Skipping breakfast increasingly common nowadays skipping breakfast associated with weight gain and other adverse health outcomes, including insulin resistance and an increased risk for developing type 2 diabetes In T2DM , skipping breakfast associated with a significant increase in HbA1c and all-day PPHG even without overeating in the evening

1. DR VASIF MAYAN M C
M2 UNIT

2. OBJECTIVE
 Explore the effects of skipping breakfast on glycemia after a
subsequent isocaloric (700kcal) lunch and dinner
 HYPOTHESIS : skipping breakfast has been consistently associated
with high HbA1c and PPHG ( Post prandial Hyperglycemia)

3. STUDY DESIGN and METHODS
 Open label Randomised controlled trial – crossover design
 22 individuals with type 2 Diabetes <10yr duration
 HbA1c 7-9%
 Age 30 – 70 yrs
 BMI 22-35 kg/m2

4.  Postprandial hyperglycemia has tremendous effect on HbA1c and
associated with future development of vascular complications even
when glycemic control is restored
 Beta cell secretory function, insulin sensitivity, muscular glucose uptake,
muscle glycogen storage, hepatic glucose output are controlled by
circardian clock
 MEAL TIMINGS are a potent synchronizer of circadian clock

5.  Skipping breakfast increasingly common nowadays
 skipping breakfast associated with weight gain and other adverse
health outcomes, including insulin resistance and an increased risk for
developing type 2 diabetes
 In T2DM , skipping breakfast associated with a significant increase in
HbA1c and all-day PPHG even without overeating in the evening

8.  consumption of a highenergy breakfast and a low-energy dinner results
in a significant reduction of all-day postprandial glycemia
 3 months of a high-energy breakfast led to a 5% reduction in HbA1c
levels in participants with type 2 diabetes

9.  in this study, the skipped breakfast was compensated for by extra calories at
lunch and dinner, making it difficult to determine whether the high glycemic
response was a consequence of breakfast omission or the extra calories

10. Inclusion criteria
 22 individuals with type 2 Diabetes <10yr duration
 HbA1c 7-9%
 Age 30 – 70 yrs
 BMI 22-35 kg/m2

11. Exclusion criteria
 Patients on OHA other than metformin
 Severe Complications of diabetes
 Thyroid/renal/hepatic/pulmonary dysfunction

12. methodology
 2 separate all day meal tests with 2-4 week interval in between
 Advised to take for 2 days prior to test and on day of testing as well.
 EACH 700kcal meal with
 20% FAT, 54% CHO, 26% PROTEIN, 7% FIBER
BREAKFAST LUNCH DINNER
Yes B 8 AM 1 30 PM 7 PM
No B - 1 30 PM 7 PM

13.  Catheter in antecubital vein
 Samples taken at 8am ( O mins)
 0, 15,30,60,90,120,150 and 180 mt after eating commenced

14.  Primary outcome
 Assessment of post prandial glycemia after lunch and dinner
 Secondary outcomes
 Plasma insulin, C-petide, intact GLP-1 (iGLP-1), FFA, Glucagon levels
after lunch and dinner

15. RESULTS
BREAKFAST LUNCH DINNER
YES B NO B YES B NO B YES B NO B
GLUCOSE
Mg/dl
218 124
-43%
192 269
+40%
235 294
+25%
INSULIN
microIU/ml
40.5 11.3
-72%
48.5 36.5
-25%
38.6 34.4
-11%
C Peptide
ng/ml
6.4 2.4
-63%
7.6 6.6
-14%
7.2 6.2
-15%
iGLP -1
pmol/L
16.2 6.4
-60%
18 14
-21%
16 14
-15%
FFA
mmol/L
231 630
+172%
280 381
36%
350 421
20%
Glucagon
pg/ml
130 103
-20%
125 137
10%
132 144
9%

22. Results
 Skipping breakfast lead to higher glycemic index response, High levels
of FFA and Glucagon to a reduced level of insulin
 Breakfast consumption solved the problem!

23. CONCLUSION
 Omission of breakfast in patients with type 2 diabetes is associated
with a significantly higher glycemic response after subsequent lunch
and dinner
 plasma FFA and glucagon levels were significantly higher
 omission of breakfast also resulted in impaired insulin secretion after
lunch and dinner
 breakfast is of major importance for glucose homeostasis including
islet function and incretin hormones throughout the day

24. Second meal phenomenon
 Enhanced β-cell responsiveness at the second meal as induced by the
first meal
 the first and the second phase of insulin release are both influenced
by β-cell memory, and the magnitude of insulin release is enhanced
significantly by previous glucose exposure
 As per this study, this effect is also is extended to dinner

25. No Breakfast day
Absence of glucose elevation because of fasting until noon
Diminish β -cell responsiveness and memory
Reduced and delayed insulin response after lunch and dinner

26.  lower insulin release by β -cells in response to nutrient depletion or
starvation induces lysosomal degradation of nascent secretory insulin
granules
 This is controlled by protein kinase D, a key player in secretory granule
biogenesis

27. GLP - 1
 impaired insulin secretion at lunch and dinner maybe due to
perturbed incretin regulation, because GLP-1 enhance β -cell memory
and sensitivity to glucose.
 higher levels of GLP-1 on the YesB day
 enhance insulin secretion
 reduce glycemic response after lunch and dinner

28. FFA
extension of the overnight fast [NoB day]
Reduced early insulin release
Higher glucose
Higher Glucagon
Higher FFA levels after lunch and dinner

29. FFA
 Inhibit insulin mediated muscle glucose transport
 Induce hepatic insulin resistance
 Increase hepatic glucose production
 Inhibit glycogen synthase after 4-6hr thereby decreasing muscle
glycogen content

30. Glucagon
 -cells producing glucagon become insensitive to the inhibitory effects of
glucose and/or insulin
 lead to postprandial hyperglucagonemia and hepatic glucose
overproduction
 high glucagon levels were observed throughout the NoB day

31. CIRCADIAN CLOCK
circadian misalignment of meal timing
Prolonged fasting [No B]
Altered transcription of circadian clock genes
Impaired glycemia

32.  Postprandial glucose – insulin relationship is characteristic of β cell failure
 This is lost in nocturnal lifestyle group
 CIRCADIAN RHYTHM has role in controlling glycemia

33. SUMMARY
 Extended fasting via breakfast skipping leads to
 plasma FFA levels
 Glucagon
 Insulin
 GLP-1 levels
deleterious effects on all-day glucose metabolism
were reversed by breakfast consumption

34. Old is gold..