The purpose of this study was to examine the potential for sustained almond consumption to reduce HbA1c concentrations among individuals with elevated values. A 16-week randomised, parallel-arm, controlled trial was conducted. Eighty-one adults with elevated HbA1c concentrations (> 5·7 %) were randomly assigned to incorporate 2 oz of raw almonds (A: n 39) or energy-matched snacks (C: n 42) into their daily diets. Body weight, body composition, plasma lipids, HbA1c, plasma vitamin E, glycaemia (by meal tolerance test and continuous glucose monitoring), dietary intake and hedonic responses to test foods were measured at stipulated time points. Participants consuming almonds ingested 253 kcal/d more than participants in the control group (P = 0·02), but this did not result in a significant difference in body weight. No statistically significant differences were observed in HbA1c concentrations, blood chemistries, body composition or glycaemia over time or between groups. However, Healthy Eating Index scores improved within the almond group as compared with the control group (P < 0·001). Additionally, the hedonic rating of almonds within the almond group did not decline as markedly as the control group’s reduced liking of the pretzel snack. Alpha-tocopherol increased significantly, and gamma tocopherol tended to decrease in the almond group, indicating compliance with the dietary intervention. Overall, daily ingestion of 2 oz of raw almonds in a self-selected diet for 16 weeks did not alter short-term or longer-term glycaemia or HbA1c concentrations in adults with elevated HbA1c concentrations, but they were well-tolerated hedonically and improved diet quality without promoting weight gain.

Nutritional education is pivotal in the medical nutritional therapy of type 2 diabetes mellitus (T2DM). The extended parallel process model (EPPM) is a health education method for inducing desirable health behaviours. The present study aimed to investigate the effect of nutritional education based on the EPPM in T2DM patients on knowledge, attitude, practice, anthropometric indices, glycaemic factors, lipid profile and adherence to the diabetic diet. A randomised, double-blind, controlled, factorial field trial was designed for T2DM patients aged 30–59 years (n 88). Participants were randomly allocated into four groups to receive EPPM-based nutritional education through gain framed message (GFM), loss framed message (LFM), their combination (G\LFM) or usual diabetic education in the control group (CG). Participants were assessed before and after the study duration. After 3 months of intervention, eighty participants finished the study. The EPPM-based intervention increased participants’ knowledge, behavioural intention, perceived sensitivity, severity, self-efficacy (P < 0·001 for all) and response efficacy (P = 0·029) in comparison with CG. GFM (P = 0·004) and G\FLM (P = 0·034) reduced carbohydrate intake and LFM (P = 0·034) and G\LFM (P = 0·047) decreased fat intake. Between-group analysis indicated interventions reduced weight (P = 0·046), BMI (P = 0·038), fasting blood sugar (P = 0·030), 2-hour postprandial blood glucose (P = 0·027) and TAG (P = 0·002) in comparison with the CG. Results were NS for protein intake, waist and hip circumference, waist:hip ratio, HbA1c, total cholesterol, LDL and HDL. Nutritional education based on EPPM could increase the knowledge and awareness of T2DM patients. Also, it could be beneficial for blood glucose amendment. Further investigations are recommended.

Breakfast is considered as the most important meal of the day. The habit of skipping this meal in adolescence tends to remain until adulthood and has been associated with cardiometabolic risk factors. The present study estimated the prevalence of skipping breakfast and its association with cardiometabolic risk factors. This is a cross-sectional study with data from the Study of Cardiovascular Risks in Adolescents (ERICA), with a nationally representative sample of 36 956 Brazilian adolescents, aged 12–17 years, enrolled in public and private schools. The outcomes were excess body weight (BMI), central obesity (waist circumference and waist:height ratio), lipid profile (total cholesterol (TC), LDL-cholesterol, HDL-cholesterol and TAG) and glycidic profile (fasting glycaemia, fasting insulin and glycated Hb). The association between skipping breakfast and each outcome was estimated using multiple Poisson regression models (prevalence ratio (PR) and 95 % CI). Prevalence of skipping breakfast was 68·7 % and, after adjustments, it was associated with excess body weight (PR = 1·30; 95 % CI 1·18, 1·43), central obesity both by waist circumference (PR = 1·27; 95 % CI 1·00, 1·61) and by waist:height ratio (PR = 1·32; 95 % CI 1·13, 1·54) and high fasting glucose levels (PR = 1·54; 95 % CI 1·09, 2·18), fasting insulin (PR = 1·64; 95 % CI 1·21, 2·22), glycated Hb (PR = 1·16; 95 % CI 1·03, 1·31) and total cholesterol (PR = 1·14; 95 % CI 1·02, 1·27). Skipping breakfast was associated with cardiometabolic risk factors in adolescence. In this context, the school environment is an ideal space to promote healthy eating habits, favouring the implementation of food and nutrition education activities to make adolescents aware of the importance of consuming breakfast daily.

