| | Diacylglycerol oil ingestion in type 2 diabetic patients with hypertriglyceridemiaReceived 10 January 2005; accepted 26 April 2005. published online 15 November 2005.
Abstract ObjectiveCoronary arteriosclerotic heart disease frequently develops in patients with diabetes. Decreased serum high-density lipoprotein cholesterol concentration and low-density lipoprotein (LDL) particle size, accompanied by hypertriglyceridemia, are associated with the onset of atherosclerosis. We recently reported that hypertriglyceridemia was significantly improved in patients with type 2 diabetes who ingested diacylglycerol (DAG) oil. The effect on variables, including LDL particle size related to lipid metabolism, however, was not examined. The present study investigated the effects on these variables in more detail. MethodsPatients with type 2 diabetes (n = 24) were assigned to receive DAG oil or triacylglycerol oil, and a 3-mo, single-blind, controlled study was performed. Patients replaced cooking oil in their daily diet with DAG or triacylglycerol oil, and anthropometry and blood sampling were performed at monthly intervals. ResultsThere were no significant differences in calorie intake or amount of test oil ingested between groups. Waist circumference and serum triacylglycerol concentrations were significantly lower and serum concentrations of high-density lipoprotein cholesterol and apolipoprotein-AI were significantly higher in the DAG oil group than in the triacylglycerol oil group. Plasma plasminogen activator inhibitor-1 concentrations were significantly lower in the DAG oil group. LDL particle size tended to increase in the DAG oil group and was significantly larger in patients who had a small initial LDL particle size (<25.5 nm). There were no significant differences in variables related to glucose metabolism or in serum concentration of free fatty acids or total ketone bodies. ConclusionsThese results indicate that DAG oil may be useful for patients who have type 2 diabetes in the management of obesity and lipid abnormalities.
Introduction  Coronary arteriosclerotic heart disease (CHD) frequently develops in patients who have diabetes [1]. Decreased serum high density and decreases in serum high-density lipoprotein cholesterol (HDL-C) concentration and low-density lipoprotein (LDL) particle size, accompanied by hypertriglyceridemia and postprandial hyperlipidemia, are associated with the onset of arteriosclerosis [2], [3], [4]. Several large-scale epidemiologic studies have suggested that a remission in hypertriglyceridemia prevents CHD [5], [6]; therefore, an improvement in hypertriglyceridemia might be particularly important for patients who have diabetes. Small, dense LDL particles are more atherogenic than larger, less dense particles [4]. Recent evidence reported in the Quebec Cardiovascular Study, in which there was a 5-y follow-up, has suggested that an increased proportion of small LDL particles (<25.5 nm) is closely associated with future cardiovascular disease, even in the presence of relatively normal LDL-C concentration, and that LDL particle size might be a factor that can be used to accurately predict risk of ischemic heart disease [7]. A diet low in fat, low in glucose, and high in food fiber is recommended for diabetics. Clear-cut efficacy is not readily achieved by dietary therapy alone in clinical practice. We previously reported the efficacy of diacylglycerol (DAG) oil in patients who had diabetes and hypertriglyceridemia in a parallel group study [8] in which hypertriglyceridemia was significantly improved in patients who ingested DAG oil daily as a cooking oil compared with patients who used conventional cooking oil. In the present study, we examined the influence of long-term ingestion of DAG oil on variables including LDL particle size related to lipid metabolism in more detail in patients with type 2 diabetes. Materials and methods Subjects and study design The randomized, single-blind, controlled parallel trial was conducted at the Itami City Hospital, Itami, Japan. Potential subjects were screened during visits to the clinic. This study with human volunteers was performed in accordance with the Helsinki Declaration of 1975 as revised in 1983. The procedures were fully explained to the volunteers. All subjects gave their signed informed consent before the start of the study. The subjects included 24 outpatients ages 38 to 79 y under continuous nutritional counseling (dietary therapy) for diabetes (Table 1). These patients were