Article open access publication

The association of substituting carbohydrates with total fat and different types of fatty acids with mortality and weight change among diabetes patients

Clinical Nutrition, Elsevier, ISSN 0261-5614

Volume 35, 5, 2016

DOI:10.1016/j.clnu.2015.08.003, Dimensions: pub.1014524018, PMID: 26342536,



  1. (1) University Medical Center Utrecht, grid.7692.a
  2. (2) University of Bonn, grid.10388.32
  3. (3) International Agency For Research On Cancer, grid.17703.32
  4. (4) Aarhus University, grid.7048.b, AU
  5. (5) German Institute of Human Nutrition, grid.418213.d
  6. (6) Istituto per lo Studio e la Prevenzione Oncologica, grid.417623.5
  7. (7) University of Naples Federico II, grid.4691.a
  8. (8) Cancer Registry and Histopathology Unit, “Civic - M.P.Arezzo” Hospital, ASP Ragusa, Italy
  9. (9) Fondazione IRCCS Istituto Nazionale dei Tumori, grid.417893.0
  10. (10) Umeå University, grid.12650.30
  11. (11) University of Gothenburg, grid.8761.8
  12. (12) German Cancer Research Center, grid.7497.d
  13. (13) Department of Clinical Sciences, Lund University, Skåne University Hospital, Malmö, Sweden
  14. (14) Danish Cancer Society, grid.417390.8
  15. (15) National Institute for Public Health and the Environment, grid.31147.30
  16. (16) Biodonostia, grid.432380.e
  17. (17) Human Genetics Foundation, grid.428948.b
  18. (18) University of Turin, grid.7605.4
  19. (19) Institute of Health Carlos III, grid.413448.e
  20. (20) Instituto de Salud Pública de Navarra, grid.419126.9


BACKGROUND: Substitution of carbohydrates with fat in a diet for type 2 diabetes patients is still debated. OBJECTIVE: This 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. METHODS: The 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. RESULTS: After 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. CONCLUSIONS: In 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.


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Research area: Medicine

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Times Cited: 12

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