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The systematic review widely focused on diabetes and the developments in nutrition and diets required to prevent or control all types of diabetes. Diabetes is characterized by high blood sugar level over prolonged period. If left untreated, diabetes causes many health complications. Acute complications can include hyperosmolar hyperglycemic state, diabetic ketoacidosis, or even death. Serious long-term health complications include chronic kidney disease, foot ulcers, damage to the eyes, cardiovascular disease, and stroke. Diabetes occurs due to either the inability of the pancreas to produce enough insulin, or the body cells improperly responding to the insulin produced. Type 1, Type 2, and the Gestational diabetes are the three major types of diabetes mellitus, although there is a collection of other specific types. The Type 1 diabetes results from the failure of pancreas to produce enough insulin due to the loss of beta cells caused by an autoimmune response. Type 2 diabetes begins with the insulin resistance, a condition in which the cells fail to properly respond to insulin. As the disease keeps progressing, a lack of insulin may develop. A combination of insufficient exercise and excessive body weight is the most common cause. Gestational diabetes is third major form, and occurs when a pregnant woman without previous history of diabetes develops high blood sugar levels. Adequate dieting, with good nutrition and regular exercise are very important in preventing or controlling diabetes. Prevention and treatment of diabetes involve maintaining healthy diet, regular physical exercise, normal body weight, and also avoiding use of tobacco. Maintaining a healthy diet, low-fat diet, low-calorie diet, paleolithic diet, very low carbohydrate diet, raw foodism, and/or ketogenic diet can help prevent or manage diabetes.
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Health Sciences Research
2020; 6(1): 5-19
http://www.aascit.org/journal/hsr
ISSN: 2375-379X
Diabetes and the Nutrition and Diets for Its
Prevention and Treatment: A Systematic Review
and Dietetic Perspective
Chinaza Godswill Awuchi
1, 2, *
, Chinelo Kate Echeta
2
, Victory Somtochukwu Igwe
2
1
Department of Physical Sciences, Kampala International University, Kampala, Uganda
2
Department of Food Science and Technology, Federal University of Technology Owerri, Owerri, Nigeria
Email address
*
Corresponding author
Citation
Chinaza Godswill Awuchi, Chinelo Kate Echeta, Victory Somtochukwu Igwe. Diabetes and the Nutrition and Diets for Its Prevention and
Treatment: A Systematic Review and Dietetic Perspective. Health Sciences Research. Vol. 6, No. 1, 2020, pp. 5-19.
Received: December 21, 2019; Accepted: January 9, 2020; Published: February 4, 2020
Abstract: The systematic review widely focused on diabetes and the developments in nutrition and diets required to prevent
or control all types of diabetes. Diabetes is characterized by high blood sugar level over prolonged period. If left untreated,
diabetes causes many health complications. Acute complications can include hyperosmolar hyperglycemic state, diabetic
ketoacidosis, or even death. Serious long-term health complications include chronic kidney disease, foot ulcers, damage to the
eyes, cardiovascular disease, and stroke. Diabetes occurs due to either the inability of the pancreas to produce enough insulin,
or the body cells improperly responding to the insulin produced. Type 1, Type 2, and the Gestational diabetes are the three
major types of diabetes mellitus, although there is a collection of other specific types. The Type 1 diabetes results from the
failure of pancreas to produce enough insulin due to the loss of beta cells caused by an autoimmune response. Type 2 diabetes
begins with the insulin resistance, a condition in which the cells fail to properly respond to insulin. As the disease keeps
progressing, a lack of insulin may develop. A combination of insufficient exercise and excessive body weight is the most
common cause. Gestational diabetes is third major form, and occurs when a pregnant woman without previous history of
diabetes develops high blood sugar levels. Adequate dieting, with good nutrition and regular exercise are very important in
preventing or controlling diabetes. Prevention and treatment of diabetes involve maintaining healthy diet, regular physical
exercise, normal body weight, and also avoiding use of tobacco. Maintaining a healthy diet, low-fat diet, low-calorie diet,
paleolithic diet, very low carbohydrate diet, raw foodism, and/or ketogenic diet can help prevent or manage diabetes.
Keywords: Diabetes Mellitus, Diabetes Causes, Diabetes Prevention, Nutrition and Diets for Diabetes Prevention,
Nutrition and Diets for Diabetes Control
1. Introduction
Diabetes mellitus (DM), commonly called diabetes, is a
group of metabolic disorders and diseases characterized by
high blood sugar levels over prolonged period. The
symptoms of high blood glucose (sugar) levels include
increased thirst, increased hunger, and frequent urination [1].
Diabetes can cause many complications if not carefully
treated and controlled. So far, there is no known cure for
diabetes. Acute complications can include hyperosmolar
hyperglycemic state, diabetic ketoacidosis, or death [1].
Serious long-term complications are cardiovascular disease,
stroke, foot ulcers, damage to the eyes, and chronic kidney
disease. Diabetes is as a result of either pancreas not making
enough insulin, or cells of the body improperly responding to
the insulin produced [3].
There are three main types of diabetes, and a collection of
“other specific types”. Diabetes type 1 results from failure of
pancreas to produce enough insulin caused by loss of beta
cells. Diabetes type 1 was earlier referred to as the juvenile
diabetes or insulin-dependent diabetes mellitus (IDDM). The
loss of beta cells is as a result of an autoimmune response
[4]. The cause of the autoimmune response is unknown [1].
Type 2 diabetes begins with the insulin resistance, a
6 Chinaza Godswill Awuchi et al.: Diabetes and the Nutrition and Diets for Its Prevention and Treatment:
A Systematic Review and Dietetic Perspective
condition where cells fail to properly respond to insulin. As
the disease progresses, lack of insulin may develop. This
form was previously known as "adult-onset diabetes" or
"non-insulin-dependent diabetes mellitus" (NIDDM). The
most common cause is combination of excessive body weight
(obesity) and insufficient exercise [1]. Gestational diabetes is
the third most common form, and occurs when a pregnant
woman without previous history of diabetes mellitus
develops high blood sugar levels [1].
Prevention and treatment of diabetes involve maintaining
healthy diet, regular physical exercise, normal body weight,
and also avoiding tobacco use. Control of blood pressure, eye
care, and maintaining proper foot care are important for
individuals with the disease [1]. Type 1 diabetes must be
properly managed with insulin injections. The type 2 diabetes
may be treated with medication with or without insulin. The
Insulin and some oral medication can cause low blood sugar
[5]. Weight loss surgery in individuals with obesity is
sometimes very effective measure in people with type 2
diabetes. Gestational diabetes often resolves after birth of the
baby [6]. Diabetic patients are advised to avoid sugars and
sugary soft drinks. They may instead opt for diet soft drinks
sweetened with sugar substitutes such as sugar alcohols [7, 8]
which contribute little or no-calorie.
