Omega-3 Fatty Acids and Diabetic
A.V. Mali, S.S. Bhise, and Surendra S. Katyare
Diabetes mellitus (DM)—one of the most common diseases—
known to mankind from the oldest time, as reported in
Egyptian manuscript about 3000 years ago, has become a
serious global problem today. However, the clear-cut dis-
tinction between type 1 and type 2 DM was made only in 1936
. DM is characterized by elevated blood glucose levels in
the body due to either impaired response of cells to insulin in
type 2 diabetes or its insufﬁcient synthesis in the body in type 1
diabetes . When cells do not utilize glucose in adequate
quantities, it accumulates in the blood leading to hyper-
glycemia. Diabetes is also associated with accelerated
atherosclerotic disease affecting arteries that supply the heart,
brain, and lower extremities. All forms of diabetes are char-
acterized by hyperglycemia which in turn leads to complica-
tions viz. nephropathy, cardiomyopathy, retinopathy,
neuropathy, and loss of RBC deformability which result due to
macro- and micro-angiopathy .
Liver plays a central role in lipid metabolism including
that of de novo synthesis of fatty acids. The liver also
modiﬁes fatty acid structure through metabolic pathways
that include desaturation, elongation, mono-oxidation, and
peroxisomal oxidation (chain shortening). These pathways
are particularly critical for the generation of end products of
polyunsaturated fatty acid (PUFA) synthesis. Thus, starting
with alpha-linolenic acid (ALA, 18:2, n-3) liver synthesizes
two major omega-3 fatty acids viz. eicosapentaenoic acid
(EPA, 20:5, n-3) and docosahexaenoic acid (DHA, 22:6,
n-3) which are important and essential for membrane
structure–function relationships. Arachidonic acid (20:4,
n-6) and DHA are the main C20–22 PUFAs present in
membranes of all tissues including that of RBC membrane
. It has been reported that in diabetes, the elongase and
desaturase activities decrease signiﬁcantly which result in
membrane lipid deformability . The ensuing membrane
lipid deformability could also contribute to diabetic com-
plications . It also has been widely reported that there is a
deﬁciency in essential fatty acid metabolism in both human
and animal diabetes [7,8].
The dietary sources of omega-3 fatty acids include ﬁsh
and seafood which are rich in EPA and DHA. Oily ﬁsh such
as salmon, trout, sardines, anchovies, mackerel, and herring
are the best sources. The other omega-3 fatty acid, ALA, is
found in plant-based foods such as ﬂaxseeds, ﬂax oil, wal-
nuts, canola oil, and soybean.
The dietary n-3 polyunsaturated fatty acids (PUFAs) have
been associated with various important functions such as
anti-inﬂammatory effects, improving endothelial function,
controlling the blood pressure, and reducing hypertriglyc-
eridemia and insulin insensitivity. According to some epi-
demiologic studies, a lower prevalence of Type 2DM was
found in populations consuming large amounts of seafood
products, which are rich in n-3 PUFAs .
The link between omega-3 fatty acids and diabetes and its
complications has not been clear so far. Some studies have
revealed protective effects with appropriate intakes of
omega-3 fatty acid, while others have found no association
at all; some researchers have even hinted that high omega-3
intakes might augment risk of diabetes. Numerous in vitro
and in vivo studies have been carried out in respect of
omega-3 fatty acids and diabetic complications. The present
review tries to summarize the reported effects and role of
omega-3 and omega-6 PUFAs in nutrition and metabolism
on diabetic complications viz. nephropathy, cardiomyopa-
thy, retinopathy, neuropathy, and loss of RBC deformability.
A.V. Mali S.S. Bhise S.S. Katyare (&)
Center for Innovation in Nutrition, Health and Diseases, IRSHA,
Bharati Vidyapeeth Deemed University, Medical College
Campus, Dhankawadi, Katraj, Pune, 411043, Maharashtra, India
©Springer International Publishing Switzerland 2016
M.V. Hegde et al. (eds.), Omega-3 Fatty Acids, DOI 10.1007/978-3-319-40458-5_16
Omega-3 and Diabetic Nephropathy
Diabetes is the leading cause of end-stage renal disease. The
complex metabolic, vascular, and inﬂammatory perturba-
tions that characterize DM often lead to progressive albu-
minuria, renal injury, and dysfunction: Diabetic renal
nephropathy (DN) and the observed complications seem to
be related to the altered membrane fatty acid composition
In type 1 diabetes, dietary n-3 LCPUFAs appear inversely
associated with the degree, but not with the incidence of
albuminuria . In experimental settings and in epidemi-
ologic studies, intake of omega-6 fatty acids was associated
with reduced albuminuria. Apparently, PUFAs do not seem
to attenuate glomerular dysfunction. However, the presently
available evidence is insufﬁcient to rule out such an effect.
