable protein intake (g/day) |
26.4 [21.6–34.5] |
| Vegetable protein intake (g/IBW/day) |
0.5 [0.4–0.6] |
| Total fat intake (g/day) |
51.4 [41.0–68.0] |
| Fat intake (g/IBW/day) |
0.9 [0.7–1.2] |
| Fat intake per energy intake (%) |
28.9 [25.1–33.3] |
| Total carbohydrate intake (g/day) |
207.3 [157.6–259.6] |
| Carbohydrate intake (g/IBW/day) |
3.6 [2.8–4.7] |
| Carbohydrate intake per energy intake (%) |
54.7 [48.2–59.6] |
| Dietary fiber intake (g/day) |
10.7 [8.5–15.2] |
| Soluble fiber intake (g/day) |
2.8 [2.0–3.9] |
| Insoluble fiber intake (g/day) |
7.6 [6.1–10.7] |
| Carbohydrate-to-fiber ratio |
18.9 [14.3–24.2] |
| Salt intake (g/day) |
10.3 [8.1–12.6] |
| Alcohol consumption (g/day) |
0.0 [0.0–2.0] |
Data was expressed as median [interquartile range] or number. IBW, ideal body weight.
Table 3 shows the association between diabetes diet-related QOL, including perceived merits of diet therapy, burden of diet therapy, and satisfaction with diet, and clinical characteristics. HbA1c levels were lower in people with high perceived merits of diet therapy (high, 7.3 [6.7–7.8] vs. low, 7.5 [7.1–8.2] %, p = 0.007) and people with high satisfaction with diet (high, 7.3 [6.8–7.8] vs. low, 7.5 [7.1–8.4] %, p = 0.010) than in those without. Moreover, there was no difference in the duration of diabetes between people with high and low burden of diet therapy (high, 17.5 [11.8–26.0] vs. low, 18.0 [12.3–24.0] years, p = 0.907), satisfaction with diet (high, 18.0 [13.0–25.0] vs. low, 16.0 [11.0–24.0] years, p = 0.544), or perceived merits of diet therapy (high, 18 [12.0–25.0] vs. low, 17.0 [12.8–24.0] years, p = 0.762).
Table 3
Clinical characteristics according to perceived merits of diet therapy, burden of diet therapy or satisfaction with diet
|
Perceived merits of diet therapy |
Burden of diet therapy |
Satisfaction with diet |
Low
(N = 140) |
High
(N = 98) |
p |
Low
(N = 166) |
High
(N = 72) |
p |
Low
(N = 140) |
High
(N = 98) |
p |
| Age (years) |
68.5
[63.0–73.0] |
69.0
[64.3–75.0] |
0.299 |
69.0
[61.3–74.0] |
69.0
[65.8–74.3] |
0.382 |
68.0
[63.0–73.0] |
69.0
[65.0–75.0] |
0.211 |
| Sex (men/women) |
66/42 |
82/48 |
0.859 |
99/67 |
49/23 |
0.278 |
51/29 |
97/61 |
0.831 |
Duration of
diabetes (years) |
17.0
[12.8–24.0] |
18.0
[12.0–25.0] |
0.762 |
18.0
[12.3–24.0] |
17.5
[11.8–26.0] |
0.907 |
16.0
[11.0–24.0] |
18.0
[13.0–25.0] |
0.544 |
| Height (cm) |
163.0
[156.0–168.6] |
163.0
[156.0–169.0] |
0.790 |
163.0
[156.0–169.0] |
163.6
[156.8–168.0] |
0.880 |
163.0
[157.0–170.0] |
163.1
[155.6–168.1] |
0.314 |
| Body weight (kg) |
63.0
[55.0–72.0] |
62.0
[55.1–70.0] |
0.563 |
63.0
[55.0–71.5] |
62.4
[55.9–69.0] |
0.955 |
64.3
[55.5–72.2] |
62.0
[55.0–70.0] |
0.343 |
Body mass
index (kg/m2) |
23.5
[21.4–26.3] |
23.6
[21.4–25.9] |
0.928 |
23.5
[21.4–26.3] |
23.5
[21.5–25.9] |
0.646 |
23.6