In 2017, an estimated 425 million individuals had diabetes
worldwide [2], with type 2 diabetes making up around 90%
of the cases [9]. This represents 8.8% of adult population,
with equal rates in both men and women. Trends suggest that
the rates will continue to rise [2]. Diabetes at least doubles an
individual's risk of early death. In 2017 alone, diabetes
resulted in about 3.2 to 5.0 million deaths [2]. The global
economic costs of diabetes-related health expenditures in
2017 were estimated at US$727 billion [2]. Average medical
expenditures among individuals with diabetes are around 2.3
times higher [10].
2. Diabetes Mellitus (DM)
2.1. Signs and Symptoms of Diabetes
The classic symptoms of untreated diabetes include
unintended weight loss, polydipsia (increased thirst),
polyphagia (increased hunger), and polyuria (increased
urination) [11]. Symptoms may develop rapidly (in weeks or
months) in type 1 diabetes, whereas they usually develop
much more slowly (years or decades) and may be absent or
subtle in type 2 diabetes. Some other symptoms of diabetes
are tiredness and weight loss.
Several other signs and symptoms mark the onset of
diabetes though they are not specific to diabetes. In addition
to the known signs and symptoms above, they also include
blurred vision, slow healing of cuts, itchy skin, headache, and
fatigue. Prolonged high blood glucose may cause glucose
absorption in lens of the eye, which results in changes in its
shape, leading to changes in vision. Long-term vision loss
may also be caused by diabetic retinopathy. Numerous skin
rashes that occur in diabetes are collectively called diabetic
dermadromes [12].
Figure 1. Overview of the most important symptoms of diabetes.
2.1.1. Diabetic Emergencies
Individuals (usually with type 1 diabetes) can also
experience the episodes of diabetic ketoacidosis (DKA).
DKA is a metabolic disturbance characterized by vomiting,
abdominal pain, and nausea, deep breathing known as
Kussmaul breathing, the smell of acetone on the breath, and
in severe cases decreased level of consciousness [13]. A rare
but equally severe likelihood is hyperosmolar hyperglycemic
state (or HHS), which is more common in the case of type 2
diabetes and is mostly the result of dehydration [13].
Treatment-related hypoglycemia (low blood sugar) is
common in individuals with type 1 diabetes (and also type 2)
depending on the medication used. Most cases can be mild and
are not regarded as medical emergencies. The effects can range
from the feelings of unease, trembling, increased appetite, and
sweating in mild cases to the more serious effects such as
changes in behavior such as aggressiveness, unconsciousness,
seizures, confusion, and (rarely) permanent, irreversible brain
damage or even death in severe cases [14]. Rapid breathing
and sweating, pale skin, cold are characteristic of low blood
sugar (hypoglycemia) but not definitive. The mild to moderate
cases can easily be self-treated by consuming foods or drinking
beverages high in sugar; but not sugar substitutes used as sugar
replacement [8]. Severe cases can result in unconsciousness
and have to be treated with injections with glucagon or
intravenous glucose, as soon as possible.
2.1.2. Complications and Risks of Diabetes
All forms of diabetes increase the risks of long-term
complications. These usually develop after several years (10
to 20) but may be the first symptoms in people who have
otherwise not received diagnosis before that time.
Retinopathy, neuropathy, and nephropathy are the potential
Health Sciences Research 2020; 6(1): 5-19 7
complications of diabetes. Major long-term complications
relate to the damage to the blood vessels. Diabetes doubles
the risks of cardiovascular diseases and about 75% of death
in individuals with diabetes are caused by coronary artery
disease [15]. Other macro-vascular diseases include
peripheral artery disease, and stroke.
The primary complications of diabetes as a result of
damage in the small blood vessels are damage to the eyes,
nerves, and kidneys. Damage to the eyes, called diabetic
retinopathy, is caused by the damage to blood vessels in the
eye retina, and can result in gradual loss of vision and
eventual blindness [16]. Diabetes also increases the risks of
having cataracts, glaucoma, and other eye problems. People
with diabetes are recommended to visit an eye specialist or
doctor once a year. The damage to the kidneys (called
diabetic nephropathy) can lead to urine protein loss, tissue
scarring, and eventually chronic kidney diseases, sometimes
requiring kidney transplantation or dialysis. Damage to the
body nerves (called diabetic neuropathy) is the most common
diabetes complication [16]. The symptoms can include pain,
altered pain sensation, tingling, and numbness, which can
result in damage to the skin. A number of diabetes-related
foot problems (such as the diabetic foot ulcers) can occur,
and may be difficult to treat, sometimes requiring
amputation. In addition, proximal diabetic neuropathy causes
a painful muscle atrophy and weakness. Also, there is a link
between diabetes and cognitive deficit. Compared to
individuals without diabetes, people with the disease have a
1.2 – 1.5-fold higher rate of decline in cognitive functions.
Having diabetes, particularly when on insulin, increases risk
of falls in older individuals [17].
2.2. Causes of Diabetes
Table 1. Comparison of type 1 and 2 diabetes.
Feature Type 1 diabetes Type 2 diabetes
Age at onset Mostly in children Mostly in adults
Autoantibodies Usually present Absent
Body size Thin or normal Often obese
Concordance in identical twins 50% 90%
Endogenous insulin Low or absent Normal, decreased or increased
Ketoacidosis Common Rare
Onset Sudden Gradual
Prevalence ~10% ~90%
The term "diabetes", without reservation, refers to diabetes
mellitus. Normally, diabetes mellitus is broadly classified
into four categories: type 1, type 2, the gestational diabetes,
and the "other specific types". "Other specific types" are a
group of few dozen individual causes. Diabetes mellitus is a
more variable disease than once thought and people may
have combinations of forms [18].
2.2.1. Type 1 Diabetes
The type 1 diabetes is characterized by the loss of the
insulin-producing beta cells of pancreatic islets, resulting in
insulin deficiency. Type 1 can be further classified as
idiopathic or immune-mediated. The majority of type 1
diabetes has the nature of immune-mediated, in which T cell-
mediated autoimmune attack results in loss of beta cells and
consequently insulin [19]. It causes around 10% of diabetes
mellitus cases in the North America and the Europe. Most
affected individuals are otherwise healthy and of healthy
weight when onset takes place. Sensitivity and
responsiveness to insulin are often normal, especially in early
stages. Though it has been referred to as the juvenile diabetes
due to its frequent onset in children, majority of people
currently living with type 1 diabetes are adults.