The authors suggest that further research is necessary to
establish the potential of PUFA consumption and supple-
mentation in DN .
In double-blind placebo-controlled trial, it was found that
12 weeks of ﬁsh oil supplement had no beneﬁcial effect on
vascular endothelial function, but improved renal function.
Thus, serum creatinine level was signiﬁcantly lower in ﬁsh
oil-treated type 2 DM patients .
In meta-analysis, in chronic kidney disease, it was found
that the use of n-3 long-chain PUFA (LCPUFA) reduced
urinary protein excretion, but there was no decline in the
glomerular ﬁltration rate (GFR). However, in view of small
number of participants in trials, different methods of
assessing proteinuria and GFR, the authors suggest that
large, high-quality trials are warranted for reliable clinical
In animal studies, it was found that in streptozotocin–
diabetic rats, twenty four hour urinary albumin excretion
was signiﬁcantly increased compared to the non-diabetic
control; gamma linolenic acid (GLA) treatment signiﬁcantly
reduced albuminuria. Intercellular adhesion molecule-1
(ICAM-1), monocyte chemoattractant protein-1 (MCP-1),
ﬁbronectin (FN) mRNA, and protein expression levels were
signiﬁcantly higher in DM kidneys, and these increases were
signiﬁcantly lowered by GLA treatment. Under in vitro
conditions, in the presence of high glucose concentration,
GLA signiﬁcantly inhibited increases in MCP-1 mRNA
expression and protein levels in mesangial and tubular
epithelial cells; ICAM-1 and FN expression showed a pat-
tern similar to the expression of MCP-1. Thus, GLA atten-
uated inﬂammation by two mechanisms: by inhibiting
enhanced MCP-1 and ICAM-1 expression as well as by
preventing the accumulation of extracellular matrix
(ECM) in diabetic nephropathy .
Eicosapentaenoic acid (EPA) has been reported to have
beneﬁcial effects on the progression of various renal diseases
including diabetic nephropathy. In KKA(y)/Ta mice, EPA
improved type 2 diabetic nephropathy possibly by attenua-
tion of metabolic abnormalities and inhibition of renal
inﬂammation, oxidative stress, and TGF beta expression
. Monocyte chemoattractant protein-1 (MCP-1) regu-
lating macrophage recruitment protein is known to be
up-regulated in patients with diabetic nephropathy. In type 2
diabetic KKA(y)/Ta mice, EPA ameliorated diabetic
nephropathy which would suggest that the observed
down-regulation of MCP-1 is critically involved in the
beneﬁcial effect of EPA, probably in concert with
improvement of other clinical parameters .
Omega-3 and Diabetic Retinopathy
The potential pathogenic mechanisms that may predispose to
diabetic retinopathy include the following: platelet dys-
function, altered eicosanoid production, increased blood
viscosity in association with impaired cell deformability, and
pathologic leukocyte/endothelium interaction. Omega-3
fatty acids exert several important biological effects on
these factors .
The vasodegenerative phase of diabetic retinopathy is
characterized by retinal vascular degeneration as also by the
inadequate vascular repair due to compromised bone
marrow-derived endothelial progenitor cells (EPCs). It is
proposed that in diabetes, n-3 PUFA deﬁciency results in
activation of acid sphingomyelinase (ASM), the central
enzyme of sphingolipid metabolism; ASM represents a
molecular metabolic link connecting the initial damage in the
retina and the dysfunction of EPCs . ASM is an important
early responder in inﬂammatory cytokine signaling. The
endothelial caveolae-associated ASM is believed to be an
essential component in mediating inﬂammation and vascular
pathology in in vivo and in vitro models of diabetic
retinopathy. Human retinal endothelial cells (HREC), as
against glial and epithelial cells, express the plasma mem-
brane form of ASM that overlaps with caveolin-1. Treatment
of HREC with DHA speciﬁcally reduced expression of the
caveolae-associated ASM, prevented tumor necrosis factor-a
(TNFa)-induced increase in the ceramide-to-sphingomyelin
ratio in the caveolae, and inhibited cytokine-induced
inﬂammatory signaling. ASM is expressed in both vascular
and neuroretina. Interestingly, however, only vascular ASM
is speciﬁcally increased in the retinas of animal models at the
vasodegenerative phase of diabetic retinopathy [20,21].