Little is known about the association between dietary choline intake and mortality. We evaluated the link between choline consumption and overall as well as cause-specific mortality by using both individual data and pooling prospective studies by meta-analysis and systematic review. Furthermore, adjusted means of cardiometabolic risk factors across choline intake quartiles were calculated. Data from the National Health and Nutrition Examination Survey (1999–2010) were collected. Adjusted Cox regression was performed to determine the risk ratio (RR) and 95 % CI, as well as random-effects models and generic inverse variance methods to synthesise quantitative and pooling data, followed by a leave-one-out method for sensitivity analysis. After adjustments, we found that individuals consuming more choline had worse lipid profile and glucose homeostasis, but lower C-reactive protein levels (P < 0·001 for all comparisons) with no significant differences in anthropometric parameters and blood pressure. Multivariable Cox regression models revealed that individuals in the highest quartile (Q4) of choline consumption had a greater risk of total (23 %), CVD (33 %) and stroke (30 %) mortality compared with the first quartile (Q1) (P < 0·001 for all comparison). These results were confirmed in a meta-analysis, showing that choline intake was positively and significantly associated with overall (RR 1·12, 95 % CI 1·08, 1·17, I2 = 2·9) and CVD (RR 1·28, 95 % CI 1·17, 1·39, I2 = 9·6) mortality risk. In contrast, the positive association between choline consumption and stroke mortality became non-significant (RR 1·18, 95 % CI 0·97, 1·43, P = 0·092, I2 = 1·1). Our findings shed light on the potential adverse effects of choline intake on selected cardiometabolic risk factors and mortality risk.

We explored the role of lipid accumulation products and visceral adiposity on the association between red meat consumption (RMC) and markers of insulin resistance (IR) and inflammation in USA adults. Data on RMC and health outcome measurements were extracted from the 2005–2010 US National Health and Nutrition Examination Surveys. Overall 16 621 participants were included in the analysis (mean age = 47·1 years, 48·3 % men). ANCOVA and ‘conceptus causal mediation’ models were applied while accounting for survey design. In adjusted models, a lower RMC was significantly associated with a cardio-protective profile of IR and inflammation. BMI had significant mediation effects on the association between RMC and C-reactive protein (CRP), apo B, fasting blood glucose (FBG), insulin, homoeostatic model assessment of IR and β-cell function, glycated Hb (HbA1c), TAG:HDL ratio and TAG glucose (TyG) index (all Ps < 0·05). Both waist circumference and anthropometrically predicted visceral adipose tissue mediated the association between RMC and CRP, FBG, HbA1c, TAG:HDL ratio and TyG index (all Ps < 0·05). Our findings suggest that adiposity, particularly the accumulation of abdominal fat, accounts for a significant proportion of the associations between red meat consumption, IR and inflammation.