The term "Brittle" diabetes, also called labile diabetes or
unstable diabetes, was traditionally used to describe the
recurrent and dramatic swings in glucose level, often
occurring for no just apparent reason in the insulin-dependent
diabetes. However, the term has no biologic basis and ought
not to be used. Type 1 diabetes can be accompanied by
unpredictable and irregular high blood sugar levels, and also
the potential for serious low blood sugar levels or diabetic
ketoacidosis. Other complications include impaired counter-
regulatory response to a low blood sugar level, infection,
endocrinopathies (e.g., Addison's disease), and gastroparesis
(which results in erratic absorption of dietary carbohydrates).
These phenomena are understood to occur no more regularly
than in 1% - 2% of people with type 1 diabetes
.
Type 1 diabetes is partly hereditary, with multiple genes,
including some HLA genotypes, known to have influence on
the risks of diabetes. In genetically susceptible individuals,
the onset of diabetes can also be triggered by at least one
environmental factor, such as diet or a viral infection. Several
viruses have been implicated, however, to date there is no
stringent or reliable evidence to support the hypothesis in
humans [20, 21]. Some traditionalists claim that some
alkaloids are therapeutic against diabetes [22]. Among
dietary factors, data suggest that a protein present in gluten,
called gliadin, may play a role in development of type 1
diabetes, although the mechanism is not completely
understood [23].
Type 1 diabetes mellitus (type 1 DM) can occur at any age,
and significant proportion is commonly diagnosed during
adulthood. The latent autoimmune diabetes of adults (the
LADA) is a diagnostic term applied when the type 1 diabetes
develops in adults; and it has a slower onset than same
condition in children. With this difference given, some use
the informal term "type 1.5 diabetes" to refer to this
condition. Adults with the LADA are frequently
8 Chinaza Godswill Awuchi et al.: Diabetes and the Nutrition and Diets for Its Prevention and Treatment:
A Systematic Review and Dietetic Perspective
misdiagnosed initially as having type 2 diabetes, relying on
age rather than cause [24].
2.2.2. Type 2 Diabetes
The type 2 diabetes is characterized by an insulin
resistance, which can be combined with relatively reduced
secretion of insulin. The defective responsiveness of the body
tissues to insulin is understood to involve the insulin
receptors. However, the specific defects are unknown.
Diabetes mellitus cases due to known defect are classified
separately. The type 2 diabetes is the most seen and common
type of diabetes mellitus [1]. Many individuals with type 2
diabetes have the evidence of prediabetes (impaired glucose
tolerance and/or impaired fasting glucose) before meeting
criteria for type 2 diabetes [25]. The progression of
prediabetes to the overt type 2 diabetes can be reversed or
slowed by medications and/or lifestyle changes that reduce
the liver's glucose production or improve insulin sensitivity
[26]. Type 2 diabetes mellitus is mostly caused by lifestyle
factors and genetics. Many lifestyle factors are known to be
contribute to the development of the type 2 diabetes,
including obesity (a body mass index, BMI, of greater than
30), poor diet, stress, urbanization, and lack of physical
activity. Excess body fat is connected with 30% of the cases
in those of Japanese and Chinese descent, 100% of Pacific
Islanders and Pima Indians, and 60 to 80% of cases in
individuals of European and African descent. Even those
who are not obese usually have a high waist-hip ratio.
The dietary factors also have influence on the risk of
developing type 2 diabetes. Excessive consumption of sugar-
sweetened drinks is associated with an increased risk [28].
The type of fats and oils in the diet is also important;
saturated fat and trans fats increase the risk, while
monounsaturated and polyunsaturated fat decrease the risk
[27]. Eating too much white rice may also increase the risk of
diabetes, while other whole grains substitution including
brown rice for white rice may lower the risks of diabetes.
Lack of physical activity is understood to cause 7% of cases
[29]. Reduced secretion and absorption of insulin leads to
high blood glucose levels.
2.2.3. Gestational Diabetes
Gestational diabetes mellitus (or GDM) is similar to type 2
diabetes in various respects, involving a combination of
relatively insufficient insulin secretion and responsiveness.
GDM occurs in about 2 to 10% of all pregnancies and may
disappear or improve after delivery. However, after
pregnancy about 5 to 10% of women with gestational
diabetes mellitus are found to have diabetes mellitus, most
commonly type 2 diabetes. GDM is entirely treatable, but
requires a careful medical supervision all through the
pregnancy. Management may include blood glucose
monitoring, dietary changes, and in most cases, insulin may
be required [30].
Though it may be short-term, untreated gestational
diabetes mellitus can damage the health of the mother or
fetus. Risks to the baby include congenital abnormalities of
the heart and central nervous system, skeletal muscle
malformations, and macrosomia (high birth weight).
Increased levels of insulin in fetus's blood may inhibit the
fetal surfactant production and cause an infant respiratory
distress syndrome. High blood bilirubin levels may result
from the destruction of red blood cell. In severe cases,
perinatal death can occur, most commonly due to poor
placental perfusion as a result of vascular impairment. Labor
induction might be indicated with a decreased placental
function. Caesarean section may be done if there is an
increased risk of injury connected with macrosomia, such as
the shoulder dystocia, or marked fetal distress [31].
2.2.4. Other Types of Diabetes Rarely
Encountered
The maturity-onset diabetes of the young (the MODY) is
an unusual autosomal dominant inherited form of diabetes, as
a result of one of various single-gene mutations causing
defects in production of insulin [32]. It is significantly less
common than type 1, type 2, and GDM, constituting 1 to 2%
of all cases. The name MODY refers to the early hypotheses
as to its nature. Occurring due to a defective gene, the disease
varies in the age at presentation and in the severity according
to specific gene defect; as a result there are at least 13
MODY subtypes. People with MODY commonly can control
it without using insulin [33].
Some diabetes cases are caused by body's tissue receptors
unresponsive to insulin (even when the levels of insulin are
normal, and is what separates it from the type 2 diabetes);
this form is quite uncommon. Genetic mutations
(mitochondrial or autosomal) can lead to defects in the
function of beta-cell. Abnormal insulin actions may also have
been determined genetically in some cases. Any disease
causing extensive damage to the pancreas can lead to
diabetes; for example, cystic fibrosis and chronic
pancreatitis. Diseases associated with excessive insulin-
antagonistic hormones secretion can cause diabetes (which is
normally resolved once the excess hormone is removed).