[21.0–26.2] |
23.5
[21.4–26.0] |
0.930 |
| Obesity (–/+) |
70/38 |
87/43 |
0.838 |
108/58 |
49/23 |
0.765 |
53/27 |
104/54 |
1.000 |
HbA1c
(mmol/mol) |
58.5
[54.1–66.1] |
56.3
[49.7–61.8] |
0.007 |
57.4
[51.9–65.0] |
57.4
[51.4–61.8] |
0.458 |
58.5
[54.1–67.8] |
56.3
[51.1–61.5] |
0.010 |
| HbA1c (%) |
7.5
[7.1–8.2] |
7.3
[6.7–7.8] |
0.007 |
7.4
[6.9–8.1] |
7.4
[6.9–7.8] |
0.458 |
7.5
[7.1–8.4] |
7.3
[6.8–7.8] |
0.010 |
Creatinine
(μmol/L) |
71.2
[59.0–87.7] |
74.3
[61.0–90.2] |
0.327 |
70.7
[59.2–88.4] |
74.3
[63.9–94.8] |
0.094 |
74.3
[61.0–91.1] |
70.7
[60.1–88.4] |
0.290 |
eGFR
(mL/min/1.73 m2) |
64.5
[55.5–75.1] |
63.3
[52.1–75.7] |
0.692 |
64.3
[55.2–76.4] |
63.7
[49.9–72.9] |
0.198 |
63.4
[52.5–72.9] |
64.3
[54.8–76.5] |
0.329 |
| Renal failure (–/+) |
106/2 |
122/7 |
0.275 |
160/5 |
68/4 |
0.571 |
76/4 |
152/5 |
0.740 |
Triglycerides
(mmol/L) |
1.3
[0.9–1.9] |
1.2
[0.8–1.7] |
0.345 |
1.3
[0.9–1.9] |
1.2
[0.8–1.7] |
0.083 |
1.3
[0.9–1.8] |
1.2
[0.8–1.8] |
0.065 |
HDL cholesterol
(mmol/L) |
1.5
[1.3–1.8] |
1.4
[1.2–1.8] |
0.529 |
1.4
[1.2–1.8] |
1.5
[1.3–1.9] |
0.132 |
1.5
[1.2–1.8] |
1.4
[1.2–1.8] |
0.999 |
Systolic blood
pressure (mmHg) |
140.0
[129.0–150.3] |
134.0
[122.3–144.0] |
0.048 |
138.0
[126.0–151.0] |
135.0
[124.0–143.5] |
0.250 |
140.0
[127.0–148.3] |
136.5
[126.0–148.8] |
0.704 |
Diastolic blood
pressure (mmHg) |
79.5
[72.8–87.0] |
78.0
[69.3–83.8] |
0.061 |
79.0
[71.0–85.0] |
78.0
[71.5–83.0] |
0.620 |
78.5
[72.0–86.0] |
78.5
[70.3–85.0] |
0.515 |
Antihypertensive
drugs (–/+) |
45/63 |
58/72 |
0.745 |
74/92 |
29/43 |
0.636 |
28/52 |
75/83 |
0.090 |
| Hypertension (–/+) |
40/68 |
51/79 |
0.832 |
67/99 |
24/48 |
0.379 |
23/57 |
68/90 |
0.045 |
Oral hypoglycemic
drug (–/+) |
7/101 |
9/121 |
1.000 |
9/157 |
7/65 |
0.350 |
9/71 |
7/151 |
0.087 |
GLP-1 receptor
agonist (–/+) |
78/30 |
101/29 |
0.411 |
123/43 |
56/16 |
0.659 |
57/23 |
122/36 |
0.397 |
| Insulin (–/+) |
78/30 |
90/40 |
0.718 |
116/50 |
52/20 |
0.834 |
51/29 |
117/41 |
0.134 |
| Smoking (–/+) |
95/13 |
112/18 |
0.826 |
143/23 |
64/8 |
0.713 |
68/12 |
139/19 |
0.660 |
| Exercise (–/+) |
65/43 |
64/66 |
0.119 |
87/79 |
42/30 |
0.483 |
45/35 |
84/74 |
0.754 |
Perceived merits
of diet therapy |
41.7
[16.7–50.0] |
75.0
[66.7–91.7] |
<0.001 |
58.3
[50.0–83.3] |
45.8
[31.3–66.7] |
<0.001 |
50.0
[33.3–66.7] |
58.3
[41.7–83.3] |
0.006 |
| Burden of diet therapy |
66.7
[50.0–75.0] |
66.7
[43.8–66.7] |
0.002 |
58.3
[41.7–66.7] |
75.0
[75.0–83.3] |
<0.001 |
75.0
[56.3–83.3] |
66.7
[41.7–66.7] |
<0.001 |
Satisfaction
with diet |
75.0
[58.3–91.7] |
75.0
[66.7–91.7] |
0.018 |
83.3
[75.0–100.0] |
66.7
[50.0–75.0] |
<0.001 |
66.7
[58.3–66.7] |
83.3
[75.0–100.0] |
<0.001 |
Median [interquartile range] was used for expression of data. The difference between groups was evaluated by Mann-Whitney U test or chi-square test.