We evaluated the effects of high-Ca fat-free milk v. low-Ca control diet on adiposity and on glycaemic control. Fourteen subjects with type 2 diabetes (aged 49·5 (sd 8·6) years, BMI 29·4 (sd 4·5) kg/m2, low habitual Ca consumption (<600 mg/d)) were included in this randomised, crossover clinical trial. Subjects participated in two 12-week experimental sessions (high-Ca fat-free milk (HC) or low-Ca control (LC)) separated by 8-week washout. Subjects daily consumed in the laboratory a breakfast shake containing 700 mg (HC) or 6·4 mg (LC) of Ca. Energy-restricted diets containing 800 mg of dietary Ca/d were prescribed. Dietary records data indicated the consumption of 1200 mg of Ca/d during HC and of 525 mg of Ca/d during LC. There was a greater reduction in body weight, body fat mass, waist circumference and waist:hip ratio after HC. Serum 25-hydoxyvitamin D and homeostatic model assessment-2 β-cell function (HOMA2-%B) increased, and serum uric acid, parathormone (PTH) and glycated Hb (HbA1c) concentrations reduced after HC. In addition, changes from baseline in terms of serum uric acid, glucose, HbA1c and PTH concentrations were lower, and those of HOMA2-%B, serum Ca and 25-hydoxyvitamin D were higher after the HC than after LC. The consumption of approximately three servings of fat-free milk and 1200 mg of dietary Ca/d enhanced weight loss, improved body composition and promoted glycaemic control in subjects with type 2 diabetes and low habitual Ca consumption (<600 mg/d).

Increased attention has been paid to circadian patterns and how predisposition to metabolic disorders can be affected by meal timing. Currently, it is not clear which role can be attributed to the foods selected at meals. On a cross-sectional sub-cohort study (815 adults) within the European Prospective Investigation into Cancer and Nutrition-Potsdam study, we investigated whether the same foods (vegetables, fruits, refined grains, whole grains, red and processed meats) eaten at different meals (breakfast, lunch or dinner) show different associations with biomarkers of cardiometabolic risk. Meal-specific usual intakes were calculated from multiple 24-h dietary recalls. Multivariable-adjusted linear regression models showed that intake of vegetables at breakfast was associated with lower LDL-cholesterol (−0·37 mmol/l per 50 g; 95 % CI −0·61, −0·12) and vegetables at dinner was associated with higher HDL-cholesterol (0·05 mmol/l per 50 g; 95 % CI 0, 0·10). Fruit intake at breakfast was associated with lower glycated Hb (HbA1c) (−0·06 % per 50 g; 95 % CI −0·10, −0·01) and fruits at dinner with lower C-reactive protein (CRP) (−0·21 mg/l per 50 g; 95 % CI −0·42, −0·01). Red and processed meat intake at breakfast was associated with higher HbA1c (0·25 % per 50 g; 95 % CI 0·05, 0·46) and CRP (0·76 mg/l per 50 g; 95 % CI 0·15, 1·36). Our results suggest that by preferring fruits and vegetables and avoiding red and processed meats at specific meals (i.e. breakfast and dinner), cardiometabolic profiles and ultimately chronic disease risk could be improved. Lunch seemed to be a less important meal in terms of food–biomarker associations.

The relationship between serum Mg and blood cell counts in Chinese adult diabetes or central obesity was assessed by investigating 8163 subjects with China Health and Nutrition Survey (mean age 59⋅6 years, 54⋅9 % men). Participants were classified according to blood Mg (below 0⋅65 mmol/l, or 0⋅66–0⋅94 mmol/l or above 0⋅95 mmol/l), type 2 diabetes (yes/no) and central obesity (yes/no). Leucocytes, erythrocytes, platelets (PLT), Hb and glycated Hb (HbA1c) were determined using standardised methods and conditions. HbAc1, leucocytes and PLT were significantly higher among subjects with central obesity than without central obesity (P < 0⋅05). A significant increase for Hb, erythrocytes, PLT, but not leucocytes, across progressive Mg groups was observed in subjects without diabetes (P < 0⋅05). Hb, erythrocytes and HbAc1 were significantly higher among subjects with higher Mg than in subjects with lower Mg with diabetes (P < 0⋅05). Central obesity disturbed the positive association between PLT count and serum Mg. Type 2 diabetes caused metabolism disorder in serum Mg, blood sugar and blood cell count. Hb, erythrocytes and PLT, but not leucocytes, are positively correlated with serum Mg, but this association is somehow disturbed by type 2 diabetes or central obesity.