Some toxins damage pancreatic beta cells and a number of
drugs impair insulin secretion, while others increase insulin
resistance (especially the glucocorticoids which may provoke
"steroid diabetes"). ICD-10 (1992) diagnostic entity, the
malnutrition-related diabetes mellitus (MRDM), was
deprecated by the WHO when the current taxonomy was
announced in 1999 [34].
The following is a list of disorders and impairments that
may increase the risks of diabetes:
a) Genetic defects of β-cell function
a. The maturity-onset diabetes of the young
b. The Mitochondrial DNA mutations
b) Genetic defects in insulin action or insulin processing
a. Defects in proinsulin conversion
b. The insulin receptor mutations
c. The insulin gene mutations
c) Exocrine pancreatic defects
a. Cystic fibrosis
b. Fibrocalculous pancreatopathy
c. Hemochromatosis
Health Sciences Research 2020; 6(1): 5-19 9
d. Pancreatectomy
e. Pancreatic neoplasia
f. The Chronic pancreatitis
d) Endocrinopathies
a. Cushing syndrome
b. Glucagonoma
c. Growth hormone excess (acromegaly)
d. Hyperthyroidism
e. Hypothyroidism
f. Pheochromocytoma
e) Infections
a. Cytomegalovirus infection
b. Coxsackievirus B
f) Drugs
a. Glucocorticoids
b. Statins
c. Thyroid hormone
d. β-adrenergic agonists
2.3. Pathophysiology and diagnosis
Insulin is the major hormone that regulates the glucose
uptake from the blood into most body cells, especially liver,
muscle, and adipose tissue, except smooth muscle, wherein
insulin acts via IGF-1. Therefore, insulin deficiency or the
insensitivity of insulin receptors play a key role in all forms
of diabetes.
The body obtains glucose from three key sources: the
intestinal absorption of food; breakdown of glycogen
(glycogenolysis), a storage form of glucose in the liver; and
by gluconeogenesis, the generation of glucose from the non-
carbohydrate substrates in the body [3]. Insulin plays a
crucial role in regulating the body glucose levels. Insulin can
inhibit the process of gluconeogenesis or the breakdown of
glycogen, it can stimulate storage of glucose in form of
glycogen, and it can stimulate transport of glucose into fats
and muscle cells [3].
Mechanism of insulin release in the normal pancreatic beta
cells. The insulin production is relatively constant within beta
cells. Its release is usually triggered by food, mostly food
containing absorbable glucose. Insulin is released normally
into the blood by the β-cells (beta cells), found in the islets of
the Langerhans in the pancreas, as a response to rising blood
glucose levels, typically after eating food. Insulin is used by
approximately two-thirds of the cells of the body to absorb
glucose from blood for use as fuel, for storage, or for
conversion to other required molecules. Lower glucose levels
result in reduced insulin release from the β-cells and in the
glycogen breakdown to glucose. This process is mostly
controlled by the glucagon, a hormone which acts opposite to
insulin [35].
If the amount of insulin available is not sufficient, or if the
insulin itself is defective, or if cells poorly respond to the
effects of insulin (known as insulin resistance), then glucose
is improperly absorbed by the body cells which require it,
and is not appropriately stored in the muscles and liver. The
net effect is poor protein synthesis, persistent high levels of
blood glucose, and other metabolic disorders, such as
metabolic acidosis in the cases of complete insulin deficiency
[3].
When the blood glucose concentration remains high with
time, the kidneys reach threshold of reabsorption, causing the
body to excrete glucose via urine (glycosuria) [36]. This
increases osmotic pressure of the urine and inhibits the water
reabsorption by the kidney, resulting in increased production
of urine (polyuria) and increased loss of fluid. Lost blood
volume is osmotically replaced from water in the body cells
and other body compartments, resulting in dehydration and
increased thirst (polydipsia) [3]. Additionally, deficiency of
intracellular glucose stimulates appetite resulting in excessive
food consumption (polyphagia).
Table 2. WHO diabetes diagnostic criteria.
Condition 2-hour glucose Fasting glucose HbA
1c
Unit mmol/l (mg/dl) mmol/l (mg/dl) mmol/mol DCCT %
Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥48 ≥6.5
Impaired fasting glycaemia <7.8 (<140) ≥6.1 (≥110) & <7.0 (<126) 42-46 6.0–6.4
Impaired glucose tolerance ≥7.8 (≥140) <7.0 (<126) 42-46 6.0–6.4
Normal <7.8 (<140) <6.1 (<110) <42 <6.0
Diabetes mellitus is characterized by persistent or
recurrent high blood sugar, and diagnosed by demonstrating
any of the following:
1) Fasting plasma glucose levels ≥ 7.0 mmol/l (126 mg/dl)
2) Glycated hemoglobin (HbA
1C
) ≥ 6.5 DCCT % (≥ 48
mmol/mol) [37].
3) Plasma glucose levels ≥ 11.1 mmol/l (200 mg/dl) 2
hours after a 75 g oral glucose load as in glucose
tolerance test (OGTT)
4) Symptoms of high blood sugarlevel and casual plasma
glucose ≥ 11.1 mmol/l (200 mg/dl)
In the absence of unmistakable high blood sugar, a positive
result should be confirmed by repeating any of the methods
above on a different day. Preferably, a fasting glucose level
should be measured due to the ease of measurement and also
the considerable time commitment of the formal glucose
tolerance testing, which takes 2 hours to complete and
provides no prognostic advantage over fasting test [38].
According to current definition, two fasting glucose
measurements above 126 mg/dl (7.0 mmol/l) is considered
diagnostic for diabetes mellitus (DM).
According to the World Health Organization, persons with
fasting glucose level from 110 - 125 mg/dl (6.1 - 6.9 mmol/l)
are considered to have an impaired fasting glucose.
Individuals with plasma glucose at least 140 mg/dl (7.8
mmol/l), but not above 200 mg/dl (11.1 mmol/l), 2 hours
after a 75 g oral glucose load are considered to have an
impaired glucose tolerance. Between these two prediabetic
10 Chinaza Godswill Awuchi et al.: Diabetes and the Nutrition and Diets for Its Prevention and Treatment:
A Systematic Review and Dietetic Perspective
states, the latter one in particular is major risk factor for the
progression to full-blown diabetes mellitus (DM), and
cardiovascular disease [39]. Since 2003, the American
Diabetes Association (ADA) uses a marginally different
range for the impaired fasting glucose of 100 – 125 mg/dl
(5.6 – 6.9 mmol/l). The glycated hemoglobin is better than
the fasting glucose for determining the risks of
cardiovascular disease and the death from any cause [40].