assigned to one of two groups: a DAG oil group comprised of 11 patients (mean age 61.5 ± 6.2 y, four men and seven women) and a triacylglycerol (TAG) oil group of 13 patients (mean age 54.3 ± 13.1 y, seven men and six women). The DAG and TAG oil groups replaced their usual cooking oil with DAG oil and TAG oil, with the same fatty acid composition as the DAG oil, respectively, and ingested the oil with a target intake of 10 g/d. The study period was 3 mo after initiating the use of the test oil in both groups. Patient medication is reported in Table 1. Dietary record Subjects were instructed to record their daily meals and snacks in a dietary diary for 3 consecutive days at the beginning and end of the test period. At the time of each clinic visit, a dietitian reviewed the food diaries and meal record after clarifying the results by patient interviews. Mean daily intakes of energy, fat, and cooking oil were calculated from the dietary record by a dietitian on the basis of the 5th Revision of the Standard Tables of Food Composition in Japan. DAG intake was estimated from the amount of DAG oil ingested and the DAG content of the DAG oil (80 g/100 g). Anthropometry and blood tests Anthropometry and fasting blood sampling were performed each month after the initiation of the test ingestion at the hospital. In anthropometry, body weight, body mass index, and waist circumference were measured. Plasma and serum were obtained by centrifugation at 1500g for 15 min at 4°C. Serum TAG concentration was measured using an enzymatic assay kit Serum (Daiya Auto TG, Daiya Chemical, Tokyo, Japan). Serum total cholesterol concentration was measured using an enzymatic assay kit (Daiya Auto T-cho, Daiya Chemical). Serum free fatty acid concentration was measured using an enzymatic assay kit (Determiner NEFA, Kyowa Medex, Tokyo, Japan). Serum LDL-C concentration was measured using an enzymatic assay kit (Cholestest LDL, Daiichi Pure Chemicals, Tokyo, Japan). Serum HDL-C concentration was measured using an enzymatic assay kit (Cholestest N HDL, Daiichi Pure Chemicals). Serum total ketone body concentration was measured using an enzymatic assay kit (3-HB Kainos, Kainos Laboratories, Inc., Tokyo, Japan). Serum insulin concentration was measured using a solid-phase radioimmunoassay kit (INSULINRIABEAD II, Dinabot, Tokyo, Japan). Serum concentrations of apolipoprotein (Apo) AI, ApoB, and ApoE were measured using a turbidimetric immunoassay kit (N-asssay TIA ApoAI-H Nittobo, N-assay TIA ApoB-H Nittobo, and N-assay TIA ApoE-H Nittobo, Nitto Boseki Co., Ltd, Tokyo, Japan). Plasma plasminogen activator inhibitor-1 (PAI-1) concentration was measured using an enzymatic immunoassay kit (TintElize PAI-1, Biopool International, Umeå, Sweden). Plasma glucose was measured using a glucose-dehydrogenase assay kit (CicaLiquid GLU; Kanto Chemicals, Tokyo, Japan). Serum glycohemoglobin A1c was measured using a latex agglutination kit (Rapidia Auto HbA1c, Fujirebio Inc., Tokyo, Japan). Analysis of serum LDL size Several methods have been established for the determination of serum LDL size. This study employed high-performance liquid chromatography using a gel filtration column, as reported by Usui et al. [10], [11]. The high-performance liquid chromatographic system consisted of an AS-8020 auto-injector, CCPS and CCPM-II pumps, and two UV-8020 detectors (Tosoh Corp., Tokyo, Japan) [12]. Lipoproteins were separated on a Superose 6HR column (300 × 10 mm; Pharmacia, Uppsala, Sweden) with 50 mmol/L of phosphate buffered saline (pH 7.4) containing 0.15 mol/L of NaCl at a flow rate of 0.5 mL/min. Lipoprotein particle size was determined based on individual elution times corresponding to the peaks on the chromatographic pattern of the cholesterol profile and were computed using a calibration curve. The procedure for this method is simple and reproducibility is very high, allowing for an accurate and quantitative analysis within a short time using a small amount of serum. Sera collected before the study and 3 mo after the initiation of the study were stored at −80°C until used in high-performance liquid chromatographic analysis. Statistical analyses Data are presented as the mean ± standard deviation of the measured values or changes from the initial values. A difference from the initial value was analyzed using paired t test and Dunnett’s multiple comparison test. An intergroup comparison was performed using Student’s t test, and statistical difference between groups with the time-lapse change was tested