Table 4 shows the relationship between diabetes diet-related QOL, including perceived merits of diet therapy, satisfaction with diet, and burden of diet therapy, and habitual diet intake. Protein intake was higher in people with high perceived merits of diet therapy (1.2 [1.0–1.6] vs. 1.1 [0.8–1.4] g/IBW/day, p = 0.023), high satisfaction with diet (1.2 [1.0–1.6] vs. 1.1 [0.8–1.4] g/IBW/day, p = 0.017), and low burden of diet therapy (1.2 [1.0–1.6] vs. 1.0 [0.8–1.3] g/IBW/day, p < 0.001) than in those without. Moreover, dietary fiber intake was higher in people with high perceived merits of diet therapy (11.6 [8.8–16.7] vs. 10.0 [7.9–13.8] g/day, p = 0.010), high satisfaction with diet (11.4 [8.8–16.1] vs. 9.7 [7.8–13.2] g/day, p = 0.007), and low burden of diet therapy (11.8 [8.7–16.5] vs. 9.7 [7.8–12.6] g/day, p = 0.004) than in those without.
Table 4
Habitual diet intake according to perceived merits of diet therapy, burden of diet therapy or satisfaction with diet
|
Perceived merits of diet therapy |
Burden of diet therapy |
Satisfaction with diet |
Low
(N = 140) |
High
(N = 98) |
p |
Low
(N = 166) |
High
(N = 72) |
p |
Low
(N = 140) |
High
(N = 98) |
p |
| Total energy intake (kcal/day) |
1,589.2
[1,306.5–2,058.7] |
1,677.2
[1,395.0–2,150.7] |
0.097 |
1,681.8
[1,395.7–2,150.7] |
1,572.3
[1,116.1–1,878.8] |
0.008 |
1,549.8
[1,227.4–1,943.0] |
1,681.8
[1,395.7–2,119.3] |
0.016 |
| Energy intake (kcal/IBW/day) |
27.4
[21.2–33.7] |
29.2
[23.2–36.2] |
0.090 |
29.2
[23.5–36.1] |
26.6
[20.5–32.5] |
0.004 |
26.0
[21.0–32.7] |
29.3
[23.2–35.9] |
0.006 |
| Total protein intake (g/day) |
64.9
[48.5–85.9] |
69.4
[57.4–89.4] |
0.055 |
71.8
[57.2–90.6] |
60.1
[46.7–76.0] |
<0.001 |
61.8
[48.9–85.8] |
70.7
[56.9–89.5] |
0.024 |
| Protein intake (g/IBW/day) |
1.1
[0.8–1.4] |
1.2
[1.0–1.6] |
0.023 |
1.2
[1.0–1.6] |
1.0
[0.8–1.3] |
<0.001 |
1.1
[0.8–1.4] |
1.2
[1.0–1.6] |
0.017 |
| Protein intake per energy intake (%) |
15.8
[14.1–18.4] |
16.8
[14.8–19.5] |
0.078 |
16.9
[14.3–19.7] |
15.9
[14.2–17.6] |
0.071 |
16.2
[14.2–18.4] |
16.4
[14.3–19.5] |
0.665 |
| Animal protein intake (g/day) |
38.9
[26.0–53.8] |
43.4
[32.2–57.4] |
0.075 |
44.7
[32.1–57.6] |
35.1
[25.2–45.8] |
<0.001 |
37.9
[28.5–49.1] |
43.3
[30.0–56.5] |
0.042 |
Animal protein intake
(g/IBW/day) |
0.7
[0.4–0.9] |
0.7
[0.6–1.0] |
0.042 |
0.8
[0.5–1.0] |
0.6
[0.4–0.8] |
<0.001 |
0.7
[0.5–0.9] |
0.8
[0.5–1.0] |
0.036 |
| Vegetable protein intake (g/day) |