2.4. Prevention of Diabetes
There preventive measure for type 1 diabetes is not known
[1]. Type 2 diabetes—which accounts for 85 to 90% of all
cases worldwide—can normally be prevented or delayed by
engaging in physical activity, eating a healthy diet, and
maintaining normal body weight [1]. Higher levels of
physical activity (over 90 minutes per day) reduce the risks
of diabetes by 28% [41]. Effective dietary changes known to
help prevent diabetes include maintaining diet rich in fiber
and whole grain, and choosing good fats, such as
polyunsaturated fats found in vegetable oils, nuts, and fish
[42]. Eating less red meat and other foods with saturated fat,
in addition to limiting sugary beverages can also help prevent
diabetes. The smoking of tobacco is also associated with
increased risk of diabetes and its related complications, thus
smoking cessation can be a key preventive measure as well
[43].
The relationship between type 2 and the main modifiable
risk factors (unhealthy diet, physical inactivity, tobacco use,
and excess weight) is similar in all the regions of the world.
In addition, there is increasing evidence that the fundamental
determinants of diabetes mellitus are a reflection of the main
forces driving social, cultural, and economic change:
globalization, population aging, urbanization, and the general
health policy environment [42].
2.5. Diabetes Management
The management of diabetes focuses on keeping blood
sugar levels very close to normal, without causing a low
blood sugar level. This can often be accomplished with
dietary changes, weight loss, exercise, and use of
appropriate medications (oral medications, insulin).
Learning about the disease and also actively participating in
the treatment is very important, since complications are
usually less severe and far less common in individuals who
have well-managed their blood sugar levels [44]. Per the
American College of Physicians (ACP), the goal of the
treatment is attaining an HbA
1C
level of 7 to 8% [45].
Attention is also given to other health issues that may
accelerate negative effects of diabetes, including smoking,
high blood pressure, lack of regular exercise, and metabolic
syndrome obesity. Specialized footwear is used widely to
reduce the risks of ulcers in at-risk diabetic feet, though
evidence for the efficiency of this remains equivocal [46].
In some developing countries, many untrained
traditionalists claimed that some bitter phytochemicals are
helpful in the treatment of diabetes [22].
2.5.1. Lifestyle
Those with diabetes can benefit from the education about
the disease and its treatment, dietary changes required, and
exercise, with the aim of keeping both the short-term and the
long-term blood glucose levels within adequate and
acceptable bounds. Additionally, given the associated higher
risk of cardiovascular disease, modifications of lifestyle are
recommended to control blood pressure [47, 48], including
healthy eating, regular exercise, and maintaining normal
weight (BMI 18 to 25).
Weight loss can prevent progression from the prediabetes
to type 2 diabetes, result in a partial remission in those with
diabetes, or decrease the risks of cardiovascular disease [49,
50]. No single dietary pattern is the best for all individuals
with diabetes [51]. Healthy dietary patterns, such as
Mediterranean diet, low-carbohydrate diet DASH diet, are
usually recommended, although no evidence support one
over the others [49, 50]. According to the ADA, reducing the
overall carbohydrate intake for people with diabetes has
shown the most evidence for glycemic improvement, and for
those with type 2 diabetes who are unable to meet the
glycemic target or where reducing anti-glycemic medication
is a priority, very-low or low carbohydrate diets are viable
approach [50]. For overweight individuals with diabetes type
2, a diet that achieves loss of weight is effective [51].
2.5.2. Medications for Diabetes Mellitus
i. Glucose Control
Most medications used for diabetes treatment act by
lowering blood sugar level through different mechanisms.
There is general consensus that when those with diabetes
maintain tight control of glucose (i.e. keeping the glucose
level in their blood within normal range), they experience
fewer complications like kidney and eye problems [52, 53].
However, there is discussion as to whether this is cost-
effective and appropriate for people later in life where
hypoglycemia risk may be more significant [54]. There are a
few different classes of anti-diabetic medication. Diabetes
type 1 can only be treated using insulin, typically with a
combination of NPH and regular insulin, or synthetic analogs
of insulin. Type 2 diabetes can also be treated with insulin at
the later stages. Some medications for diabetes type 2 are
available by oral, such as metformin, while others are
available by only injection such as the GLP-1 agonists.
Generally, metformin is recommended as first-line
treatment for diabetes type 2, as there is adequate evidence
that it decreases mortality. Metformin works by reducing the
liver's production of [55]. Several other groups of
medications, mostly given by mouth, can also decrease blood
sugar levels in type 2 diabetes. They include sulfonylureas
(agents that increase insulin release), SGLT2 inhibitors
(agents that increase excretion of glucose in the urine),
acarbose (agents that decrease the absorption of sugar from
intestines), and Thiazolidinedione (agents that make body
more sensitive to insulin) [55]. When insulin is used in
diabetes type 2, a long-acting formulation is often initially
added, while continuing oral medications. Then the doses of
Health Sciences Research 2020; 6(1): 5-19 11
insulin are increased to the glucose targets.
ii. Blood Pressure
Since cardiovascular disease is serious complication
associated with diabetes mellitus, blood pressure levels lower
than 130/80 mmHg have been recommended. However,
evidence supports lower than or equal to anywhere between
140/90 mmHg – 160/100 mmHg. The only added benefit
found for blood pressure target below this range was an
isolated reduction in risk of stroke, and this was accompanied
by increased risks of other serious adverse events [56]. A
review in 2016 found potential harm to treating less than 140
mmHg [57]. Among medications that lower blood pressure,
the angiotensin-converting enzyme inhibitors (the ACEIs)
improve the outcomes in individuals with diabetes whereas
the similar medications, known as angiotensin receptor
blockers (ARBs), do not [58]. Aspirin is also recommended
for individuals with cardiovascular problems, however the
routine use of aspirin is not found to improve the outcomes in
uncomplicated diabetes mellitus.
iii. Surgery
Weight loss surgery in people with type 2 diabetes and
obesity is usually an effective measure. Many can maintain
normal blood sugar level with little or no medications
following a surgery and long-term mortality is often
decreased [59]. There is, however, short-term mortality risk
of below 1% from the surgery [60]. The body mass index
(BMI) cutoffs for when the surgery is appropriate are still
unclear [59]. It is recommended, however, that this option be
considered in individuals who are not able to get both their
blood sugar and body weight under control. A pancreas
transplant can be occasionally considered for those with
diabetes type 1 who have severe complications of their
diseases, including end-stage kidney disease demanding
kidney transplantation.
iv. Support
In countries using a system of general practitioner, such as
the UK, care may take place mostly outside hospitals, with
hospital-based specialists care used only in the case of
difficult blood sugar control, complications, or research
projects. In other circumstances, the specialists and general
practitioners share care in team approach. The home
telehealth support may be an effective management technique
[61].
