• Marjo J Campmans-Kuijpers, Ivonne Sluijs, Ute Nöthlings, Heinz Freisling, Kim Overvad, Heiner Boeing, Giovanna Masala, Salvatore Panico, Rosario Tumino, Sabina Sieri, Ingegerd Johansson, Anna Winkvist, Verena A Katzke, Tilman Kuehn, Peter M Nilsson, Jytte Halkjær, Anne Tjønneland, Annemieke M Spijkerman, Larraitz Arriola, Carlotta Sacerdote, Aurelio Barricarte, Anne M May, and Joline W Beulens.
• Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: M.J.E.Campmans-Kuijpers@Umcutrecht.nl.
• Clin Nutr. 2016 Oct 1; 35 (5): 1096-102.

BackgroundSubstitution of carbohydrates with fat in a diet for type 2 diabetes patients is still debated.ObjectiveThis study aimed to investigate the association between dietary carbohydrate intake and isocaloric substitution with (i) total fat, (ii) saturated fatty acids (SFA), (iii) mono-unsaturated fatty acids (MUFA) and (iv) poly-unsaturated fatty acids (PUFA) with all-cause and cardiovascular (CVD) mortality risk and 5-year weight change in patients with type 2 diabetes.MethodsThe study included 6192 patients with type 2 diabetes from 15 cohorts of the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at recruitment with country-specific food-frequency questionnaires. Cox and linear regression were used to estimate the associations with (CVD) mortality and weight change, adjusting for confounders and using different methods to adjust for energy intake.ResultsAfter a mean follow-up of 9.2 y ± SD 2.3 y, 791 (13%) participants had died, of which 268 (4%) due to CVD. Substituting 10 g or 5 energy% of carbohydrates by total fat was associated with a higher all-cause mortality risk (HR 1.07 [1.02-1.13]), or SFAs (HR 1.25 [1.11-1.40]) and a lower risk when replaced by MUFAs (HR 0.89 [0.77-1.02]). When carbohydrates were substituted with SFAs (HR 1.22 [1.00-1.49]) or PUFAs (HR 1.29 [1.02-1.63]) CVD mortality risk increased. The 5-year weight was lower when carbohydrates were substituted with total fat or MUFAs. These results were consistent over different energy adjustment methods.ConclusionsIn diabetes patients, substitution of carbohydrates with SFAs was associated with a higher (CVD) mortality risk and substitution by total fat was associated with a higher all-cause mortality risk. Substitution of carbohydrates with MUFAs may be associated with lower mortality risk and weight reduction. Instead of promoting replacement of carbohydrates by total fat, dietary guideline should continue focusing on replacement by fat-subtypes; especially SFAs by MUFAs.Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

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