Rev. Med. Chir. Soc. Med. Nat., Iaşi – 2016 – vol. 120, no.

INTERNAL MEDICINE - PEDIATRICS ORIGINAL PAPERS

DIETARY VITAMIN D, CALCIUM, AND MAGNESIUM INTAKE

IN TYPE 2 DIABETES PATIENTS

Andreea Gherasim, Lidia Iuliana Arhire *, Otilia Niţă, Alina Delia Popa,
Alexandra Maria Burlui, Mariana Graur, Laura Mihalache
University of Medicine and Pharmacy “Grigore T. Popa”-Iasi
Faculty of Medicine
Department of Medical Specialties (II)
*Corresponding author. E-mail: [email protected]

DIETARY VITAMIN D, CALCIUM, AND MAGNESIUM INTAKE IN TYPE 2 DIABE-

TES PATIENTS (Abstract): Aim: To estimate specific nutrient intake in patients with type 2
diabetes. Material and Methods: The study was conducted on a group of subjects with type
2 diabetes. The collected data included: anthropometry, lifestyle, blood measurements, and
the mean daily nutrient intake assessed by the EPIC food frequency questionnaire. Results:
The study group included 101 subjects with type 2 diabetes mellitus (DM) with a mean age
of 60.610 years, of which 45 men (5910.6 years) and 56 women (629.6 years). The aver-
age energy intake was 1714.4713.9 Kcal/day, with a statistically significant gender differ-
ence (1877.7850.9 kcal/day for men, 1583.1554.9 kcal/day for women, p = 0.039), and the
average daily micronutrient intake was 2.441.44 g/day for vitamin D, 724.5263.2 mg/day
for calcium (Ca), 266.798 mg/day for magnesium (Mg), which was low compared to die-
tary recommendations. Calcium intake was correlated with intake of carbohydrates, saturated
fatty acids (SFA), monounsaturated fatty acids (MUFA), fiber and energy. Vitamin D intake
was correlated only with protein intake (R=0.695), while magnesium intake correlated with
intake of fibers, energy, carbohydrates and SFA. Conclusions: Our study in patients with
type 2 diabetes showed a reduced average intake of calcium, magnesium and vitamin D
compared to standard recommendations, requiring an individualized approach. Keywords:
NUTRIENTS, FOOD FREQUENCY QUESTIONNAIRE, TYPE 2 DIABETES MELLITUS.

The assessment of nutritional intake assessment method in epidemiological

through food survey consists in collecting studies. FFQ are used to characterize die-
information on the amount and type of tary exposures and to explore the relation-
foods ingested and on calculating nutrient ship between diet, risk of illness and/or
intake based on their composition. Even disease progression. Diabetes is an ex-
tough dietary research methods (dietary tremely important medical condition, given
patterns research) are imperfect and the its prevalence, negative impact on life ex-
methodological aspects of analysis have pectancy and quality and the extremely
some limitations, they are widely used for high costs involved (3). Medical nutrition
nutritional recommendations and food poli- therapy has an important role in the preven-
cies (1,2). Food frequency questionnaires tion and management of type 2 diabetes.
(FFQ) are the most commonly used dietary The aim of this study was to assess the

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 Dietary vitamin D, calcium, and magnesium intake in type 2 diabetes patients

specific nutrient intake in a group of pa- significance of p<0.05.