2.6. Epidemiology
In 2017, a record of 425 million individuals had diabetes
in the whole world, up from an estimated 382 million in 2013
and from about 108 million in 1980 [62]. Accounting for
shifting age structure of global population, diabetes
prevalence is 8.8% among adults, nearly the double rate of
4.7% in 1980 [62]. Type 2 makes up around 90% of the
cases. A number of data indicate rates are approximately
equal in men and women, but male excess in diabetes is
found in many populations with higher incidence of type 2
diabetes, likely due to sex-related differences in the insulin
sensitivity, the consequences of obesity and the regional body
fat depositions, and other contributing factors such as
tobacco smoking, alcohol intake, and high blood pressure
[63].
The WHO estimates that diabetes caused 1.5 million
deaths in 2012, making diabetes the 8
th
leading cause of
death [62]. However another 2.2 million deaths in the whole
world were attributable to high blood glucose levels and the
increased risks of cardiovascular diseases and other
associated complications, such as kidney failure, which
usually lead to premature death and are usually listed as the
underlying cause of death certificates rather than diabetes
[62]. For example, in 2017, [2] estimated that diabetes caused
4 million deaths worldwide (a significant increase from the
WHO report in 2012), using modeling to estimate total
number of deaths that may be directly or indirectly associated
with diabetes.
Diabetes occurs all over the world but is more common
(mostly type 2 diabetes) in more developed countries.
However, the highest increase in the rates has been found in
low- and middle-income countries [62], where over 80% of
diabetic deaths occur [64], mainly due to poor management
and treatment of the disease. The fastest prevalence increase
is expected in Africa and Asia, where most individuals with
diabetes will most likely live in 2030 [65]. The increase in
rates in developing nations follows the trend of lifestyle
changes and urbanization, including less physically
demanding work, increasingly sedentary lifestyles, and the
global nutrition transitions, marked by the increased
consumption of foods that are highly energy-dense but with
poor nutrient profile (often high in saturated fats and sugar,
sometimes called the "Western-style" diet) [62, 65]. The
global number of diabetes cases may increase by over 48%
between 2017 and 2045 [2].
2.7. Societal and Cultural Significance
The 1989 St. Vincent Declaration [66] was the result of
internationally concerted efforts to improve care accorded to
the people with diabetes. Doing so is vital not only in terms
of life expectancy and quality of life but also economically
and productivity-related resources for the governments and
healthcare systems; expenses due to diabetes have shown to
be major drain on health.
Several countries established more and less fruitful
national diabetes programmes for improvement of treatment
of the disease [67]. People with diabetes who have symptoms
of neuropathy such as tingling or numbness in the feet or the
hands are two times as likely to be unemployed as people
without the symptoms. In 2010, the diabetes-related
emergency room (ER) rates of visit in the US were higher
among individuals from the lowest income communities (i.e.
526 per 10,000 population) than from highest income
communities (i.e. 236 per 10,000 population). Around 9.4%
of diabetes-related emergency room visits were for the
uninsured [68].
2.8. Other Animals
In other animals, diabetes is most often encountered in cats
12 Chinaza Godswill Awuchi et al.: Diabetes and the Nutrition and Diets for Its Prevention and Treatment:
A Systematic Review and Dietetic Perspective
and dogs. Middle-aged animals are most usually affected.
Female dogs are two times as likely to be affected as the males,
whereas according to some sources, the male cats are also more
susceptible than females. In both species, all the breeds may be
affected, but a number of small dog breeds are most likely to
develop diabetes, such as the Miniature Poodles. The feline
diabetes is strikingly related to human diabetes type 2. The
Burmese breed, together with the Russian Blue, Norwegian
Forest, and Abyssinian cat breeds, indicated an increased risk of
diabetes, while several breeds showed lower risks. There is a
connection between overweight and an increased feline diabetes
risks. The symptoms may relate to polyuria and fluid loss, but
the course may also be insidious (producing harm in a stealthy,
usually, gradual manner). Diabetic animals are more susceptible
to infections. The long-term complications acknowledged in
humans are much infrequent in animals. The principles of
treatment (oral antidiabetics, subcutaneous insulin, weight loss)
and management of emergencies (for example, ketoacidosis) are
similar to those treatments in humans.
2.9. Research Development
Inhalable insulin has been developed [69]. The original
products were withdrawn because of side effects [69]. In
June 2014, Afrezza, under development by pharmaceuticals
company MannKind Corporation, was permitted by the US
FDA for general sale. An advantage to inhaled insulin is
more convenient and easy to use. The transdermal insulin in
form of cream has been developed and many trials are being
conducted on individuals with type 2 diabetes [70].
2.10. Diets and Nutrition for Diabetes and Its
Prevention
Maintaining a healthy diet, low-fat diet, low-calorie diet,
paleolithic diet, very low carbohydrate diet, raw foodism,
and/or ketogenic diet can help prevent or manage diabetes.
2.10.1. Healthy Diet
A healthy diet is any diet that helps to improve or maintain
overall health. Healthy diet provides the body with the
essential nutrition: fluid, micronutrients, macronutrients, and
adequate calories [71]. A healthy diet is essential for
nutrition and good health. It protects an individual against
numerous chronic noncommunicable diseases, such as
diabetes (especially type 2), heart disease, and cancer [72].
Eating a variety of diets and consuming less salt, saturated
and industrially-produced trans-fats, and sugars are essential
for a healthy diet.
A healthy diet may contain whole grains, fruits, and
vegetables, and includes little or no processed foods and
sweetened beverages. Requirements for a healthy diet may be
met from a variety of animal-based and plant-based foods,
though a non-animal source of the vitamin B12 is required
for those following a vegan diet [73]. Various nutrition
guides are published by the governmental, medical, and
nutritional institutions to educate people on what to be eating
to be healthy. The nutrition facts labels are also compulsory
in many countries to allow the consumers to choose foods
based on components relevant to health, rather than just
merely satisfying their appetite.
