1. What is the difference in total carbohydrate, fiber, and sugar intake in adults with and without diabetes in the United States? What is the difference in total carbohydrate, fiber, and sugar intake in males and females with and without diabetes?
Jenna McClure
National Health and Nutrition Examination Survey (NHANES) Project
December 8, 2014

2. Background In 2012, >9% of the US population had diabetes2
In 2010, diabetes was 1 of the top 10 causes of death in the US2
Diet is key for optimal diabetes management6
Carbohydrates (CHO) are the key nutrient for achieving glycemic control6
Minimum recommended intake for CHO is 130 grams/day
Fiber recommendations: at least 14 grams per 1000 calories consumed
Sugary beverages/added sugar should be limited or avoided
Untreated and uncontrolled diabetes can lead to health complications and high health care costs2,5

3. Objectives
1. Determine the total carbohydrate, fiber, and sugar intake of the US adult population with in NHANES and
2. Determine the total carbohydrate, fiber, and sugar intake of the US adult population with diabetes
3. Compare the total carbohydrate, fiber, and sugar intake of the US adult population with and without diabetes.
4. Compare the total carbohydrate, fiber, and sugar intake of the US adult males and females with and without diabetes.

4. Demographic, dietary, laboratory, and questionnaire data obtained
Final Study Sample
NHANES
NHANES
Demographic, dietary, laboratory, and questionnaire data obtained
Subjects that were < 21 yrs old were excluded due to likelihood of type 1 diabetes, possible discrepancies in responses, and potential for skewed data due to increased kcal and CHO intake.
Subjects with excessive kcal and CHO intake were excluded due to possibility of false intake data and probability of skewed data
Limit for CHO decided by 95th confidence interval
Study only included people who reported or reported or denied diabetes
Subjects in final sample determined to be reliable
n= 20, 686
Excluded < 21 yrs old
n= 11,960
Excluded males >7,000 kcals; females > 5,000
n= 10,967
Excluded males >401 gm CHO; females >528 gm CHO
n= 10, 414
Excluded “Don’t know,” refused or “Borderline” diabetes
Final sample:
n= 10, 206
Figure 1. Flow sheet of final sample study

5. Table 1. Demographic data
Demographic Variable
Diabetes (n=1,333)
No Diabetes (n=8,873)
Age (yrs): Mean ± SD
62 ± 12.7
49 ± 17.6
Gender: n (%)
Males
Females
662 (49.7%)
671 (50.3%)
4300 (48.5%)
4573 (51.5%)
Race: n (%)
Non-Hispanic White
Non-Hispanic Black
Mexican American
Other Hispanic
Other
518 (38.9%)
360 (27%)
252 (18.9%)
149 (11.2%)
54 (4.1%)
4370 (49.3%)
1601 (18%)
1552 (17.5%)
937 (10.6%)
413 (4.7%)
Annual Household Income (dollars): n (%)
0-14,999
15,000-34,999
35,000-64,999
65,000- >/=100,000
>20,000
<20,000
Refused/Don’t Know
225 (16.9%)
428 (32.2%)
295 (22.2%)
234 (17.6%)
73 (5.5%)
21 (1.6%)
47 (3.5%)
1138 (12.9%
2395 (26.9%)
2075 (23.4%)
2459 (26.7%)
343 (3.9%)
75 (0.8%)
341 (3.9%)
Highest Level of Education Completed: n (%)
<9th Grade
9-11th Grade
HSGrad/GED
Some College/AA
College Grad/+
Refused
286 (21.5%)
274 (20.6%)
289 (21.7%)
322 (24.2%)
157 (11.8%)
0 (0%)
5 (.4%)
1061 (12%)
1396 (15.7%)
2113 (23.8%)
2403 (27.1%)
1890 (21.3%)
4 (.0%)
6 (.1%)

6. Demographics: Race No Diabetes Diabetes Other Other Non Hispanic Black
Mexican
American
Mexican
American
Non Hispanic Black
Other Hispanic
Other Hispanic
Non Hispanic White
Non Hispanic White
Figure 2. Distribution of race in adults with diabetes
Figure 3. Distribution of race in adults without diabetes

7. Demographics: Education level
Refused
Refused
No Diabetes
Diabetes
College Grad/+
<9th Grade
<9th Grade
College Grad/+
9-11th Grade
Some College/AA
9-11th Grade
Some College/AA
HS Grad/GED
HS Grad/GED
Figure 4. Distribution of education level in adults with diabetes
Figure 5. Distribution of education level in adults without diabetes

8. Outcome Variables Demographics:
* All variables were analyzed the same for the and data sets
Demographics:
Categorical: gender, race, education level, annual household income
Continuous: age
Dietary:
Continuous: total carbohydrate intake, fiber intake, sugar intake
Laboratory
Continuous: HgA1C, fasting glucose
Diabetes status
Categorical: presence of diabetes