tients with type 2 DM and to compare these
with the standard dietary recommendations. RESULTS
Of the analyzed parameters, compared
MATERIAL AND METHODS by gender, a statistically significant differ-
The study group included 101 adult sub- ence was found for weight, height and
jects with type 2 DM who did not take BMI. Regarding the presence of specific
inulin and were scheduled for the regular chronic complications of diabetes, 5.1% of
medical checkup at the diabetes ambulatory the study subjects had retinopathy, 22.2% -
unit; patients’ mean age was 60.610 years, neuropathy, 1% - peripheral arterial disease
45 were men (mean age 5910.6 years) and (PAD), and 76% hypertension, with gender
56 women (mean age 629.6 years). Partic- differences, but lacking statistical signifi-
ipants were interviewed face-to-face about cance (tab. I).
lifestyle, area of residence, education, oc- The average energy intake was
cupation, physical activity, medical history. 1714.4713.9 Kcal/day, with a statistically
To assess dietary intake, we used the EPIC significant difference between genders
FFQ which was validated earlier on a Ro- (1877.7850.9 kcal/day for men,
manian population (4). The questionnaire 1583.1554.9 kcal/day for women,
consists of 130-items (foods and drinks) p=0.039). Otherwise, there were no statisti-
divided into 10 major food groups, and cally significant differences between men
subjects were asked to specify the frequen- and women in macro- and micronutrients
cy of their consumption during the last intake (tab. II). The percentage of caloric
year. Portion sizes were evaluated by dis- macronutrients was balanced according to
cussion and demonstration drawings. Data guidelines, as follows: carbohydrates
collected via questionnaire were analyzed 49.02% (48.8% for men, 49.2% for wom-
by FETA-FFQ EPIC Tool for Analysis (5), en), proteins 19.2% (19.1% for men and
which converted data on food consumption 19.3% for women) and lipids 31.88%
into nutrient intake. In addition, infor- (32.1% for men, 31.5% for women). Total
mation regarding diabetes duration and energy intake correlated with the intake of
chronic complications were obtained. carbohydrates, proteins and lipids. These
Weight, height, and waist circumference percentages are consistent with dietary
(WC) were measured and body mass index recommendations (6).
(BMI) was calculated. Also measured were Only 13.9% of subjects ingested the
systolic (SBP) and diastolic blood pressure recommended daily dose of calcium (1200
(DBP). Blood was collected for biological mg/day): 13.3% of men and 14.3% of
parameter measurement (blood glucose, women (p>0.05). As to magnesium, 25.7%
glycated hemoglobin - HbA1c). Statistical of subjects ingested the recommended daily
analysis was performed using SPSS v17. dose (22.2% of men and 28.6% of women,
The significance of differences between the p>0.05) and 5% (4.4% of men and 5.4% of
mean values of the studied variables was women, p> 0.05) ingested the recommend-
checked using the Mann-Whitney test, ed daily dose of vitamin D. No statistically
ANOVA and chi-square test for independ- significant correlation was found between
ent samples, considering statistically sig- the intake of vitamin D, calcium, and mag-
nificant those differences with a level of nesium and age, BMI, duration of diabetes

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 Andreea Gherasim et al.

and HbA1c. However, there was a statisti- tween vitamin D intake and fasting blood
cally significant inverse correlation be- glucose (R = -0.272, p = 0.017).

TABLE I
General characteristics of the study group
MeanSD; 95% CI
Parameters
Total (n=101) Men (n=45) Women (n=56) Sig. *
Age (years) 60.610.1;58.6-62.6 5910.6;55.8-62.2 629.6;59.4-64.5 >0.05
Weight (kg) 8816.5;84.8-91.3 91.616.3;86.7-96.5 85.116.2;80.8-89.5 0.048
Height (cm) 166.39;164.6-168.1 173.26;171.4-175 160.86.9;159-162.6 <0.001
BMI (kg/m 2) 31.85.4;30.7-32.8 30.55.1;28.9-32 32.85.4;31.4-34.3 0.026
WC (cm) 105.312.1;102.9-107.7 105.111.2;101.7-108.5 105.512.9;101.9-109 >0.05
Duration of DM 5.55.1;4.4-6.6 5.86;3.9-7.8 5.34.5;4-6.5 >0.05
Glycaemia (mg/dl) 143.335.2;135.4-151.3 141.734.1;130.2-153.3 144.836.5;133.2-156.3 >0.05
HbA1c (%) 6.91.2;6.7-7.2 71.3;6.6-7.4 6.91.1;6.6-7.2 >0.05
N, %
Retinopathy 5.1 6.8 3.6 >0.05
Neuropathy 22.2 13.6 29.1 >0.05
Nephropathy 0 0 0
PAD 1 0 1.8 >0.05
Stroke 4 6.7 1.8 >0.05
Myocardial infarction 1 2.2 0 >0.05
Angina 8 8.9 7.3 >0.05
Hypertension 76 68.9 81.8 >0.05
*between Men and Women