The primary aim was to investigate the effects of nut and seed consumption on markers of glucose metabolism in adults with prediabetes. Studies with a randomised controlled trial (RCT) design, comparing the effects of a diet containing nuts or seeds against a diet without nuts or seeds in adults with prediabetes, were considered eligible. Primary outcome measures included fasting plasma glucose (FPG), 2-h plasma glucose during oral glucose tolerance test and glycated Hb (HbA1c) concentrations. Studies were identified by searching PubMed and Scopus electronic databases and by checking full texts and reference lists of relevant records. Risk of bias was assessed using the Cochrane Collaboration’s tool. We included five RCT involving 371 adults with prediabetes or at risk of diabetes; three RCT investigated the effects of whole nut consumption and two the effects of ground flaxseed consumption. Consumption of 57 g/d pistachios or mean intake of 60 g/d almonds for 4 months improved FPG and fasting plasma insulin (FPI) concentrations, insulin resistance, cellular glucose uptake in lymphocytes and β-cell function. Consumption of 56 g/d walnuts for 6 months was not found to affect FPG or HbA1c concentrations. Consumption of 13 g/d flaxseed for 3 months improved FPG and FPI concentrations and insulin resistance. In a second study, however, flaxseed consumption was not found to affect markers of glucose metabolism. The risk of bias was generally low, thus the reported results could be reliable. Further investigation of nut and seed consumption effects in the field of prediabetes is warranted.

Diabetes mellitus is a global epidemic, characterised as a heterogeneous group of metabolic disorders associated with high risk of CVD. Green banana biomass, which is composed of resistant starches (RS) and cannot be hydrolysed by amylases, delays gastric emptying and modulates insulin sensitivity, thus contributing to improve metabolic disorders. The aim of the present study was to investigate the effects of consumption of RS from green banana biomass on body composition, fasting plasma glucose, glycated Hb (HbA1c) and homeostasis model assessment of insulin resistance in subjects with pre-diabetes or type 2 diabetes on top of treatment. Middle-aged subjects (n 113) of both sexes with pre-diabetes (HbA1c: 5·7–6·4 %) or diabetes (HbA1c ≥ 6·5 %) were randomised to receive nutritional support plus green banana biomass (40 g) (RS: approximately 4·5 g, G1, n 62) or diet alone (G2, n 51) for 24 weeks. Body composition, biochemical analyses and dietary intake were evaluated at the beginning and end of the study. In the experimental group (G1), consumption of RS was associated with reduction in HbA1c (P = 0·0001), fasting glucose (P = 0·021), diastolic blood pressure (P = 0·010), body weight (P = 0·002), BMI (P = 0·006), waist and hip circumferences (P < 0·01), fat mass percentage (P = 0·001) and increase in lean mass percentage (P = 0·011). In controls (G2), reductions were observed in waist and hip circumferences (P < 0·01), HbA1c (P = 0·002) and high-density lipoprotein-cholesterol (P = 0·020). In pre-diabetes or diabetes, non-significant differences were observed in the percentage reduction in HbA1c and fasting glucose in exploratory analyses. Our results indicate that the consumption of bioactive starches is a good dietary strategy to improve metabolic control and body composition.

Unfavourable dietary habits, such as skipping breakfast, are common among ethnic minority children and may contribute to inequalities in cardiometabolic disease. We conducted a longitudinal follow-up of a subsample of the UK multi-ethnic Determinants of Adolescent Social well-being and Health cohort, which represents the main UK ethnic groups and is now aged 21–23 years. We aimed to describe longitudinal patterns of dietary intake and investigate their impact on cardiometabolic risk in young adulthood. Participants completed a dietary behaviour questionnaire and a 24 h dietary intake recall; anthropometry, blood pressure, total cholesterol and HDL-cholesterol and HbA1c were measured. The cohort consisted of 107 White British, 102 Black Caribbean, 132 Black African, 98 Indian, 111 Bangladeshi/Pakistani and 115 other/mixed ethnicity. Unhealthful dietary behaviours such as skipping breakfast and low intake of fruits and vegetables were common (56, 57 and 63 %, respectively). Rates of skipping breakfast and low fruit and vegetable consumption were highest among Black African and Black Caribbean participants. BMI and cholesterol levels at 21–23 years were higher among those who regularly skipped breakfast at 11–13 years (BMI 1·41 (95 % CI 0·57, 2·26), P=0·001; cholesterol 0·15 (95 % CI –0·01, 0·31), P=0·063) and at 21–23 years (BMI 1·05 (95 % CI 0·22, 1·89), P=0·014; cholesterol 0·22 (95 % CI 0·06, 0·37), P=0·007). Childhood breakfast skipping is more common in certain ethnic groups and is associated with cardiometabolic risk factors in young adulthood. Our findings highlight the importance of targeting interventions to improve dietary behaviours such as breakfast consumption at specific population groups.