9. Outcome variables Dietary Outcome Variables How Obtained
Table 2. Dietary outcome variables
Dietary Outcome Variables
How Obtained
Statistical Analysis
Data Analysis
Total carbohydrates
Obtained from one day diet recalls
Measured in grams
Continuous variable
Displayed as mean ± standard deviation
Independent T-test
Independent T-tests used to compare intake based on diabetes status in (1) total population, (2) males, (3) females
Fiber
Independent T-tests used to compare intake based on diabetes status in: (1) total population, (2) males, (3) females
Sugar

10. Other Outcome Variables How Obtained Statistical Analysis
Table 3. Other outcome variables
Other Outcome Variables
How Obtained
Statistical Analysis
Data Analysis
Presence of diabetes
“Doctor told you have diabetes?”
Answer choices: yes, no, don’t know (excluded), borderline (excluded)
Categorical variable
Displayed as frequencies (% of count)
Used to compare dietary intake & laboratory data
Assessed in total population, males, females
Laboratory data: Hemoglobin A1C (%)
Collected and measured during the in-person interview
Continuous variable
Displayed as mean ± standard deviation
Independent T-tests
Pearson’s Correlation coefficient
Independent T-tests used to determine difference in HgA1C and diabetes status
Pearson’s correlation to assess HgA1C & CHO intake based on diabetes status
Laboratory data: Fasting Glucose (mg/dL)
Independent T-tests used to determine difference in fasting glucose and diabetes status

11. Demographic Outcome Variables Statistical Analysis Data Analysis
Table 4. Demographic outcome variables
Demographic Outcome Variables
Statistical Analysis
Data Analysis
Race
Categorical variable
Displayed as frequencies (% of count)
Spearman’s rho
ANOVA
Spearman’s rho used to compare race and carbohydrate intake
ANOVA used to determine differences among race groups
Education Level
Spearman’s rho used to compare education level and carbohydrate intake
ANOVA used to determine differences among education groups
Annual household income
Spearman’s rho used to compare income and carbohydrate intake
ANOVA used to determine differences among income groups

12. Carbohydrate Intake Diabetes No Diabetes 199 ± 84.6 240.3 ± 97.4
Table 5. CHO intake based on diabetes status
Diabetes
No Diabetes
Indep.
t-test
p value
Total
Sample
199 ± 84.6
240.3 ± 97.4
T10204=
<0.001
Males
218.5 ± 90.9
240.3 ± 105.2
T4960=
Females
179.7 ± 73
209.7 ± 78
T5242=
CHO intake data (measured in grams) for the total sample, males, and females. Data is displayed as mean and standard deviation (mean ± SD). Differences between data were determined by Independent T-test. Mean CHO intake was significantly lower in people with diabetes in all categories. Significant determined by p<0.05.
Figure 6. Difference in CHO intake based on presence of diabetes

13. Fiber Intake
Table 6. Fiber intake based on diabetes status
Diabetes
No Diabetes
Indep. T-test p
value
Total sample
14.8 ± 8.6
15.5 ± 9.2
T10204=
0.009
Males
16.4 ± 9.7
16.8 ± 10
T4960=
2.17
Females
13.2 ± 7
14.2 ± 8.1
T5242=
0.004
Diabetes
No Diabetes
Fiber intake data (measured in grams) for the total sample, males, & females. Data is displayed as mean and standard deviation (mean ± SD). Differences between data were determined by Independent T-test. Mean fiber intake was significantly lower in people with diabetes in the total population and females. Significant determined by p<0.05.
Figure 7. Difference in CHO intake based on presence of diabetes

14. Sugar Intake Diabetes No Diabetes 78.7 ±50.3 107.7 ± 61.2 82.5 ± 54
Table 7. Sugar intake based on diabetes status
Diabetes
No Diabetes
Indep t-test
p value
Total sample
78.7 ±50.3
107.7 ± 61.2
T10204=
<0.001
Males
82.5 ± 54
120.5 ± 68.6
T4960=
Females
74.9 ± 46
96 ± 50.4
T5242=
Sugar intake data (measured in grams) for the total sample, males, and females. Data is displayed as mean and standard deviation (mean ± SD). Differences between data were determined by Independent T-test. Mean sugar intake was significantly lower in people with diabetes in all categories. Significant determined by p<0.05.
Figure 8. Difference in CHO intake based on presence of diabetes

15. Carbohydrate intake and Hemoglobin A1C (HgA1C)
Table 8. The relationship between carbohydrate intake and HgA1c
Using Pearson’s correlation coefficient, there was a significant relationship between Hemoglobin A1C and CHO intake for the total sample (p<0.001), males (p<0.001), and females (p<0.001). There was not a significant relationship between Hemoglobin A1C and CHO intake for those with diabetes (p=.093) or those without diabetes (p=.075). Significance was determined by p<0.05.
Pearson’s correlation coefficient (r)
Effect size (rr)
p value
HgA1C: Total sample
-.083
.006
<0.001
HgA1C: Diabetes
.047
.002
.093
HgA1C: No diabetes
-.019
.075
HgA1C: Males
-.120
.014
HgA1C: Females
-.071
.005