TABLE II
Daily intake of energy and nutrients
MeanSD; 95% CI
Parameters Total (N=101) Men (N=45) Women (N=56) Sig.
Energy (Kcal/day) 1714.4713.9; 1877.7850.9; 1583.1554.9; 0.039
1573.4-1855.3 1622.1-2133.4 1434.5-1731.7
Carbohydrates (g/day) 210.293.6; 229.4113.9; 194.870.8; >0.05
191.7-228.7 195.2-263.6 175.8-213.7
Fibers (g/day) 18.89.2;17-20.6 19.311.2;15.9-22.6 18.57.3;16.5-20.4 >0.05
Proteins (g/day) 82.439;74.7-90.1 9049.4;75.1-104.8 76.327;69.1-83.5 >0.05
Lipids (g/day) 61.629.7;55.7-67.4 65.136.5;54.1-76.1 58.822.8;52.7-64.9 >0.05
MUFA (g/day) * 2211.7;19.7-24.3 23.314.2;19.1-27.6 20.99.1;18.5-23.4 >0.05
PUFA (g/day)* 12.66.6;11.3-13.9 13.18;10.7-15.5 12.15.2;10.7-13.5 >0.05
SFA (g/day)* 219.7;19.1-23 22.111.6;18.6-25.6 20.28;18-22.3 >0.05
Calcium (mg/day) 724.5263.2; 736.9278.9; 714.6251.9; >0.05
672.6-776.5 653.1-820.7 647.1-782
Vitamin D (g/day) 2.441.44;2.16-2.73 2.731.57;2.26-3.2 2.211.29;1.87-2.56 >0.05
Magnesium (mg/day) 266.798.1; 268.498.1; 265.398.9; >0.05
247.3-286 238.9-297.9 238.8-291.8
* MUFA=monounsaturated fatty acids, PUFA= polyunsaturated fatty acids, SFA=saturated fatty acids

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 Dietary vitamin D, calcium, and magnesium intake in type 2 diabetes patients

The intake of vitamin D, calcium, and prospective randomized controlled trials

magnesium was positively statistically sig- showed that nutrients, other than carbohy-
nificantly correlated with all macronutrients drates, affected glycemic control and ex-
analyzed (energy, carbohydrates, fibers, plained the mechanisms by which these
proteins, and lipids). Thus, we conducted a nutrients influenced insulin secretion and
multivariate linear regression to find out action. Magnesium supplements decrease
which of the macronutrients and energy the risk of complications in people with
significantly influence the intake of micro- diabetes, improving insulin secretion and
nutrients. Regarding calcium intake, it de- insulin signaling (11). The results of a large
pended on carbohydrate, saturated fat, mon- prospective study suggested the beneficial
ounsaturated fat, fiber and energy intake, in role of both vitamin D and calcium intake
that order, explaining 83.5% of the total in reducing the risk of type 2 diabetes (12).
calcium intake. Vitamin D intake remained Food supplementation is preferred both in
significantly influenced only by protein preventing and treating diabetes (13).
intake (R = 0.695). Magnesium intake was When analyzing the questionnaire-
influenced by the intake of fiber, energy, derived data we found that most of our sub-
carbohydrates and saturated fat in a propor- jects, both male and female, had a lower
tion of 90%. Subsequently, ROC curve average daily intake of micronutrients (vit-
analysis highlighted that for the diabetics in amin D, calcium, and magnesium) compared
our study an intake of 259.03 g carbohy- to standard recommendations (1200 mg Ca,
drates would suffice to provide the recom- 5 g vitamin D and 320 mg Mg for women
mended daily dose of calcium. This would and 420 mg men), but without statistically
mean that this population should increase significant gender differences. These nutri-
carbohydrate intake to 60% of daily energy tional deficiencies are however consistent
intake, or increase caloric intake, in order to with the statistical data on the Romanian
reach the recommended calcium intake. population, namely a low intake of fruits
and vegetables, fish and dairy products (14).
DISCUSSION It is also suggested that low vitamin D levels
A norm caloric balanced diet usually are an independent risk factor in diseases
provides all the nutrients, and supplements prognosis (15). Interaction between vitamin
are required only in at risk sub-populations D and calcium is known and treatment of
or when deficiencies are demonstrated (6). these deficiencies is done together. The
Some authors (7) have shown that a high- consumption of foods rich in calcium is safe
carb low-fat diet has been associated with a in terms of cardiovascular risk, use of calci-
higher risk of developing type 2 diabetes. um supplements should be reserved for
Foods with a high glycemic index together patients who truly need supplementation
with an increased proportion of lipids, were (16). Magnesium depletion is a common
also found to increase the risk of diabetes problem in patients with DM and it affects
(8). Schulze et al. (9) concluded in the glycemic status and progress of complica-
EPIC-Potsdam study that replacing carbo- tions (17). Magnesium is a cofactor for vit-
hydrates with protein and PUFA was asso- amin D biosynthesis, transport, and activa-
ciated with a reduced risk of type 2 diabe- tion. The consequences of suboptimal mag-
tes. A systematic review (10) based on nesium status in diabetic populations eating