24.8
[20.8–32.9] |
27.3
[22.7–34.9] |
0.050 |
26.9
[22.3–35.5] |
24.8
[20.2–29.9] |
0.035 |
25.0
[21.1–30.8] |
27.1
[22.1–35.5] |
0.049 |
Vegetable protein intake
(g/IBW/day) |
0.4
[0.4–0.6] |
0.5
[0.4–0.6] |
0.033 |
0.5
[0.4–0.6] |
0.4
[0.4–0.5] |
0.033 |
0.4
[0.4–0.5] |
0.5
[0.4–0.6] |
0.022 |
| Total fat intake (g/day) |
48.6
[37.1–64.6] |
55.5
[42.9–69.0] |
0.045 |
56.2
[43.1–68.7] |
47.1
[37.1–58.7] |
0.002 |
48.0
[36.9–60.3] |
56.2
[43.1–68.7] |
0.008 |
| Fat intake (g/IBW/day) |
0.8
[0.6–1.1] |
1.0
[0.7–1.2] |
0.035 |
0.9
[0.7–1.3] |
0.8
[0.6–1.0] |
0.001 |
0.8
[0.6–1.1] |
0.9
[0.7–1.2] |
0.005 |
| Fat intake per energy intake (%) |
28.3
[24.4–32.4] |
29.2
[25.6–33.9] |
0.193 |
29.3
[25.2–34.0] |
27.7
[25.1–30.7] |
0.064 |
28.3
[24.9–31.6] |
29.0
[25.8–33.6] |
0.286 |
| Total carbohydrate intake (g/day) |
199.6
[153.0–246.0] |
212.0
[160.7–267.2] |
0.304 |
208.3
[163.5–264.0] |
201.9
[147.6–234.6] |
0.093 |
199.6
[152.6–237.8] |
213.3
[160.8–270.0] |
0.158 |
Carbohydrate intake
(g/IBW/day) |
3.4
[2.6–4.2] |
3.6
[3.0–4.6] |
0.290 |
3.6
[2.9–4.6] |
3.4
[2.6–4.0] |
0.078 |
3.3
[2.7–3.9] |
3.7
[2.8–4.6] |
0.079 |
| Carbohydrate intake per energy intake (%) |
55.1
[49.4–60.9] |
54.3
[46.1–59.0] |
0.085 |
53.5
[45.9–59.4] |
55.7
[50.8–60.2] |
0.050 |
55.3
[49.4–60.0] |
54.2
[47.0–59.5] |
0.353 |
| Dietary fiber intake (g/day) |
10.0
[7.9–13.8] |
11.6
[8.8–16.7] |
0.010 |
11.8
[8.7–16.5] |
9.7
[7.8–12.6] |
0.004 |
9.7
[7.8–13.2] |
11.4
[8.8–16.1] |
0.007 |
| Soluble fiber intake (g/day) |
2.6
[1.9–3.5] |
3.0
[2.1–4.2] |
0.018 |
3.0
[2.1–4.2] |
2.5
[1.8–3.1] |
0.002 |
2.5
[1.9–3.4] |
3.0
[2.2–4.1] |
0.007 |
| Insoluble fiber intake (g/day) |
7.1
[5.8–9.9] |
8.3
[6.4–11.9] |
0.009 |
8.3
[6.3–11.7] |
7.0
[5.8–9.0] |
0.003 |
7.0
[5.7–9.4] |
8.0
[6.3–11.7] |
0.013 |
| Carbohydrate-to-fiber ratio |
20.1
[16.0–24.8] |
17.5
[13.2–23.0] |
0.007 |
18.0
[13.2–24.1] |
20.2
[16.1–24.5] |
0.058 |
19.5
[15.8–24.3] |
18.7
[13.2–24.2] |
0.188 |
| Salt intake (g/day) |
10.0
[8.1–11.9] |
10.5
[8.2–12.8] |
0.314 |
10.6
[8.5–12.8] |
9.4
[7.2–11.8] |
0.011 |
9.8
[7.4–12.1] |
10.5
[8.4–12.8] |
0.048 |
Alcohol consumption
(g/day) |
0.0
[0.0–2.8] |
0.0
[0.0–0.9] |
0.132 |
0.0
[0.0–1.7] |
0.0
[0.0–2.7] |
0.673 |
0.0
[0.0–2.8] |
0.0
[0.0–0.9] |
0.132 |
IBW, ideal body weight. Median [interquartile range] was used for expression of data. Mann-Whitney U test was used for evaluation of the difference between groups.