In type 2 diabetes animal model, DHA-rich diet pre-
vented diabetes-induced increase in the number of retinal
acellular capillaries and signiﬁcantly enhanced the life span
of type 2 diabetic animals by blocking the up-regulation of
ASM and other inﬂammatory markers in diabetic retina.
DHA-rich diet also normalized the numbers of circulating
EPCs, improved EPC colony formation, and prevented the
222 A.V. Mali et al.
increase in ASM activity in EPCs . The absence of ASM
in ASM(-/-) mice or inhibition of ASM activity by DHA
prevents acellular capillary formation .
Oxidative stress and inﬂammation play a signiﬁcant role in
the pathobiology of diabetic retinopathy. It is suggested that
increased consumption of PUFAs may prevent or postpone the
occurrence of diabetic retinopathy. In STZ–diabetic rats with
retinopathy, changes in serum glutathione peroxidase,
brain-derived neurotrophic factor (BDNF), vascular endothelial
growth factor (VEGF), and interleukin 6 (IL-6) reverted to near
control by ALA treatment, especially in ALA + STZ
group. The observations lend support to the concept that both
oxidative stress and inﬂammation are involved in DR, and ALA
treatment is of beneﬁt in its prevention .
Diabetes increases oxidative stress, nitrotyrosine con-
centrations, and apoptosis in the retina. As a consequence,
the total thickness of retinas decreases signiﬁcantly com-
pared to that in the control rats. In particular, in the diabetic
rats the thickness of the outer and inner nuclear layers was
reduced signiﬁcantly, and loss of ganglion cell layer
(GCL) is evident. Administration of insulin and DHA, and
lutein alone or in combination with insulin could prevent
these retinal changes. In the diabetic rats the electroretino-
gram showed impairment of b-wave amplitude and latency
time. DHA and lutein prevented all these changes even
under hyperglycemic conditions. Lutein and DHA were able
to normalize all the diabetes-induced biochemical, histo-
logical, and functional modiﬁcations. In view of the
observed beneﬁcial effects relating to the cell death mecha-
nisms, further studies to evaluate the use of insulin and
DHA, and lutein as potential adjuvant therapies to help
prevent vision loss in diabetic patients, are desirable .
In db/db mice, n-3 PUFA diet signiﬁcantly preserved
retinal function to levels similar to those observed in
non-diabetic control mice on normal chow. Conversely,
retinal function gradually deteriorated on-6 PUFA-rich diet.
Also, in the n-3 PUFA-fed mice there was an enhanced
ability to respond to glucose challenge. Interestingly, the
protection of visual function was independent of cytopro-
tective or anti-inﬂammatory effects of n-3 PUFAs.
In T2DM mice, dietary n-3 PUFA preserved retinal
function which is consistent with the notion that with dys-
lipidemia it negatively impacts retinal function. Keeping in
mind the beneﬁcial effects of dietary n-3 PUFAs on visual
function, the authors suggest that increasing n-3 PUFA
intake in diabetic patients may slow the progression of
vision loss in T2DM .
The n-3 LCPUFAs inﬂuence retinal cell gene expression,
cellular differentiation, and cellular survival. DHA is a major
structural fatty acid of retinal photoreceptor outer segment
membranes and hence can inﬂuence the function of the
photoreceptor membrane. DHA activates a number of
nuclear hormone receptors which in turn operate as
transcription factors for molecules that modulate oxidation–
reduction sensitive and proinﬂammatory processes. DHA
can also affect the retinal cell signaling mechanisms
involved in phototransduction. Thus, DHA may play a major
role in signaling cascades by enhancing activation of
membrane-bound retinal proteins and may also be involved
in rhodopsin regeneration. Evidently, insufﬁciency of DHA
is associated with alterations in retinal function .