16. Hemoglobin A1C and Fasting Glucose
Table 9. The difference in HgA1C and fasting glucose based on presence of diabetes
Diabetes
No Diabetes
Indep. T-test
p value
Hemoglobin A1c (%): Total sample
7.3 ± 1.7
5.5 ± .7
T9727=
<0.001
Fasting glucose (mg/dL): Total sample
158.3± 68.6
102.1 ± 20.3
T4766=
Laboratory data were collected during in-person interviews for and NHANES data sets. Data are displayed as mean and standard deviation (mean ± SD). Differences between data were determined by the parametric test, Independent T-test. There was a statistical difference in Hemoglobin A1C and fasting glucose in those with and without diabetes. Significance was determined by p<0.05.

17. Carbohydrate Intake and Race
Post Hoc comparisons using a Scheffe correction indicated that mean CHO intake was significantly higher in Mexican Americans (243.9g ± 97.2, n=1804) when compared to Non-Hispanic whites (235g ± 94.9, n=1086; p=.025) and Non-Hispanic blacks (226.9g ± 100.9, n=1961; p<0.001).
Figure 9. Difference in CHO intake based on race

18. Carbohydrate Intake and Education Level
Post Hoc comparisons using a Scheffe correction indicated that the adults with less than a 9th grade education level had a statistically lower mean CHO intake (219.6g ± 95.4, n=1347) compared to those with a HS education/GED (237g ± 96.9, n=2402; p<0.001), some college/AA (239.3g ± 97.1, n=2725; p<0.001), and college graduate/+ (240g ± 91.9, n=2047; p<0.001).
Figure 10. Difference in CHO intake based on education level

19. Carbohydrate Intake and Income
Post Hoc comparisons using a Scheffe correction indicated that the adults with a household income of 75,000-99,999 (246.2g ± 96.1, n=85) consumed significantly more CHO than those with a household income of 5,000-9,999 (216.3g ± 98.3, n=75; p=.03) and those with a household income of 10,000-14,999 (218.1 ± 95.4, n=133; p=.002). Those with a household income ≥100,000 (244.5g ± 95.3, n=94) also consumed significantly more CHO than those with a household income of 5,000-9,999 (p=.033) and 10,000-14,999 (p=.002).
Figure 11. Difference in CHO intake based on annual household income

20. Conclusions Nutrient Total Sample Males Females Carbohydrates
Table 10. Mean differences in dietary intake in adults with diabetes
Nutrient
Total Sample
Males
Females
Carbohydrates
-41.3 grams*
-55 grams*
-30 grams*
Fiber
-0.7 grams*
-0.4 grams
-1 grams*
Sugar
-29 grams*
-38 grams*
-21 grams*
*Indicates statistical significance; p<0.05
Adults with diabetes consume significantly less carbohydrates, fiber, and sugar compared to adults without diabetes.
All differences are statistically significant, with the exception of fiber intake in males.
All values also appear clinically significant, with the exception of fiber intake in all categories
Interestingly, the distribution of calories from carbohydrates was similar in adults with and without diabetes (40.8% and 41.4%, respectively)

21. Conclusions
Significantly negative relationship between CHO intake and HgA1c:
Total sample
Males (total sample)
Females (total sample)
Adults with diabetes have significantly higher HgA1c values compared to adults without diabetes
Mean fasting HgA1C in adults with diabetes: 7.3%
Exceeds targets for HgA1C < 7% 6
Fasting glucose is significantly higher in adults with diabetes compared to adults without diabetes
Mean fasting glucose in adults with diabetes: 56.2 mg/dL
Exceeds targeted fasting glucose levels: 70 to 130 mg/dL6

22. Conclusions
Carbohydrate intake was higher among Mexican Americans compared to Non Hispanic Whites and Non Hispanic Blacks
Non Hispanic whites had a higher intake of carbohydrates compared to Non Hispanic Blacks
Adults with a lower education level had a lower mean carbohydrate intake compared to adults with at least a high school education
Adults with an annual household income of at least $75,000 consumed more carbohydrates than those making less than $15,000

23. Limitations
Possible discrepancies or inaccuracies in dietary data given nature of diet recalls
One day recall may not be representative of usual intake
Dependent on memory and honesty
Data lacking in nutrient sources; only analyzing total CHO, fiber, and sugar
Unknown if nutrients are naturally occurring or added/synthetic
Data was not adjusted for demographic variables
Potential for falsely significant results
Method for obtaining diabetes diagnosis is a potentially confounding limitation
Diagnosis is self-reported, may not be 100% accurate

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