Dietary acid load and risk of type 2 diabetes among Malaysian

postmenopausal Chinese women

Presenter : Lim Sook Yee

The Global Prevalence of Diabetes

8

8.1

8.2

8.3

8.4

8.5

8.6

8.7

8.8

8.9

2013 2035

Total diabetes

Total diabetes

Guariguata L et al., 2014

around 55% of the world’s diabetes population is from Asia

%

Year

Trend of diabetes in Malaysia

11.6

15.2

17.5

14.9

20.8 22.5

0

5

10

15

20

25

NHMS III (2006) NHMS 2011 NHMS 2015

Total diabetes (≥ 18 years)

Total diabetes (≥ 30 years)

Prevalence (%)

Prevalence of people by age and sex, 2017

International Diabetes Federation

The identification of modifiable risk factors for diabetes is thus a

priority issue

What is dietary acid load?

• Acidic diet

– Diet that high in animal proteins such as derived from red meat and cheese.

• Alkaline diet

– Diet that high in potassium, magnesium and calcium such as derived from vegetables and fruits.

Historical of Acid-base Balance Theory

Sherman & Sinclair (1907) (Cations and

anions of the mineral)

Sherman and Gettler (1912)

(A list of acid-base elements in 47 different

kinds of food)

Shohl & Sato (1923)

(Experiment on two normal infant)

Gonick et al. (1968)

(H+ from organic sulfur and hydrolysis of phosphoesters)

Gonick & Goldberg (1966) (urinary acid

excretion due to invariably alkaline in

feces )

Remer (1994)

[potential renal acid load (PRAL)

Frassetto et al. (1998)

[net endogenous acid production (NEAP)]

Remer (2000)

(5 factors: food composition, bioavailability, sulfate production, grades of dissociation of phosphorus and

the valence ions of Cal and Mg

Remer (2000) How the 4 main organs interact in managing acid-base homeostasis?

• Figure 1 show how the 4 main organs interact in managing acid-base homeostasis. – At first, intestine is the initial organ to absorb nutrients and alters the blood bicarbonate level

base on the food composition consumed. – Intestine determines the absorbed amounts of sulfur-containing amino acids (AA-SH) and

alkali salts of nonmetabolizable organic acids (OA-) before they involve in the liver buffer system.

– In the liver system, it produces hydrogen ions (H+) and alkali ions (OH-) by oxidizing the absorbed AA-SH and OA.

– The H+ and OH- are finally excreted by kidney. – On the other hand, lungs are responsible to regulate the volatile acids, carbonic acid (H2CO3)

without adding or subtracting H+ into the blood

(Adapted from Remer, 2000)

Previous studies

a diet with high acid-forming potential might increase the risk of type 2 diabetes.

states that men with highest PRAL quartile had 61 % increased type 2 diabetes prevalence in over 5 years follow-up period

Problem statement

• Dietary acid load is associated with chronic diseases especially cardiovascular disease, diabetes, cancer and osteoporosis. However, the result is INCONSISTENT and the study is SCARCE in postmenopausal Asians population.

Objective

• to determine the association between dietary acid load and blood glucose level among postmenopausal Chinese women.

Methodology

Study design

• Analytical cross sectional study

Location • NACSCOM in Kuala Lumpur and

Selangor

Sampling design

• Two-stage sampling technique

• simple random sampling to select seven affiliates

• Participants were recruited based on the inclusion and exclusion criteria.

Ethical approval

The ethical clearance was obtained from

• Ethics Committee for Research Involving Human Subjects with project reference number was FPSK (FR16) P019.

Data collection instrument

Questionnaire sociodemographic background

Global Physical Activity Questionnaire (GPAQ)

Validated semi-quantitative food frequency questionnaire (FFQ)

Dietary acid load estimation

PRAL score (Remer, 1994):

+ 0.49 x protein (g/day)

+ 0.037 x phosphorus (mg/d)

-0.021 x potassium (mg/d)

-0.026 x magnesium (mg/d)

-0.013 x calcium (mg/d)

= PRAL (mEq/d)

NEAP score(Frassetto et al., 1998):

[54:5 x protein intake (g/d) / potassium intake (mEq/d]

- 10:2

-PRAL and -NEAP +PRAL and +NEAP

base-forming potential acid -forming potential

Results: characteristics of the participants

Results: characteristics of the participants Table 1. characteristics of women (n = 217) cont.