There is emerging evidence that glycaemic variability (GV) plays an important role in the development of diabetic complications. The current study aimed to compare the effects of lifestyle intervention (LI) with and without partial meal replacement (MR) on GV. A total of 123 patients with newly diagnosed and untreated type 2 diabetes (T2D) were randomised to receive either LI together with breakfast replacement with a liquid formula (LI+MR) (n 62) or LI alone (n 61) for 4 weeks and completed the study. Each participant was instructed to have three main meals per d and underwent 72-h continuous glucose monitoring (CGM) both before and after intervention. Measures of GV assessed by CGM included the incremental AUC of postprandial blood glucose (AUCpp), standard deviation of blood glucose (SDBG), glucose CV and mean amplitude of glycaemic excursions (MAGE). After a 4-week intervention, the improvements in systolic blood pressure (P=0·046) and time in range (P=0·033) were more pronounced in the LI+MR group than in the LI group. Furthermore, LI+MR caused significantly greater improvements in all GV metrics including SDBG (P=0·005), CV (P=0·002), MAGE (P=0·016) and AUCpp (P<0·001) than did LI. LI+MR (v. LI) was independently associated with improvements in GV after adjustment of covariates (all P<0·05). Our study showed that LI+MR led to significantly greater improvements in GV compared with LI, suggesting that LI+MR could be an effective treatment to alleviate glucose excursions.

Elevated circulating cholesterol levels are a risk factor for CVD which is also associated with sub-optimal vascular function. There is emerging evidence that anthocyanins can cause beneficial cardio-protective effects by favourably modulating lipoprotein profiles. We compared the effects of blood orange juice which is rich in anthocyanins and blonde orange juice without anthocyanins on LDL-cholesterol and other biomarkers of CVD risk, vascular function and glycaemia. In all, forty-one participants (aged 25–84 years) with a waist circumference >94 cm (men) and >80 cm (women) completed a randomised, open label, two-arm cross-over trial. For 28 d participants ingested (i) 500 ml blood orange juice providing 50 mg anthocyanins/d and (ii) 500 ml blonde orange juice without anthocyanins. There was a minimum 3-week washout period between treatments. LDL-cholesterol and other biomarkers associated with CVD risk and glycaemia were assessed at the start and end of each treatment period. No significant differences were observed in total, HDL- and LDL-cholesterol, TAG, glucose, fructosamine, nitric oxide, C-reactive protein, aortic systolic blood pressure and diastolic blood pressure or carotid-femoral and brachial-ankle pulse wave velocity after 28 d ingestion of blood orange juice compared with standard orange juice. The lack of effect on LDL-cholesterol may be due to the modest concentration of anthocyanins in the blood orange juice.