using two-way analysis of variance (ANOVA). Data were analyzed on intention-to-treat samples. Skewed variables such as TAG were logarithmically transformed. Correlation coefficients were assessed using Pearson’s product-moment correlation test. Differences were considered statistically significant at P < 0.05 using a two-tailed test. Statistical analyses were performed with StatView 5.0 (SAS Institute, Cary, NC, USA). Results Based on judgments made by the physicians in charge, no aggravation of physical conditions or adverse effects were noted after ingestion of the test oils throughout the study period in any patient in the DAG or TAG oil group. Further, no liver, renal, or pancreatic abnormalities were noted in the blood tests. No changes in medication or dose were made during the study period. Based on the dietary diary, there were no differences in daily energy intake, fat intake, or amount of test oil ingested between groups (Table 3). Anthropometry Table 4 lists the anthropometric values measured every month after the initiation of ingestion of the test oil. Waist circumference was significantly decreased in the DAG oil group compared with the TAG oil group when using ANOVA, although there were no significant differences in changes from initial values in the DAG oil group when using paired t test and Dunnett’s multiple comparison test. Changes from the initial values in waist circumference were also significantly different between groups when using ANOVA (DAG oil group: −1.2 cm at 1 mo, −1.1 cm at 2 mo, and −1.5 cm at 3 mo). Body mass index was not significantly different between groups. Blood test Table 5, Table 6, Table 7 present blood chemistry values measured every month after the initiation of test oil ingestion. Variables related to glucose metabolism, such as blood glucose and insulin levels, were not significantly different between groups (Table 5), and there was no difference in the homeostasis model assessment index calculated from the blood glucose and insulin levels between groups (Table 5). Changes in each variable listed in Table 5 were not significantly different between groups using ANOVA. Decreases in serum TAG concentrations after 3 mo of consumption of the DAG oil were significantly different from the initial values according to paired t test and the decreasing tendency was shown with Dunnett’s multiple comparison test (P = 0.08). Serum TAG levels decreased and serum HDL-C increased in the DAG oil group compared with the TAG oil group and there were significant differences in the two variables (Table 6). There were no significant differences in concentrations of free fatty acids or total ketone bodies between groups (Table 6). Changes in each variable listed in Table 6 were not significantly different between groups using ANOVA. Serum ApoAI was significantly increased and plasma PAI-1 was significantly decreased in the DAG oil group (Table 7). Changes from the initial value in PAI-1 were also significantly different between groups using ANOVA. Changes in each variable except PAI-1 listed in Table 7 were not significantly different between groups using ANOVA. LDL particle size analysis by high-performance liquid chromatography Table 8 lists the LDL particle sizes before and 3 mo after the initiation of test oil ingestion. There were no significant differences across patients. In patients whose initial LDL particle size was no larger than 25.5 nm, there was a significant difference in the third month; LDL particle size increased in the DAG oil group compared with the TAG oil group. Relation between changes in serum TAG concentrations and LDL particle size Figure 1 shows the relation between changes in serum TAG concentrations and LDL sizes for all patients. There was a strong negative correlation between parameters, indicating that LDL size increased with a decrease in serum TAG concentration. Discussion When outpatients with type 2 diabetes under continuous nutritional counseling ingested DAG oil in this study, waist circumference, serum TAG, and plasma PAI-1 were significantly decreased, and serum HDL-C and ApoAI were significantly increased after the 3-mo test period compared with the TAG oil group, despite equivalent nutritional value throughout the study period and no significant differences in the amount of test oil ingested between groups. In addition, LDL particle size was increased in patients with a small initial LDL particle in the DAG oil group. There were no significant differences in serum concentrations of