Advances in Therapy

, Volume 33, Issue 3, pp 447–459 | Cite as

Obese Patients with Type 2 Diabetes on Conventional Versus Intensive Insulin Therapy: Efficacy of Low-Calorie Dietary Intervention

  • Dimitrios BaltzisEmail author
  • Maria G. Grammatikopoulou
  • Nikolaos Papanas
  • Christina-Maria Trakatelli
  • Evangelia Kintiraki
  • Maria N. Hassapidou
  • Christos Manes
Original Research



The aim of this prospective study was to assess the results of a standard low-calorie dietary intervention (7.5 MJ/day) on body weight (BW) and the metabolic profile of obese patients with type 2 diabetes mellitus (T2DM) on intensive insulin therapy (IIT: 4 insulin injections/day) versus conventional insulin therapy (CIT: 2/3 insulin injections/day).


A total of 60 patients (n = 60, 23 males and 37 postmenopausal females) were recruited and categorized into two groups according to the scheme of insulin treatment. Thirty were on IIT (13 males and 17 females) and an equal number on CIT (10 males and 20 females). BW, body mass index (BMI), HbA1c, and metabolic parameters were compared at 6 and 12 months after baseline.


Significant reductions were observed in the BW, BMI, HbA1c (p ≤ 0.001 for all) and cholesterol (p ≤ 0.05) at 6 months post-intervention. At 1 year, median BW reduction was 4.5 kg (3.3, 5.8) for patients on IIT and 4.8 kg (3.6, 7.0) for those on CIT. The 12-month dietary intervention increased prevalence of normoglycemia in the IIT group and reduced the prevalence of obesity prevalence among the CIT participants (all p < 0.001). CIT patients with BW reduction ≥5.0% demonstrated 11-fold greater chances of being normoglycemic (odds ratio 11.3, 95% CI 1.1–110.5). BW reduction ≥7.0% was associated with CIT, being overweight, and having normal HDLc, LDLc, and cholesterol levels. A reduction in BW between 5.0% and 6.9% was associated with IIT, normoglycemia, and obesity.


A 12-month 1800-kcal dietary intervention achieved significant BW and HbA1c reductions irrespectively of insulin regimen. CIT was associated with BW reduction greater than 8.0%, whereas IIT was associated with higher rates of normoglycemia.


Diet therapy Dietary intervention Insulin Intensive treatment Nutrition Obesity Type 2 diabetes mellitus 



No funding or sponsorship was received for this study or publication of this article. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published.


Dimitrios Baltzis, Maria G. Grammatikopoulou, Nikolaos Papanas, Christina-Maria Trakatelli, Evangelia Kintiraki, Maria N. Hassapidou, and Christos Manes declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Compliance with Ethics Guidelines

The institutional ethics committee of the Papageorgiou General Hospital approved the study and patients gave their informed consent prior to participation.

Supplementary material

12325_2016_300_MOESM1_ESM.pdf (195 kb)
Supplementary material 1 (PDF 194 kb)