The World Health Organization makes the following 5
recommendations with respect to both individuals and
populations: [72]
1. Eat 400 g of fruits and vegetable or above per day
(cassava, potatoes, sweet potatoes, and other starchy
root crops do not count). A healthy diet also contains
legumes (for example, beans, lentils), whole grains and
nuts.
2. Limit intake of fats. Less than 30% of total calories
should come from fat. Prefer unsaturated fats to
saturated fats. Shun trans fats.
3. Limit the intake of the simple sugars to below 10% of
calorie (below 25 grams or below 5% of calories per
day may even be better).
4. Limit sodium and salt from all sources and make sure
that salt is iodized. Below 5 g of salt per day have
been shown to reduce the risks of cardiovascular
diseases.
5. Maintain healthy weight by consuming approximately
the same number of calories the body is using.
Table 3. The three healthy patterns.
Food group/subgroup (units) U.S. style Med-style Vegetarian
Fruits (cup equivalent, eq) 2 2.5 2
Vegetables (cup eq) 2.5 2.5 2.5
Dark green 1.5 per week 1.5 per week 1.5 per week
Red/orange 5.5 per week 5.5 per week 5.5 per week
Starchy 5 per week 5 per week 5 per week
Legumes 1.5 per week 1.5 per week 3 per week
Others 4 per week 4 per week 4 per week
Grains (oz eq) 6 6 6.5
Whole 3 3 3.5
Refined 3 3 3
Dairy (cup eq) 3 2 3
Protein Foods (oz eq) 5.5 6.5 3.5
Meat (red and processed) 12.5 per week 12.5 per week --
Poultry 10.5 per week 10.5 per week --
Seafood 8 per week 15 per week --
Eggs 3 per week 3 per week 3 per week
Nuts/seeds 4 per week 4 per week 7 per week
Health Sciences Research 2020; 6(1): 5-19 13
Food group/subgroup (units) U.S. style Med-style Vegetarian
Processed soy (including tofu) 0.5 per week 0.5 per week 8 per week
Oils (g) 27 27 27
Solid fats limit (g) 18 17 21
Added sugars limit (g) 30 29 36
Source: [74]
2.10.2. Low-fat Diet
A low-fat diet is a diet that restricts fats, and often
cholesterol and saturated fat as well. Low-fat foods are
intended to reduce occurrence of conditions such as heart
diseases and obesity, which increases the risks of diabetes
and can worsen diabetes in already diabetic patients. For
weight loss, low-fat diets perform similarly to low-
carbohydrate diets, since macronutrients compositions do not
determine weight loss success [75]. Fat provides 9 calories/g
while carbohydrates and protein each provide 4 calories/g.
The Institute of Medicine recommends restricting fat intake
to 35% or less of total calories to control the intake of
saturated fat [76]. Although low fats may affect the
functional properties of foods [77, 78], restricting fats intake
within the recommended limit is required for healthy living
and managing diabetes.
According to the National Academies Press, high-fat diet
often contain unacceptably high amounts of saturated fats,
even if saturated fats from tropical oils and animal products
are avoided. This is due to all fats contain some levels of
saturated fatty acids. For instance, if an individual chose fats
with 20% saturated fatty acids, the setting of fat intake at
35% of the total calories mean that 7% of the calories would
come from the saturated fat. For this reason, Institute of
Medicine and many nutritional institutions recommend
consuming no more than 35% of the calories from fat [79].
Low-fat diets have been promoted to prevent heart disease
and obesity. Lowering fat intake from 35 to 40% of total
calories to 15 to 20% of total calories has shown to reduce
total and LDL cholesterol by 10 – 20%; however, most of
this reduction is due to a decrease in saturated fat intake [80].
2.10.3. Paleolithic Diet
The Paleolithic diet, caveman diet, stone-age diet, or Paleo
diet is a modern fad diet
requiring sole or predominant
consumption of foods acknowledged to have been available
to human during the Paleolithic era [81]. The digestive
abilities of the anatomically modern humans, however, are, to
a large extent, different from those of the pre-Homo sapiens
humans, and has been used to criticize the core premise of
the diet [82].
While there is wide variation in the way the
paleolithic diet is interpreted [83], the diet typically includes
fruits, nuts, vegetables, meat, and roots, and typically
excludes foods such as sugar, processed oils, alcohol, salt,
etc. The diet is based on avoiding processed food and the
foods humans began eating after Neolithic Revolution when
humans transitioned from the hunter-gatherer lifestyles to
settled agriculture [81].
The scientific literatures commonly use the term "Paleo
nutrition pattern", which is variously described as:
1) vegetables, nuts, roots, meat, organ meats, and fruits;
2) vegetables (including root vegetables), nuts, fish, meat,
eggs, and fruit (including fruit oils, e.g., coconut oil,
palm oil, and olive oil), and it excluded dairy, legumes,
extra sugar, grain-based foods, and nutritional products
of industry (such as refined carbohydrates and refined
fats);
and
3) avoids processed foods, and lay emphasis on eating
vegetables, nuts and seeds, fruits, eggs, and lean meats
[83].
As of 2016 there are limited information on the metabolic
effects on the humans eating a paleolithic diet, but data are
based on the clinical trials which have not been enough to
have a sufficient statistical significance to allow the call for
generalizations [81, 83]. These preliminary trials have
indicated that participants consuming a paleolithic nutrition
pattern had better metabolic and cardiovascular health than
individuals eating a standard diet [81, 84], though the
evidence is sufficient enough to recommend the paleolithic
diet for treatment of metabolic syndrome [84], but it may
also be used to reduce the risks of diabetes and other
nutritional diseases. As of 2014 there was lack of evidence
that paleolithic diet is effective in treatment of inflammatory
bowel disease [85].
2.10.4. Low-carbohydrate Diets
(Carbohydrate-Restricted Diets)
Low-carbohydrate diets, also known as carbohydrate-
restricted diets (CRDs) are the diets that restrict consumption
of carbohydrate relative to the average diet. Diets high in
carbohydrates (e.g., pasta, sugar, bread) are limited, and
replaced with the foods containing higher percentage of
protein (e.g., meat, shellfish, eggs, cheese, poultry, fish, nuts,
and seeds) and fat, as well as low carbohydrate foods, such as
chard, collards, spinach, kale, and other fibrous vegetables.