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 Andreea Gherasim et al.

modern diets are important because of the CONCLUSIONS

interactions of magnesium with the nutrients In our group of diabetics, calcium in-
calcium and vitamin D. All three must be take was insufficient and depended on the
supplemented simultaneously (18). intake of carbohydrates, saturated fat,
Given that the proportion of macronu- monounsaturated fat, fiber and energy.
trients is according to guidelines, it means Vitamin D intake was low and depended
that increasing the food amount of vitamin only on protein intake. Magnesium intake
D, calcium and magnesium, could be was low and was also influenced by the
achieved only by increasing the calories. intake of fiber, energy, carbohydrates and
Therefore, one emerging conclusion is that saturated fat. Evaluating the sources of
each case should be addressed individually. vitamin D, calcium and magnesium for
Correcting these deficiencies would im- each patient could lead to correct recom-
prove glycemic control and reduce the risk mendations of either dietary adjustments or
of complications. use of supplements.

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NOUTĂȚI
NEWS

CORRELATION OF MONOCYTE/HDL CHOLESTEROL RATIO WITH SYNTAX

SCORES IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE

Monocytes play a pivotal role in the inflammatory cascade, being the first inflammatory cell
type that infiltrates early atherosclerotic plaques. The study authors investigated the role of
monocyte/HDL cholesterol ratio in predicting the severity and complexity of coronary l e-
sions quantified by the SYNTAX score in patients with stable coronary artery disease unde r-
going coronary angiography. The study was conducted over a 3-year period, 428 patients
underwent coronary angiography being investigated. All patients were clinically stable. They
were excluded from the study patients with an acute coronary syndrome, malignancy, acute
or chronic inflammatory diseases of the liver, kidney or other organ and pati ents who had
previously undergone percutaneous coronary intervention and coronary artery bypass graf t-
ing. Transthoracic echocardiography was performed in all patients, and left ventricular eje c-
tion fraction (LVEF) was calculated using Simpson’s method. Severe coronary artery disease
was defined as having a SYNTAX score ≥ 23. The patients were divided into two groups:
those with low SYNTAX score (< 23) and those with high SYNTAX score (≥23). Of the 428
patients included in the study, 161 patients had a SYNTAX score ≥ 23. The treatment with
ACE inhibitors or angiotensin receptor blockers, beta blockers, statins and acetyl salicylic
acid were similar in low and high SYNTAX score groups. Also, age, gender, hypertension,
smoking status, instance of diabetes mellitus, hyperlipidemia, and positive family history
were similar between groups. In the patients with SYNTAX score ≥ 23, multivessel disease
showed a higher incidence. Monocyte/HDL cholesterol ratio and C-reactive protein (CRP)
were significantly higher in patients with high SYNTAX score (p<0,001). As well, WBC
count, total bilirubin, LVEF and HDL level were significantly correlated with SYNTAX
score in stable coronary artery disease. Left ventricular ejection fraction was lower in the
group with high monocyte/HDL cholesterol ratio and high SYNTAX scores. The cutoff va l-
ue of monocyte/HDL cholesterol ratio that predicted a high SYNTAX score was 24, with a
sensitivity of 66% and a specificity of 65,1%. In conclusion, monocyte/HDL cholesterol r a-
tio is significantly associated with SYNTAX score. Monocyte/HDL cholesterol ratio can be
used as a prognostic marker in patients with stable coronary artery diseas e, because it is an
quickly accessible and inexpensive test (H. Kundi, E. Kiziltunc, M. Cetin, H. Cicekcioglu, Z.
G. Cetin, G. Cicek, E. Ornek. Association of monocyte/HDL-C ratio with SYNTAX scores
in patients with stable coronary artery disease. Herz 2016; 41(6): 523–529).

Nicoleta Dima

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