In the older group (age ≥65 years old), dietary fiber intake was significantly different across the diet-related QOL groups. Compared with that in their counterparts, dietary fiber intake was higher in those with high burden of diet therapy (12.7 [9.7–18.6] vs. 9.9 [7.9–13.8] g/day, p < 0.001), those with low satisfaction with diet (12.1 [9.0–16.5] vs. 10.3 [8.0–13.3] g/day, p = 0.011), and those with high perceived merit of diet therapy (12.6 [9.1–17.1] vs. 10.2 [8.4–13.9] g/day, p = 0.006). In the younger group (age <65 years old), there was no difference between participants with high (10.2 [7.6–15.2] g/day) and low (9.9 [7.7–13.0] g/day) burden of diet therapy (p = 0.758). On the other hand, participants with low satisfaction with diet (10.7 [8.0–16.7] g/day) tended to have a higher fiber intake than those without (9.6 [6.2–11.1] g/day) (p = 0.054), and participants with high perceived merits of diet therapy (11.6 [9.1–18.2] g/day) had a higher fiber intake than those without (9.6 [7.0–12.5] g/day) (p = 0.023).
The odds ratios (ORs) for diabetes diet-related QOL, including “burden of diet therapy,” “satisfaction with diet,” and “perceived merits of diet therapy” across dietary fiber intake are shown in Table 5. Dietary fiber intake was related to perceived merits of diet therapy (OR 1.07 [95% CI: 1.00–1.15], p = 0.049), burden of diet therapy (OR 0.90 [95% CI: 0.82–0.98], p = 0.022), and satisfaction with diet (OR 1.18 [95% CI: 1.09–1.27], p < 0.001), after adjusting for covariates.
Table 5
Odds ratio of dietary fiber intake on perceived merits of diet therapy, burden of diet therapy, and satisfaction with diet
|
Perceived merits of diet therapy |
Burden of diet therapy |
Satisfaction with diet |
| Odds ratio (95% CI) |
p |
Odds ratio (95% CI) |
p |
Odds ratio (95% CI) |
p |
| Dietary fiber intake (g/day) |
1.07 (1.00–1.15) |
0.049 |
0.90 (0.82–0.98) |
0.022 |
1.18 (1.09–1.27) |
<0.001 |
| Energy intake (kcal/IBW/day) |
1.04 (1.00–1.08) |
0.036 |
0.98 (0.94–1.03) |
0.440 |
0.96 (0.92–0.99) |
0.016 |
| Age (years) |
1.02 (0.99–1.05) |
0.318 |
1.02 (0.99–1.06) |
0.180 |
1.01 (0.98–1.05) |
0.378 |
| Women |
1.11 (0.58–2.13) |
0.753 |
0.65 (0.33–1.29) |
0.221 |
1.11 (0.59–2.10) |
0.751 |
| Obesity (+)* |
0.71 (0.38–1.35) |
0.302 |
1.26 (0.66–2.40) |
0.966 |
1.14 (0.61–2.15) |
0.681 |
| HbA1c (%) |
1.04 (0.77–1.40) |
0.793 |
0.88 (0.63–1.22) |
0.435 |
0.82 (0.60–1.12) |
0.222 |
| Log (creatinine +1) (Δ1 incremental) |
0.96 (0.33–2.78) |
0.947 |
1.64 (0.60–4.47) |
0.331 |
1.70 (0.63–4.59) |
0.296 |
| Presence of hypertension (+)† |
0.64 (0.35–1.17) |
0.150 |
1.26 (0.66–2.40) |
0.480 |
0.63 (0.35–1.15) |
0.133 |
| Oral hypoglycemic drug (+)‡ |
1.38 (0.42–4.62) |
0.602 |
0.59 (0.19–1.84) |
0.366 |
0.79 (0.26–2.38) |
0.671 |
| GLP-1 receptor agonist (+)§ |
1.15 (0.54–2.45) |
0.714 |
0.80 (0.36–1.75) |
0.568 |
0.74 (0.35–1.60) |
0.449 |
| Insulin (+)|| |
0.65 (0.33–1.29) |
0.219 |
0.73 (0.36–1.50) |
0.388 |
1.57 (0.79–3.10) |
0.197 |
| Smoking (+)¶ |
0.72 (0.30–1.75) |
0.466 |
0.63 (0.25–1.58) |
0.325 |
1.07 (0.45–2.54) |
0.877 |
| Exercise (+)** |
0.89 (0.49–1.61) |
0.702 |
0.83 (0.45–1.55) |
0.566 |
1.24 (0.70–2.23) |
0.462 |
IBW, ideal body weight.
* Obesity was defined as body mass index ≥25 kg/m2 (=1) or not (=0).
† Presence of hypertension was defined as the absence of hypertension (=0) or the presence of hypertension (=1).
‡ Oral hypoglycemia drug was defined as not use of oral hypoglycemia drug (=0) or use of oral hypoglycemia drug (=1).
§ GLP-1 receptor agonist was defined as not use of GLP-1 receptor agonist (=0) or use of GLP-1 receptor agonist (=1).