Hammes et al. maintained STZ–diabetic rats on ﬁsh oil
(750 mg Maxepa, 5 times per week for six months), con-
taining 14 % eicosapentaenoic acid (EPA) and 10 %
docosahexaenoic acid. The treatment resulted in a twofold
increase of EPA in total fatty acids and a reduction in the
thromboxane 2/3 ratio from 600 (untreated diabetic rats) to
50 (treated diabetic rats). However, despite these biochem-
ical changes, diabetes-associated pericyte loss remained
unaffected, and the formation of acellular, occluded capil-
laries was increased by 75 %. Based on these observations,
the authors concluded that dietary ﬁsh oil supplementation
may be harmful for the diabetic microvasculature in the
retina. These results are in contradiction with the beneﬁcial
effects cited above . However, it may be pointed out that
in the studies by Hammes et al., the doses of DHA and EPA
were several times higher and also for a longer duration
(20 weeks). It is therefore possible that the undesirable
adverse effects ensued due to over dosages and treatment for
prolonged period. As against this in the former studies, the
authors treated the STZ–diabetic rats with 13.3 mg DHA/kg
body weight for a period of 12 weeks .
Lipid composition of retinal membranes reﬂected the
dietary manipulation. In STZ–diabetic rats, diabetes ampli-
ﬁed some fatty acid changes consistent with reduced desat-
urase activity that was evident. Diabetes produced
signiﬁcant reduction in rod function (−33 %) only in the
absence of ﬁsh oil, whereas cone responses (−46 %) and
inner retinal oscillatory potentials (−47 %) showed either no
effect of diet or a partial diet effect with a signiﬁcant diabetes
effect. A diet balanced in long-chain PUFAs modiﬁes retinal
lipid membranes in diabetes and prevents rod dysfunction.
Dietary modiﬁcation was not found in the cone or glial
response, but a partial improvement was evident in the
oscillatory potentials (OPs), most likely secondary to the
larger photoreceptor output .
Omega-3 and Diabetic Cardiomyopathy
The worldwide increasing prevalence of T2DM poses an
immense public health hazard leading to a variety of com-
plications, such as cardiovascular diseases, nephropathy, and
Omega-3 polyunsaturated fatty acids (PUFAs) offer pro-
tection against cardiovascular disease which is one of the
16 Omega-3 Fatty Acids and Diabetic Complications 223
major causes of death in patients with DM by virtue of their
antihyperlipidemic, antihypertensive, anti-inﬂammatory, and
other properties. Omega-6 PUFAs are also cardioprotective
In type 2 diabetic patients, without or with autonomic
neuropathy and normal healthy subjects, BP and ECG were
monitored during a 24 h period and during a 2 hr hyper-
glycemic clamp. Delta QTc during the night was blunted in
diabetics and delta LF/HF was decreased in patients with
autonomic neuropathy. In hyperglycemia, QTc and LF/HF
increased signiﬁcantly in normal healthy subjects while in
patients without autonomic neuropathy only LF/HF
increased. A 6 month treatment with n-3 PUFA partially
restored delta LF/HF and delta QTc only in patients without
autonomic neuropathy .
Studies on heart rate variability (HRV) and n-3 PUFA
have been performed in several populations such as patients
with ischemic heart disease, diabetes mellitus, and chronic
renal failure, and in healthy subjects. These studies have
demonstrated a positive association between cellular content
of n-3 PUFA and HRV. Also, supplementation with n-3
PUFA increased HRV and thereby decreased the risk of
arrhythmic events and provided protection against sudden
cardiac death (SCD) .
Administration of formulation omega-3 with Fenugreek
terpenenes (Om3/terp) considerably inhibited key enzymes
related to diabetes. Thus, a-amylase activity decreased by 46
and 52 %, and maltase activity decreased by 37 and 35 %,
respectively, in pancreas and plasma. Additionally, this
supplement helped protect the b-cells of the experimental
animals from death and damage. Interestingly, the formula-
tion of Om3/terp also modulated key enzyme related to
hypertension and angiotensin-converting enzyme (ACE) by
37 % in plasma and kidney. Administration of fenugreek
essential oil to surviving diabetic rats improved starch and
glucose oral tolerance additively. Om3/terp also signiﬁcantly
decreased the levels of glucose, triglyceride (TG), total
cholesterol (TC), and LDL cholesterol (LDL-C) in the
plasma and liver of diabetic rats and increased the HDL
cholesterol (HDL-C) level, which helps in maintaining the
homeostasis of blood lipids. Taken together, the ﬁndings
suggest that this formulation of Om3/terp exhibits attractive
properties and can, therefore, be considered for future
application in the development of anti-diabetic,
anti-hypertensive, and hypolipidemic foods .