  1. 1.
    Galli-Tsinopoulou A, Grammatikopoulou MG, Stylianou C, Emmanouilidou E, Kokka P. Diabese youngsters have 3.7 more chances in developing metabolic syndrome compared with the obese. J Endocrinol Invest. 2010;33:549–53.CrossRefPubMedGoogle Scholar
  2. 2.
    Blonde L. Benefits and risks for intensive glycemic control in patients with diabetes mellitus. Am J Med Sci. 2012;343:17–20.CrossRefPubMedGoogle Scholar
  3. 3.
    Percik R, Stumvoll M. Obesity and cancer. Exp Clin Endocrinol Diabetes. 2009;117:563–6.CrossRefPubMedGoogle Scholar
  4. 4.
    Rorive M, Letiexhe MR, Scheen AJ, Ziegler O. Obesity and type 2 diabetes. Rev Med Liege. 2005;60:374–82.PubMedGoogle Scholar
  5. 5.
    Baker ST, Jerums G, Prendergast LA, Panagiotopoulos S, Strauss BJ, Proietto J. Less fat reduction per unit weight loss in type 2 diabetic compared with nondiabetic obese individuals completing a very-low-calorie diet program. Metabolism. 2012;61:873–82.CrossRefPubMedGoogle Scholar
  6. 6.
    Pataky Z, Bobbioni-Harsch E, Golay A. Obesity: a complex growing challenge. Exp Clin Endocrinol Diabetes. 2010;118:427–33.CrossRefPubMedGoogle Scholar
  7. 7.
    Evert AB, Boucher JL, Cypress M, Dunbar SA, Franz MJ, Mayer-Davis EJ, Neumiller JJ, Nwankwo R, Verdi CL, Urbanski P, Yancy WS Jr. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2014;37(Suppl 1):S120–43.CrossRefPubMedGoogle Scholar
  8. 8.
    Veves A, Baltzis D, Eleftheriadou I. Diabetes treatment: recent developments. Adv Ther. 2013;30:1031–2.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Damon S, Schatzer M, Hofler J, Tomasec G, Hoppichler F. Nutrition and diabetes mellitus: an overview of the current evidence. Wien Med Wochenschr. 2011;161:282–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Mangou A, Grammatikopoulou MG, Mirkopoulou D, Sailer N, Kotzamanidis C, Tsigga M. Associations between diet quality, health status and diabetic complications in patients with type 2 diabetes and comorbid obesity. Endocrinol Nutr. 2012;59:109–16.CrossRefPubMedGoogle Scholar
  11. 11.
    Franz MJ, Powers MA, Leontos C, Holzmeister LA, Kulkarni K, Monk A, Wedel N, Gradwell E. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc. 2010;110:1852–89.CrossRefPubMedGoogle Scholar
  12. 12.
    Sakamoto M, Inoue G, Tsuyusaki K, Usui K, Watanabe M, Irie J, Atsuda K, Yamada S. Comparison of oxidative stress markers in type 2 diabetes: basal bolus therapy versus twice daily premixed insulin analogs. Intern Med. 2010;49:355–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Tesfaye S, Chaturvedi N, Eaton SE, Ward JD, Manes C, Ionescu-Tirgoviste C, Witte DR, Fuller JH, Group EPCS. Vascular risk factors and diabetic neuropathy. N Engl J Med. 2005;352:341–50.CrossRefPubMedGoogle Scholar
  14. 14.
    Ray KK, Seshasai SR, Wijesuriya S, Sivakumaran R, Nethercott S, Preiss D, Erqou S, Sattar N. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet. 2009;373:1765–72.CrossRefPubMedGoogle Scholar
  15. 15.
    Group AC, Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, Marre M, Cooper M, Glasziou P, Grobbee D, Hamet P, Harrap S, Heller S, Liu L, Mancia G, Mogensen CE, Pan C, Poulter N, Rodgers A, Williams B, Bompoint S, de Galan BE, Joshi R, Travert F. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560–72.CrossRefGoogle Scholar
  16. 16.
    Fritsche A, Larbig M, Owens D, Haring HU, Group Gs. Comparison between a basal-bolus and a premixed insulin regimen in individuals with type 2 diabetes-results of the GINGER study. Diabetes Obes Metab. 2010;12:115–23.CrossRefPubMedGoogle Scholar
  17. 17.
    Swinnen SG, Hoekstra JB, DeVries JH. Insulin therapy for type 2 diabetes. Diabetes Care. 2009;32(Suppl 2):S253–9.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Brownell KD. Dieting readiness. Weight Con Dig. 1990;1:5–10.Google Scholar
  19. 19.
    Institute of Medicine. Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity. In: Thomas PR, editor. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington; 1995Google Scholar
  20. 20.
    Nielsen JV, Jonsson E, Nilsson AK. Lasting improvement of hyperglycaemia and bodyweight: low-carbohydrate diet in type 2 diabetes–a brief report. Ups J Med Sci. 2005;110:69–73.CrossRefPubMedGoogle Scholar
  21. 21.
    Connolly J, Romano T, Patruno M. Selections from current literature: effects of dieting and exercise on resting metabolic rate and implications for weight management. Fam Pract. 1999;16:196–201.CrossRefPubMedGoogle Scholar