|| Insulin treatment, insulin secretagogues, insulin sensitizers, and nutrient load reducers were defined as without (=0) or with (=1).
¶ Smoking status was defined as non-smoker (=0) or smoker (=1).
** Exercise status was defined as non-regular exerciser (=0) or regular exerciser (=1).
Discussion
This is the first study to examine the association between diabetes diet-related QOL and dietary fiber intake among people with T2D. The study results revealed that dietary fiber intake was positively associated with perceived merits of diet therapy and satisfaction with diet but negatively associated with burden of diet therapy.
Dietary fiber intake slows the movement of food through the digestive tract and slows digestion and absorption of carbohydrates, thereby reducing the rise in blood glucose levels [10, 30]. Moreover, dietary fiber intake enhances satiety and reduces food intake at future meals [31]. In general, high dietary fiber intake takes a long time to chew, which may increase sensory satiety and reduce meal size [32, 33]. High dietary fiber intake has been related to good glycemic control [10, 11], and it was related to high perceived merits of diet therapy in the present study. Further, dietary fiber intake has been related to lower body fat mass and higher skeletal muscle mass in people with T2D [34]. High dietary fiber intake may increase perceived merits of diet therapy because it contributes to body composition. Moreover, high dietary fiber intake may increase satisfaction with diet because it, especially viscous dietary fiber intake, induces satiation [12].
In this study, dietary fiber intake was negatively associated with the burden of diet therapy. Benefits of high dietary fiber intake include reducing blood pressure, serum cholesterol levels, risk of coronary heart disease, and weight control, and improving glycemic control and gastrointestinal function [35]. Dietary fiber intake has many benefits; however, high dietary fiber intake was associated with burden of diet therapy in this study. Dietary fiber intake was positively associated with perceived merits of diet therapy and negatively associated with burden of diet therapy, and perceived merits of diet therapy and burden of diet therapy were negatively correlated. A previous study showed that diet therapy was the most burdened therapy compared with medication and other therapies in people with chronic kidney disease [36]. Therefore, we considered this to be the same case in people with T2D. This may be the reason why high dietary fiber intake increases the burden of diet therapy, although it contributes to high perceived merits of diet therapy. Discovering ways to reduce the burden of diet therapy while maintaining or increasing dietary fiber intake is necessary to improve the diabetes diet-related QOL in people with T2D. In this study, protein intake was also associated with diabetes diet-related QOL, similar to the association found for dietary fiber intake. Although the clear reason for this association is unknown, the risk of sarcopenia in people with T2D is reportedly higher than that in the general population, and this relationship has received a lot of attention recently [37]. Thus, protein intake is recommended to prevent sarcopenia. Therefore, people who consume adequate protein might have increased the burden of diet therapy, feeling the need to consume adequate protein for preventing sarcopenia. On the other hand, it has been reported that consuming a protein-rich diet gives a feeling of fullness [38]. Therefore, people who consume protein might have high perceived merits of diet therapy and satisfaction with diet.