It has been suggested that omega-3 FA treatment partially
blocks the development of experimental diabetic cardiomy-
opathy possibly by affecting sarcoplasmic reticulum calcium
transport activity . Diabetic cardiomyopathy has also been
associated with a decrease in Na
-ATPase activity and
expression as well as alterations in membrane lipid compo-
sition. Diabetes signiﬁcantly decreased activities of alpha 1
(a1) and alpha 2 (a2) isoforms and mRNA levels of a2 and
beta 1(b1) isoforms. At the protein level, a1-isoform
increased, while both a2- and b1-isoforms decreased. Chan-
ges in fatty acid content of the membrane were consistent with
the inhibition of desaturase activity; supplementation with
ﬁsh oil produced an increase in the incorporation of EPA in
the membrane. Supplementation with ﬁsh oil also increased
the level of b1-isoforms and restored the activity of the
a2-isoenzyme without signiﬁcant changes in the level of a1-
and a2-isoforms. Based on these studies, the authors suggest
that ﬁsh oil therapy may be effective in preventing some of the
adverse consequences of diabetic cardiomyopathy .
In patients with type 2 DM and cardiovascular autonomic
neuropathy, combined treatment with n-3 PUFA, benfoti-
amine, and a-lipoic acid resulted in signiﬁcant positive
changes in TC, TG, and LDL and HDL cholesterol levels.
However, the efﬁcacy of this treatment was not related to the
improved compensation of DM, but was due to the direct
inﬂuence of pharmacological agents on the metabolic rate
Diets higher in ﬁsh and omega-3 LCPUFA may reduce
cardiovascular risk in diabetes by inhibiting platelet aggre-
gation, improving lipid proﬁles, and reducing cardiovascular
mortality. Fish and omega-3 LCPUFA can be recommended
to people with diabetes and included into a diabetes man-
agement program .
In STZ–diabetic rat model, the myocardial levels of
matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of
matrix metalloproteinase-4 (TIMP-4) changed. There was
reduction in troponin (Tnl) and alpha-actinin protein levels.
The diabetes-induced alterations in MMP-2 and TIMP-4
contribute to myocardial contractile dysfunction by targeting
TnI and alpha-actinin. Treatment with sodium selenate or
with omega-3 ﬁsh oil with vitamin E had improved these
parameters . Doxycycline, a MMP-2 inhibitor, or an
antioxidant selenium treatment in vivo prevented
diabetes-induced cardiac dysfunction signiﬁcantly . The
author suggests that antioxidants and MMP inhibitors both
could regulate MMP function, but may also utilize different
mechanisms of action in cardiomyocytes, particularly related
to beta-AR signaling pathway .
There is also evidence to suggest that besides other car-
diomyopathies the anti-inﬂammatory action of omega-3
PUFAs may have beneﬁcial effects on chronic chagasic
cardiomyopathy due to improved control of the inﬂamma-
tory response. The authors predict that patients will have
lower inﬂammatory markers and an improved metabolic and
anthropometric proﬁle .
224 A.V. Mali et al.
Omega-3 and Diabetic Neuropathy
Diabetic neuropathy is a degenerative complication of dia-
betes accompanied by an alteration of nerve conduction
velocity (NCV) and Na
In STZ–diabetic rats, supplementation with DHA only
partially prevented the decrease in NCV and did not affect
nerve blood ﬂow (NBF). On the other hand, supplementation
with GLA–lipoic acid (GLA-LA) conjugate was more
effective than supplementation with DHA alone in prevent-
ing experimental diabetic neuropathy. The difference could
be due in part to an antioxidant protective effect of LA on
Adeﬁciency in essential fatty acid metabolism has been
widely reported in both human and animal diabetes. Sup-
plementation with ﬁsh oil was less effective on diabetic
neuropathy than n-6 fatty acids. The partial effect of n-3 fatty
acids might be attributed to the presence of EPA which
competes with arachidonic acid and thereby ampliﬁes the
diabetes-induced decrease in this fatty acid in serum and
tissues. Fish oil supplementation changed the fatty acid
content of sciatic nerve membranes, decreasing C18:2(n-6)
fatty acids and preventing the decreases in arachidonic acids
and oleic acid C18:1(n-9) fatty acids .