free fatty acids or total ketone bodies between groups. Several studies have reported that hypertriglyceridemia is derived from increased TAG-rich lipoprotein and decreased serum HDL-C concentration and LDL particle size via the lipid transport system [13], [14]. Increases in serum HDL-C concentration and LDL particle size observed in the DAG oil group in the present study might have been related to an improvement in hypertriglyceridemia. As shown in Fig. 1, there was a significant negative correlation between changes in serum TAG concentrations and LDL particle size, strongly suggesting that the serum TAG concentration is a potent regulatory factor related to LDL particle size in diabetes. There were no changes observed in serum ApoB concentrations in either group, indicating that the number of circulating LDL particles did not change. Several cross-sectional studies have demonstrated that a predominance of small, dense LDL particles is associated with the presence of CHD [15], [16], [17]. Further, prospective studies have demonstrated that abnormalities in LDL particle size preceded the onset of CHD [7], [18], [19]. Considering these findings, it is suggested that the increase in LDL particle size achieved in this study by DAG oil ingestion might be meaningful as it relates to a therapeutic strategy for decreasing the risk of CHD in patients with diabetes. However, it may remain unknown whether insulin resistance or other factors related to insulin resistance directly regulate LDL particle size. In this study, LDL particle size was increased, whereas the levels of fasting glucose, glycohemoglobin A1c, and insulin were unchanged. These results suggest that LDL particle size is more directly influenced by TAG metabolism than by insulin sensitivity. These findings are consistent with results reported by Hirano et al. [20]. There is a correlation between the amount of visceral fat with waist circumference and plasma PAI-1 concentration in humans [21], [22], [23]. Dietary DAG oil decreases the accumulation of visceral fat compared with TAG oil [24], [25]. Therefore, the decreases in waist circumference and plasma PAI-1 concentration observed in this study might have been due to a decrease in the amount of abdominal visceral fat. Moreover, because the accumulation of visceral fat is closely related to TAG synthesis in the liver [26], decreased visceral fat may have played a role in the decreased serum TAG concentration in the DAG oil group. Although the mechanisms of action of DAG on visceral fat are not fully elucidated, the unique metabolism of DAG might contribute to its action because the heat of combustion and rate of absorption of DAG are similar to those of TAG, which has the same fatty acid composition [27]. Kondo et al. [28] reported that the initial products of digestion of TAG are 2-MAG and fatty acids and those for 1,3-DAG are mainly 1(3)-MAG and fatty acids. Because the affinities of 2-MAG and 1(3)-MAG for the enzyme involved in TAG resynthesis, monoacylglycerol acyltransferase, are markedly different [29], TAG resynthesis in small intestinal epithelial cells might be delayed after DAG ingestion, and this might suppress the increase in serum TAG concentration after DAG ingestion. Recent human studies have indicated that the increase in postprandial serum TAG concentration was smaller in the DAG oil group than in the TAG oil group [30], [31]. Because impaired postprandial TAG clearance is associated with visceral obesity [32], [33], the specific metabolism of DAG in the small intestine might, at least in part, be involved in the decreased amount of visceral fat. Further investigation is necessary. 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a Department of Nutrition, Koshien University, Takarazuka, Hyogo, Japan b Health Care Products Research Laboratories No.1, Kao Corporation, Bunka, Sumida-ku, Tokyo, Japan c Department of Food and Nutritional Science, Toita Women’s College, Shiba, Minato-ku, Tokyo, Japan d Biological Science Laboratories, Kao Corporation, Ichikai-machi, Haga-gun, Tochigi, Japan e Department of Internal Medicine, Suita Municipal Hospital, Suita, Osaka, Japan f Department of Internal Medicine, Itami City Hospital, Itami, Hyogo, Japan g Department of Nutrition, Itami City Hospital, Itami, Hyogo, Japan h College of Liberal Arts and Sciences, Tokyo Medical and Dental University, Ichikawa, Chiba, Japan  Corresponding author. Tel.: +81-3-5630-7266; fax: +81-3-5630-9436.
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