  22. 22.
    Daly A, Franz M, Holzmeister LA, Kulkarni K, O'Connell B, Wheeler M. New diabetes nutrition resources. J Am Diet Assoc. 2003;103:832–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Institute of Medicine (US). Dietary reference intakes: the essential guide to nutrient requirements. Washington DC: National Academies Press; 2006.Google Scholar
  24. 24.
    American Diabetes Association. Nutrition recommendations and interventions for diabetes. Diabetes Care. 2008;31:S61–78.CrossRefGoogle Scholar
  25. 25.
    Dyson PA, Kelly T, Deakin T, Duncan A, Frost G, Harrison Z, Khatri D, Kunka D, McArdle P, Mellor D, Oliver L, Worth J, Diabetes UKNWG. Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabet Med. 2011;28:1282–8.CrossRefPubMedGoogle Scholar
  26. 26.
    World Health Organisation. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation, vol. 894. World Health Organ Tech Rep SerGeneva. Switzerland: World Health Organisation; 2000.Google Scholar
  27. 27.
    Veves A, Manes C, Murray HJ, Young MJ, Boulton AJ. Painful neuropathy and foot ulceration in diabetic patients. Diabetes Care. 1993;16:1187–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Alberti KG, Zimmet P, Shaw J. Metabolic syndrome—a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med. 2006;23:469-80.CrossRefPubMedGoogle Scholar
  29. 29.
    American Diabetes Association. Standards of medical care in diabetes–2014. Diabetes Care. 2014;37(Suppl 1):S14–80.CrossRefGoogle Scholar
  30. 30.
    Tsakiraki M, Grammatikopoulou MG, Stylianou C, Tsigga M. Nutrition transition and health status of Cretan women: evidence from two generations. Public Health Nutr. 2011;14:793–800.CrossRefPubMedGoogle Scholar
  31. 31.
    Sourial N, Wolfson C, Zhu B, Quail J, Fletcher J, Karunananthan S, Bandeen-Roche K, Beland F, Bergman H. Correspondence analysis is a useful tool to uncover the relationships among categorical variables. J Clin Epidemiol. 2010;63:638–46.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Look ARG, Pi-Sunyer X, Blackburn G, Brancati FL, Bray GA, Bright R, Clark JM, Curtis JM, Espeland MA, Foreyt JP, Graves K, Haffner SM, Harrison B, Hill JO, Horton ES, Jakicic J, Jeffery RW, Johnson KC, Kahn S, Kelley DE, Kitabchi AE, Knowler WC, Lewis CE, Maschak-Carey BJ, Montgomery B, Nathan DM, Patricio J, Peters A, Redmon JB, Reeves RS, Ryan DH, Safford M, Van Dorsten B, Wadden TA, Wagenknecht L, Wesche-Thobaben J, Wing RR, Yanovski SZ. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care. 2007;30:1374–83.CrossRefGoogle Scholar
  33. 33.
    Colagiuri S. Diabesity: therapeutic options. Diabetes Obes Metab. 2010;12:463–73.CrossRefPubMedGoogle Scholar
  34. 34.
    Fritsche A, Haring H. At last, a weight neutral insulin? Int J Obes Relat Metab Disord. 2004;28 Suppl 2:S41–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Bohn B, Scheuing N, Jehle PM, Laubner K, Born B, Merger S, Hummel M, Krakow D, Voll A, Zimmermann A, Zimny S, Holl RW, Dpv, initiatives APV, the German BCNDm and Obesity. Are insulin analogues detemir or glulisine used preferentially in overweight/obese subjects? A German multicentre analysis of 38560 type 2 diabetic patients from the DPV registry. Exp Clin Endocrinol Diabetes. 2014;122:602–7.CrossRefPubMedGoogle Scholar
  36. 36.
    The Diabetes Control and Complications Trial Research Group. The effect of intensive diabetes therapy on measures of autonomic nervous system function in the Diabetes Control and Complications Trial (DCCT). Diabetologia. 1998;41:416–23.CrossRefPubMedCentralGoogle Scholar
  37. 37.
    Shan L, Hao PP, Chen YG. Efficacy and safety of intensive insulin therapy for critically ill neurologic patients: a meta-analysis. J Trauma. 2011;71:1460–4.CrossRefPubMedGoogle Scholar
  38. 38.
    Valensi P, Shaban J, Benroubi M, Kawamori R, Borzi V, Shah S, Wenying Y, Prusty V, Hansen JB, Gumprecht J, Panel ISE. Predictors of achieving HbA(1c) <7% and no hypoglycaemia 6 months after initiation of biphasic insulin aspart 30 in patients with type 2 diabetes in the IMPROVE study. Curr Med Res Opin. 2013;29:601–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Skyler JS, Bergenstal R, Bonow RO, Buse J, Deedwania P, Gale EA, Howard BV, Kirkman MS, Kosiborod M, Reaven P, Sherwin RS. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care. 2009;32:187–92.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Pontiroli AE, Miele L, Morabito A. Increase of body weight during the first year of intensive insulin treatment in type 2 diabetes: systematic review and meta-analysis. Diabetes Obes Metab. 2011;13:1008–19.CrossRefPubMedGoogle Scholar