Results Table 2. Bivariate Pearson correlation coefficients for rate of Blood glucose level, NEAP, PRAL score and controls.

Blood glucose is weakly but significantly correlate with PRAL score, BMI and age

Result: regression Table 3. regression analysis of PRAL score and control variables predicting high blood glucose

Table 4. regression analysis of NEAP score and control variables predicting high blood glucose

Result: 4 quartiles of NEAP scores and blood glucose level

P value = ns, One-way ANOVA analysis.

Result: 4 quartiles of PRAL scores and blood glucose level

P value = ns, One-way ANOVA analysis.

Discussion

• Result revealed that PRAL score was positively associated with blood glucose level after adjusted for covariates, but not for NEAP score.

• PRAL is estimated based on intake of five nutrients including protein, potassium, phosphorous, magnesium and calcium, whereas NEAP only considers protein and potassium intake.

• The differences in equation used to estimate the PRAL and NEAP score, might explain inconsistent findings association with blood glucose level.

Discussion

• The underlying mechanism by which high dietary acid load increased the blood glucose level remains unclear, Rylander et al. (2009) suggested:

– acid-base balance may influence mineral homeostasis by regulating the absorption of calcium and magnesium in the kidneys, and studies in human have shown that calcium and magnesium are important minerals for insulin action.

Conclusion

Our findings suggest that a high dietary acid load PRAL score was associated with an increased blood glucose level in postmenopausal Chinese women.

Acknowledgement

• This research was funded by Fundamental Research Grant Scheme (FRGS), Ministry of Higher Education, Malaysia.

• Supervisors: A.P. Dr. Chan Yoke Mun, Prof. Zalilah Mohd Shariff, Dr. Chin Yit Siew and Dr. Vasudevan Ramachandran

• Research team members: Mr. Leiu Kok Hong and Mr. Chan Kai Sze

References

• Atlas, D. (2006). International diabetes federation. Press Release, Cape Town, South Africa, 4.

• Chan, J. C., Malik, V., Jia, W., Kadowaki, T., Yajnik, C. S., Yoon, K.-H., & Hu, F. B. (2009). Diabetes in Asia: epidemiology, risk factors, and pathophysiology. Jama, 301(20), 2129-2140.

• Fagherazzi, G., Vilier, A., Bonnet, F., Lajous, M., Balkau, B., Boutron-Ruault, M.-C., & Clavel-Chapelon, F. (2014). Dietary acid load and risk of type 2 diabetes: the E3N-EPIC cohort study. Diabetologia, 57(2), 313-320.

• Fenton, T. R., Tough, S. C., Lyon, A. W., Eliasziw, M., & Hanley, D. A. (2011). Causal assessment of dietary acid load and bone disease: a systematic review & meta-analysis applying Hill's epidemiologic criteria for causality. Nutrition journal, 10(1), 41.

• Guariguata, L., Whiting, D. R., Hambleton, I., Beagley, J., Linnenkamp, U., & Shaw, J. E. (2014). Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes research and clinical practice, 103(2), 137-149.

• Rebolledo, O. R., Hernandez, R. E., Zanetta, A. C., & Gagliardino, J. (1978). Insulin secretion during acid-base alterations. American Journal of Physiology-Endocrinology and Metabolism, 234(4), E426.

References

• Remer, T. 2000. Acid‐Base in Renal Failure: Influence of Diet on Acid‐Base Balance. Seminars in dialysis, hlm. 221-226.

• Rylander, R., Tallheden, T., & Vormann, J. (2009). Acid-base conditions regulate calcium and magnesium homeostasis. Magnesium research, 22(4), 262-265.

• Shoichiro (2016). High Dietary Acid Load Score Is Associated with Increased Risk of Type 2 Diabetes in Japanese Men: The Japan Public Health Center–based Prospective Study–. The Journal of nutrition, 146(5), 1076-1083.

• Whittaker, J., Cuthbert, C., Hammond, V., & Alberti, K. (1982). The effects of metabolic acidosis in vivo on insulin binding to isolated rat adipocytes. Metabolism-Clinical and Experimental, 31(6), 553-557.

• Xu, H., Jia, T., Huang, X., Risérus, U., Cederholm, T., Ärnlöv, J., Carrero, J.J. (2014). Dietary acid load, insulin sensitivity and risk of type 2 diabetes in community-dwelling older men. Diabetologia, 57(8), 1561-1568.