Higher intake of energy, total fat, and protein at dinner than at breakfast is associated with greater risk for diabetes-related, cardiovascular disease (CVD)-related, and all-cause mortality in people with diabetes, according to the results of a study published in Diabetes Care.

Studies have shown that high energy intake at dinner may be associated with metabolic disorder through disrupted circadian gene expression, but the extent to which energy and macronutrient distribution throughout the day affects the natural course of diabetes has not yet been determined.

To assess the association of differences in energy and macronutrient intake during dinner vs breakfast with the risk for disease-specific and overall mortality among individuals with diabetes, data were analyzed from 4699 participants aged ≥18 years with diabetes (48.6% women) in the National Health and Nutrition Examination Survey (NHANES) in the period 2003 to 2014.

Food intake was measured by a 24-hour dietary recall on 2 nonconsecutive days. The first recall was conducted in person and the second was conducted over the phone 3 to 10 days after the first. Values for differences in energy intake between meals were stratified into quintiles, with quintile 1 having the greatest intake at breakfast compared with dinner and quintile 5 having the greatest intake at dinner compared with breakfast.


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Individuals with energy intake levels in quintile 5 were more likely to be younger, men, and non-Hispanic white, with higher income, body mass index (BMI), total energy intake, and diet quality. Individuals in quintile 5 also had a significantly higher risk for diabetes-related (hazard ratio [HR], 1.92; 99% CI, 1.08-3.42) and CVD mortality (HR, 1.69; 99% CI, 1.02-2.80) than those in quintile 1.

The researchers also examined differences in specific macronutrient intake levels. Individuals in quintile 5 for total fat intake had a significantly higher risk for CVD mortality (HR, 1.67; 99% CI, 1.01-2.76) than those in quintile 1. Individuals in quintile 5 for protein intake also had a significantly higher risk for CVD mortality (HR, 1.96; 99% CI, 1.14-3.39), as well as diabetes-related mortality (HR, 1.92; 99% CI, 1.06-3.49) and all-cause mortality (HR, 1.46; 99% CI, 1.05-2.01) compared with those in quintile 1. Individuals in quintile 5 for animal protein intake had a significantly higher risk for diabetes-related mortality (HR, 1.94; 99% CI, 1.07-3.51) and all-cause mortality (HR, 1.49; 99% CI, 1.10-2.03) than those in quintile 1. Individuals in quintile 5 for unsaturated fatty acid intake had a significantly higher risk for CVD mortality (HR, 1.85; 99% CI, 1.07-3.20) than those in quintile 1. No significant association was found between carbohydrate distribution and mortality risk.

Several predictive models determined that risk for disease-specific and all-cause mortality could be reduced through lifestyle changes, such as the following:

· Switching 5% of total energy intake from dinner to breakfast was predicted to reduce the HR for diabetes-related and CVD mortality by 4% and 5%, respectively.

· Replacing 5% of total energy from fat at dinner with 5% of total energy from protein was predicted to reduce the HR for diabetes-related and CVD mortality by 9% and 12%, respectively.

· Replacing 5% of total energy from protein at dinner to breakfast was predicted to reduce both the HRs for diabetes-related and CVD mortality by 11%.

Overall, this study showed that excessive energy consumption at dinner compared with breakfast was associated with an elevated risk for diabetes-related, CVD, and all-cause mortality among individuals with diabetes, primarily because of higher energy intake from fat and protein at dinner. The results of this study indicated the importance of energy distribution across meals, especially for individuals with diabetes.

Limitations to this study included using only 2 days of 24-hour food intake recall, which may not have accounted for all intake fluctuations. This study also did not distinguish between different types of diabetes. Future studies are warranted to examine the associations found in this study in terms of type 1 and type 2 diabetes, as well as the long-term implications of macronutrient distribution on mortality outcomes.

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Reference

Han T, Gao J, Wang L, et al. The association of energy and macronutrient intake at dinner versus breakfast with disease-specific and all-cause mortality among people with diabetes: the U.S. National Health and Nutrition Examination Survey, 2003-2014 [published online April 30, 2020]. Diabetes Care. doi:10.2337/dc29-2289

This article originally appeared on Endocrinology Advisor