Whether supplementation with DHA alone could prevent
neuropathy in STZ-induced diabetes was determined in
separate experiments. Eight weeks of diabetes induced sig-
niﬁcant decreases in NCV, NBF, and sciatic nerve and
-ATPase activities. Na
activity was signiﬁcantly lower in sciatic nerve membranes
of diabetic rats and was signiﬁcantly restored in diabetic
animals that received ﬁsh oil supplementation. Diabetes
induced a speciﬁc decrease of a1- and a3-isoform activity
and protein expression in sciatic nerve membranes. Fish oil
supplementation restored partial activity and expression to
varying degrees depending on the isoenzyme. These effects
were associated with a signiﬁcant beneﬁcial effect on NCV.
This study indicates that ﬁsh oil has beneﬁcial effects on
diabetes-induced alterations in sciatic nerve Na
activity and function .
Liposomes containing DHA phospholipids, at a dose of
60 mg/kg, were given daily to diabetic rats by gavage. DHA
phospholipids totally prevented the decrease in NCV and
NBF; DHA phospholipids also prevented the decrease in
-ATPase activity in the RBCs but not in the sciatic
nerve. The levels of DHA in the sciatic nerve membranes
correlated with NCV. The results demonstrate a protective
effect of daily doses of DHA in experimental diabetic neu-
ropathy. Thus, treatment with DHA phospholipids could
provide a suitable approach for evaluation in clinical trials
. It is also reported that highly puriﬁed ethyl esteriﬁca-
tion product of natural EPA (EPA-E) has signiﬁcant
beneﬁcial effects on diabetic neuropathy and serum lipids as
well as other diabetic complications such as nephropathy
and macroangiopathy .
Omega-3 and Red Blood Cell Deformability
The content of PUFA is known to affect membrane ﬂuidity
and cell signaling. Patients with insulin resistance display a
pattern of higher proportion of long-chain saturated fatty
acids, mainly palmitic, stearic, and arachidic acids.
Decreased levels of erythrocyte membrane DHA in
end-stage renal diseases with type 2 diabetes patient group
suggest that there may be reduced endogenous synthesis of
DHA due to the decreased desaturase and elongase activities
Omega-3 fatty acids increased red blood cell (RBC) de-
formability and decreased plasma viscosity. Also, there is a
drop in red cell aggregation after treatment with omega-3
capsule. Thus, there is growing evidence to suggest that
omega-3 FA can delay atherogenesis . The omega-3 FA
gets incorporated into RBC phospholipids at the expense of
C18:2 omega-6 FA. At the same time, the total unsaturation
index of phospholipids increases. This in turn brings about
increase in membrane ﬂuidity which is responsible for the
increased erythrocyte deformability. The observed changes
have been attributed to incorporation of omega-3 FA in
erythrocyte phosphatidylcholine (PC) [40,41]. Daily sup-
plementation of 3 g of n-3 FA (EPA and DHA) increased
unsaturation of PC and phosphatidylethanolamine (PE). At
the same time, there was slight decrease in PC and PE
content, but the content of sphingomyelin (SPM) increased.
This supplementation caused a 42 % decrease in plasma
triacylglycerol levels. However, the membrane ﬂuidity was
In subjects supplemented with ﬁsh oil, the levels of n-3
FA increased signiﬁcantly in erythrocytes. This was mainly
at the expense of linolenic (18:n6) and oleic acid (18:n1); the
relative amount of arachidonic acid was unchanged .
The total phospholipid/CHL ratio was unchanged while the
PC + SPM/PE increased which is consistent with the
observations of Popp-Snijders et al. .
Supplementation with functional foods which are rich in
omega-3 fatty acids (e.g., ﬁsh oils among others) may be a
novel strategy to reduce insulin insensitivity, dyslipidemia,
hypertension, retinopathy and pro-inﬂammatory state,
improved renal function as well as improved RBC
16 Omega-3 Fatty Acids and Diabetic Complications 225
The forgoing results suggest that n-3 PUFA supplemen-
tation in diet presents many beneﬁts in T2DM management
mainly in terms of diabetic complications. However, the
treatment is less effective with respect to glucose control,
inﬂammation and oxidative stress. Nonetheless, n-3 PUFA
supplementation may be a reasonable therapeutic strategy in
individuals with T2DM to decrease the risk of complications.
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