It is possible that people who had not obtained positive changes in weight or glycemic control in spite of diet therapy were likely to have a higher burden of diet therapy; however, causal relationships could not be found owing to the cross-sectional nature of our study. Moreover, our study did not find a significant correlation between dietary fiber intake and HbA1c levels. Further, dugs, physical activity, lifestyle as well as diet might significantly affect glycemic control; however, these factors were not considered in our study.
In this study, we showed the association between dietary fiber intake and diabetes diet-related QOL in people with T2D. On the other hand, no previous studies investigated the association between dietary fiber intake and diet-related QOL in people without diabetes. The association between that high dietary fiber intake positively correlates with satiation has been confirmed in people without diabetes [12]; thus, there is a possibility that dietary fiber intake may be positively correlated with diet-related QOL in people without diabetes.
This study has some limitations. First, a cross-sectional design was used, and causal associations could not be revealed. Second, this study included only Japanese individuals, affecting the generalizability of the findings to other ethnic groups. Third, we did not assess the association between dietary fiber intake and socioeconomic status, although the association between socioeconomic status and dietary fiber intake in people with T2D has been reported [39]. Fourth, the findings of this study may not be applicable to other patients with diabetes. In fact, the proportion of participants with household incomes of more than 5 million yen was lower than the proportion of participants with household incomes of less than 5 million yen [39], suggesting that this group may have had a lower household income than the general population earning 4,430,000 yen [40]. Fifth, we could not evaluate the intake of resistant starch, which is the one of the components of dietary fiber. Sixth, there were differences in background characteristics between the included and excluded groups in this study (Supplemental Table 1 and Table 2).
In conclusion, dietary fiber intake is related to diabetes diet-related QOL, including perceived merits of diet therapy, burden of diet therapy, and satisfaction with diet in people with T2D. In the future, we need to find ways to reduce burden of diet therapy while maintaining perceived merits of diet therapy and satisfaction with diet by high dietary fiber intake.
Acknowledgments
We would like to thank Editage (www.editage.com) for English language editing.
Availability of Data and Materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Disclosure
Nakanishi N received a research grant from Tanuma Green House Foundation. Okada H received personal fees from Mochida Pharma Co. Ltd., Teijin Pharma Ltd., MSD K.K., Mitsubishi Tanabe Pharma Corporation, AstraZeneca K.K., Sumitomo Dainippon Pharma Co., Ltd., Novo Nordisk Pharma Ltd., Daiichi Sankyo Co., Ltd, Eli Lilly Japan K.K, Kyowa Hakko Kirin Company Ltd, Kissei Pharmaceutical Co., Ltd, Takeda Pharmaceutical Co., Ltd, Kowa Pharmaceutical Co., Ltd, Ono Pharmaceutical Co., Ltd., and Sanofi K.K. Hamaguchi M received a research grant from AstraZeneca K.K., Ono Pharma Co. Ltd., Kowa Pharma Co. Ltd. The other authors declare no conflict of interest.
Author Contributions
FT: design of the work, analysis and interpretation of data and written the manuscript. YH: conception and design the work, acquisition, analysis and interpretation of data and revising the manuscript. AK and RS: conception and design the work, acquisition data and contributed Discussion. YK (Yuka Kawate), YK (Yuriko Kondo), TO (Takuro Okamura), NN, SM, TO (Takafumi Osaka), HO, TS and EU: acquisition data and contributed Discussion. MH: design of the work, acquisition data and contributed Discussion. MA and MY: acquisition data and contributed Discussion. MF: conception and design the work, acquisition and interpretation of data and revising the manuscript. All authors have read and agreed to the published version of the manuscript.
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