CVD is the leading cause of death worldwide. Diet is a key modifiable component in the development of CVD. No official UK diet quality index exists for use in UK nutritional epidemiological studies. The aims of this study are to: (i) develop a diet quality index based on components of UK dietary reference values (DRV) and (ii) determine the association between the index, the existing UK nutrient profile (NP) model and a comprehensive range of cardiometabolic risk markers among a British adult population. A cross-sectional analysis was conducted using data from the Airwave Health Monitoring Study (n 5848). Dietary intake was measured by 7-d food diary and metabolic risk using waist circumference, BMI, blood lipid profile, glycated Hb (HbA1c) and blood pressure measurements. Diet quality was assessed using the novel DRV index and NP model. Associations between diet and cardiometabolic risk were analysed via multivariate linear models and logistic regression. A two-point increase in NP score was associated with total cholesterol (β −0·33 mmol/l, P<0·0001) and HbA1c (β −0·01 %, P<0·0001). A two-point increase in DRV score was associated with waist circumference (β −0·56 cm, P<0·0001), BMI (β −0·15 kg/m2, P<0·0001), total cholesterol (β −0·06 mmol/l, P<0·0001) and HbA1c (β −0·02 %, P=0·002). A one-point increase in DRV score was associated with type 2 diabetes (T2D) (OR 0·94, P=0·01) and obesity (OR 0·95, P<0·0001). The DRV index is associated with overall diet quality and risk factors for CVD and T2D, supporting its application in nutritional epidemiological studies investigating CVD risk in a UK population.

This study was conducted to elucidate the effects of decaffeinated green coffee bean extract (GCE) on anthropometric indices, glycaemic control, blood pressure, lipid profile, insulin resistance and appetite in patients with the metabolic syndrome (Mets). Subjects were randomly allocated to consume 400 mg GCE or placebo capsules twice per d for 8 weeks. Both groups were advised to follow an energy balanced diet. After GCE supplementation, systolic blood pressure (SBP) significantly reduced compared with the placebo group (−13·76 (sd 8·48) v. −6·56 (sd 9·58) mmHg, P=0·01). Also, GCE treatment significantly reduced fasting blood glucose (FBS) (−5·15 (sd 60·22) v. 29·42 (sd 40·01) mg/dl (−0·28 (SD 3·34) v. 1·63 (SD 2·22) mmol/l); P=0·03) and homoeostatic model of assessment of insulin resistance in comparison to placebo (−1·41 (sd 3·33) v. 1·23 (sd 3·84), P=0·02). In addition, waist circumference (−2·40 (sd 2·54) v. −0·66 (sd 1·17) cm, P=0·009) and appetite score (−1·44 (sd 1·72) v. −0·2 (sd 1·32), P=0·01) of the individuals supplemented with GCE indicated a significant decline. Besides, weight and BMI reduction in the intervention group was almost twice as much as the placebo group; however, this discrepancy was marginally significant (weight: −2·08 (sd 2·11) v. −0·92 (sd 1·30) kg, P=0·05). No difference was observed in terms of glycated Hb (HbA1c) percentage and lipid profile parameters between the two groups. To sum up, GCE administration had an ameliorating effect on some of the Mets components such as high SBP, high FBS and Mets main aetiological factors including insulin resistance and abdominal obesity. Furthermore, GCE supplementation could reduce appetite level.

Animal studies indicate that the composition of gut microbiota may be involved in the progression of insulin resistance to type 2 diabetes. Probiotics and/or prebiotics could be a promising approach to improve insulin sensitivity by favourably modifying the composition of the gut microbial community, reducing intestinal endotoxin concentrations and decreasing energy harvest. The aim of the present review was to investigate the effects of probiotics, prebiotics and synbiotics (a combination of probiotics and prebiotics) on insulin resistance in human clinical trials and to discuss the potential mechanisms whereby probiotics and prebiotics improve glucose metabolism. The anti-diabetic effects of probiotics include reducing pro-inflammatory cytokines via a NF-κB pathway, reduced intestinal permeability, and lowered oxidative stress. SCFA play a key role in glucose homeostasis through multiple potential mechanisms of action. Activation of G-protein-coupled receptors on L-cells by SCFA promotes the release of glucagon-like peptide-1 and peptide YY resulting in increased insulin and decreased glucagon secretion, and suppressed appetite. SCFA can decrease intestinal permeability and decrease circulating endotoxins, lowering inflammation and oxidative stress. SCFA may also have anti-lipolytic activities in adipocytes and improve insulin sensitivity via GLUT4 through the up-regulation of 5'-AMP-activated protein kinase signalling in muscle and liver tissues. Resistant starch and synbiotics appear to have favourable anti-diabetic effects. However, there are few human interventions. Further well-designed human clinical studies are required to develop recommendations for the prevention of type 2 diabetes with pro- and prebiotics.