  41. 41.
    Deakin T. The diabetes pandemic: is structured education the solution or an unnecessary expense? Pract Diabetes. 2011;28:1–7.CrossRefGoogle Scholar
  42. 42.
    Unger J. Uncovering undetected hypoglycemic events. Diabetes Metab Syndr Obes. 2012;5:57–74.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    van Dieren S, Czernichow S, Chalmers J, Kengne AP, de Galan BE, Poulter N, Woodward M, Beulens JW, Grobbee DE, van der Schouw YT, Zoungas S. Weight changes and their predictors amongst 11 140 patients with type 2 diabetes in the ADVANCE trial. Diabetes Obes Metab. 2012;14:464–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Handelsman Y, Bloomgarden ZT, Grunberger G, Umpierrez G, Zimmerman RS, Bailey TS, Blonde L, Bray GA, Cohen AJ, Dagogo-Jack S, Davidson JA, Einhorn D, Ganda OP, Garber AJ, Garvey WT, Henry RR, Hirsch IB, Horton ES, Hurley DL, Jellinger PS, Jovanovic L, Lebovitz HE, LeRoith D, Levy P, McGill JB, Mechanick JI, Mestman JH, Moghissi ES, Orzeck EA, Pessah-Pollack R, Rosenblit PD, Vinik AI, Wyne K, Zangeneh F. American association of clinical endocrinologists and american college of endocrinology—clinical practice guidelines for developing a diabetes mellitus comprehensive care plan—2015. Endocr Pract. 2015;21(Suppl 1):1–87.CrossRefPubMedGoogle Scholar
  45. 45.
    Brown AF, Mangione CM, Saliba D, Sarkisian CA, California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with D. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003;51:S265–80.CrossRefPubMedGoogle Scholar
  46. 46.
    Miller CK, Edwards L, Kissling G, Sanville L. Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: results from a randomized controlled trial. Prev Med. 2002;34:252–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Papanas N, Katsiki N, Putz Z, Mikhailidis DP. Diabetes, obesity and vascular disease–an update. Curr Pharm Des. 2013;19:4900–3.CrossRefPubMedGoogle Scholar
  48. 48.
    Papanas N, Steiropoulos P, Nena E, Tzouvelekis A, Skarlatos A, Konsta M, Vasdekis V, Maltezos E, Bouros D. Predictors of obstructive sleep apnea in males with metabolic syndrome. Vasc Health Risk Manag. 2010;6:281–6.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Fabricatore AN, Wadden TA, Ebbeling CB, Thomas JG, Stallings VA, Schwartz S, Ludwig DS. Targeting dietary fat or glycemic load in the treatment of obesity and type 2 diabetes: a randomized controlled trial. Diabetes Res Clin Pract. 2011;92:37–45.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Rw N. Cholesterol lowering in type 2 diabetes: what is the optimum approach? Clin Diabetes. 2008;26:8–13.CrossRefGoogle Scholar
  51. 51.
    Papazoglou N, Manes C, Chatzimitrofanous P, Papadeli E, Tzounas K, Scaragas G, Kontogiannis I, Alexiades D. Epidemiology of diabetes mellitus in the elderly in northern Greece: a population study. Diabet Med. 1995;12:397–400.CrossRefPubMedGoogle Scholar
  52. 52.
    Symeonidis G, Papanas N, Mavridis G, Maltezos E. Evidence that patients at diagnosis of type 2 diabetes mellitus in Northern Greece are increasingly younger and more obese during the last years. Acta Diabetol. 2003;40:1–2.CrossRefPubMedGoogle Scholar
  53. 53.
    Papanas N, Maltezos E. Antidiabetic treatment: though lovers be lost, love shall not. World J Diabetes. 2012;3:158–60.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Healthcare 2016

Authors and Affiliations

  • Dimitrios Baltzis
    • 1
    • 2
    Email author
  • Maria G. Grammatikopoulou
    • 3
  • Nikolaos Papanas
    • 4
  • Christina-Maria Trakatelli
    • 1
  • Evangelia Kintiraki
    • 1
  • Maria N. Hassapidou
    • 3
  • Christos Manes
    • 5
  1. 1.3rd Department of Internal MedicinePapageorgiou General HospitalThessalonikiGreece
  2. 2.Microcirculation Lab and Joslin-Beth Israel Deaconess Foot CenterHarvard Medical SchoolBostonUSA
  3. 3.Department of Human Nutrition and DieteticsAlexander Technological Educational InstituteThessalonikiGreece
  4. 4.Diabetes Center, Second Department of Internal MedicineDemocritus University of ThraceAlexandroupolisGreece
  5. 5.Diabetes CenterPapageorgiou General HospitalThessalonikiGreece

Personalised recommendations