Dietary behaviour modification may change eating habits and reduce the impact of poor nutrition. This study aimed to evaluate the effects of daily consumption of a healthier snack bar on snacking habits and glycated Hb (HbA1c) within a 6-week intervention. In all, twenty-eight participants were randomly allocated to two groups to either consume the bars as the main snack for 6 weeks (n 14) or receipt of the bars was delayed for 6 weeks (n 14) following a stepped-wedge design. All participants had HbA1c concentrations measured at weeks −1, 0, 4, 6, 10 and 12. A short dietary habits questionnaire was self-completed at weeks 0, 6 and 12. Participants consumed the bars they received instead of other snacks, and found that the healthier snack bar was acceptable as part of their daily dietary pattern. Over the 12 weeks, there was a significant reduction in intake of biscuits, cakes and pies (approximately 2 servings/week, P<0·05) in both groups. Fruit juice intake was reduced (approximately 1 serving/week, P=0·029) in the first group. In all, twenty participants (71·4 %) experienced a decrease (n 15) or no change (n 5) in HbA1c (range 0–4 mmol/mol), whereas eight participants experienced an increase in HbA1c (range 0·5–2·5 mmol/mol). There was high compliance with the healthier snack intervention and a trend towards a favourable effect on glucose homoeostasis. Habitual snacking behaviour has the potential to be improved through changes in the food supply, and in the longer term may reduce the impact of poor nutrition on public health.

The aim of this study was to analyse the association between plain water intake and glycated Hb (HbA1c) in the National Diet and Nutrition Survey (2008–2012) rolling survey. These data included diet (4-d diaries) and HbA1c (fasted blood sample) measures of 456 men and 579 women aged 44 (sd 18) years with full information on covariates of interest (age, ethnicity, BMI, smoking status, education, other beverage intake, energy intake and fibre). Data were analysed using sex-stratified linear and logistic regressions modelling the associations of cups per d (240 ml) of plain water with HbA1c, and odds of HbA1c≥5·5 %, respectively. Substitution analyses modelled the replacement of sugar-sweetened beverages, fruit juice and artificially sweetened beverages with plain water. After adjustment, 1 cup/d of plain water was associated with a −0·04 % lower HbA1c (95 % CI −0·07, −0·02) in men. In logistic regression, men had a 22 % (95 % CI 10, 32 %) reduced odds of HbA1c≥5·5 %/cup per d of plain water. There was no evidence of an association with either HbA1c or odds of HbA1c≥5·5 % in women. None of the substitution models was associated with a change in odds of HbA1c≥5·5 %. Plain water intake was associated with lower HbA1c in men but not in women. Substituting water for specific beverages was not associated with a reduced odds of HbA1c≥5·5 %, suggesting that the addition of water is the more pertinent factor. Future trials should test whether the relationships between water intake and HbA1c is causal as this could be a cost-effective and simple health intervention.

Research points to postprandial glucose and TAG measures as preferable assessments of cardiovascular risk as compared with fasting values. Although elevated postprandial glycaemic and lipaemic responses are thought to substantially increase chronic disease risk, postprandial glycaemia and lipaemia have historically only been considered separately. However, carbohydrates and fats can generally ‘compete’ for clearance from the stomach, small intestine, bloodstream and within the peripheral cell. Further, there are previous data demonstrating that the addition of carbohydrate to a high-fat meal blunts the postprandial lipaemic response, and the addition of fat to a high-carbohydrate meal blunts the postprandial glycaemic response. Thus, postprandial glycaemia and lipaemia are interrelated. The purpose of this brief review is 2-fold: first, to review the current evidence implicating postprandial glycaemia and lipaemia in chronic disease risk, and, second, to examine the possible utility of a single postprandial glycaemic and lipaemic summative value, which will be referred to as the metabolic load index. The potential benefits of the metabolic load index extend to the clinician, patient and researcher.