However, there is a lack of general standardization of how
much carbohydrates low-carbohydrate diets must have,
which has complicated research [86]. A low-carbohydrate
diet reduces body exposure to high glucose levels, leads to
weight loss, decrease the risk of obesity, and prevent or
control diabetes, and other related metabolic imbalance. A
definition, from American Academy of Family Physicians,
identifies low-carbohydrate diets as having below 20%
carbohydrate content [87].
There is no enough evidence that eating low-carbohydrate
provides any particular health benefits, apart from weight
loss where low-carbohydrate diets also achieve similar
outcomes to other diets, since weight loss is determined
mainly by calorie restriction and adherence [88].
Nevertheless, a loss of weight is required in obese people to
reduce the risks of diabetes, maintain healthy lifestyle, and
14 Chinaza Godswill Awuchi et al.: Diabetes and the Nutrition and Diets for Its Prevention and Treatment:
A Systematic Review and Dietetic Perspective
reduce the risk of cardiovascular diseases. Consequently, it is
scientific and logically conclusive to say that, for those with
obesity and overweight, maintaining and adhering to low-
carbohydrate diets is essential for reducing the risk of
diseases such as diabetes, cardiovascular disease, etc. An
extreme form of a low-carbohydrate diet –ketogenic diet – is
made as medical diet for treating epilepsy [85, 89]. Through
celebrity endorsement it has come to be popular weight-loss
fad food, but there is no evidence of distinctive benefits for
this purpose, and it can have a few initial side effects [89].
The British Dietetic Association (BDA) named it among the
top 5 worst celeb foods to avoid in 2018 [89].
There is little evidence for effectiveness of low-
carbohydrate diet for individuals with type 1 diabetes [86].
For some people, it may be feasible to adhere to a low-
carbohydrate regime in combination with carefully-managed
insulin dosing, it can be hard to strictly maintain and there
are some concerns about the potential adverse health effect
caused by the diet [86]. In general, individuals with type 1
diabetes are advised to maintain an individualized eating plan
[86].
The proportion of carbohydrates of all types in a diet is not
directly linked to the risks of diabetes type 2, although there
is some evidence linking diets containing some high-
carbohydrate products, such as white rice or sugar-sweetened
drinks, are associated with increased risks of type 2 diabetes.
Some evidence indicates that eating fewer carbohydrate
foods can reduce biomarkers of diabetes type 2 [90, 91].
A 2018 report on diabetes type 2 by the European
Association for Study of Diabetes (EASD) and the American
Diabetes Association (ADA) found that low-carbohydrate
diets may not be as good as Mediterranean diets for
improving glycemic control, and also that although having
healthy body weight is vital, there is no single ratio of intake
of carbohydrate, proteins, and fat that is optimal for every
individual with type 2 diabetes [92]. There is no sufficient
evidence that diets with low-carbohydrate are better than
conventional healthy diets, wherein carbohydrates typically
account for over 40% of calories consumed [93]. Low-
carbohydrate dieting has no effects on the kidney function of
individuals who have type 2 diabetes [94].
Limiting carbohydrate consumption commonly results in
improved glucose control, though without long-term weight
loss [90], but there may be immediate (2 to 10 weeks)
noticeable weight loss, depending on the amounts of other
energy-giving nutrients, especially fats. Low-carbohydrate
diet can be useful to help individuals with type 2 diabetes
lose weight, although no single approach is proven to be
consistently superior [95]. According to the American
Diabetes Association, people with diabetes should be
developing a healthy eating pattern rather than focusing on
individual micronutrients, macronutrients, or single foods.
ADA recommended that the carbohydrate in a diet should
come from legumes, vegetables, fruits, dairy (yogurt and
milk), and whole grains, while sugary drinks and highly-
refined foods should be avoided [95]. The ADA also stated
that reducing the overall intake of carbohydrate for people
with diabetes has shown the most evidence for glycemia
improvement and may be applied in a range of eating
patterns that meet individual requirements and preferences,
and for people with type 2 diabetes who cannot meet the
glycemic target or where reducing anti-glycemic medication
is a priority, low or very-low-carbohydrate diets are viable
approach.
2.10.5. Very-low-calorie Diet
A very-low-calorie diet (VLCD), also called
semistarvation diet or crash diet [96], is type of fad diet with
extremely or very low daily food energy consumption.
VLCD is defined as a diet containing 800 kilocalories (3,300
kJ) or less per day [97, 98]. Modern medically supervised
very-low-calorie diets (VLCDs) use total meal replacement,
with regulated formulation in Europe and Canada which have
the recommended daily requirements for fatty acids, protein,
vitamins, minerals, trace elements, and electrolyte balance.
Carbohydrates can be completely absent, or partly substituted
for the protein; this choice has significant metabolic effects.
Medically supervised very-low-calorie diets have specific
therapeutic application for rapid loss of weight, such as
before a bariatric surgery or in morbid obesity, using
formulated, nutritionally complete liquid foods containing
not more than 800 kilocalories per day for maximum of 12
weeks [97]. Unmonitored very-low-calorie diets with
insufficient macronutrient and mineral intakes have the
potential to cause electrolyte imbalance and unexpected
death via ventricular tachycardia either upon refeeding or by
starvation [99].
2.10.6. Raw Foodism
Raw foodism, also called rawism or following raw food
diet, is dietary practice of consuming only or mostly foods
that are unprocessed and uncooked. Depending on the
philosophy, or the type of lifestyle and the results desired,
raw food diets can include a selection of vegetables, nuts,
fruits, seeds, eggs, meat, fish, and dairy products [100].
Also, the diet may include simply processed food, such as
cheese, numerous types of sprouted seeds, and fermented
foods such as sauerkraut, yogurts, kefir, or kombucha, but
normally not foods that have been homogenized,
pasteurized, or produced with synthetic pesticides, solvents,
food additives, and fertilizers. Raw food diets are diets
entirely or mostly composed of food that is uncooked or
cooked at low temperatures. When uncooked, many starch
molecules are more likely resistant to digestion in the body,
thereby reducing the glucose levels. Cooking improves the
digestibility of nutrients [77]. The medical authorities have
defined raw foodism as a fad diet. The raw food diets,
precisely raw veganism, fail to provide the essential
minerals and nutrients such as iron, calcium, and protein.
Claims held by the raw food proponents are
pseudoscientific [101].
2.10.7. Ketogenic Diet
The ketogenic diet is high-fat, adequate-protein, and low-
carbohydrate diet that is used primarily in medicine to treat
Health Sciences Research 2020; 6(1): 5-19 15
difficult-to-control (i.e. refractory) epilepsy in children. The
ketogenic diet compels the body to burn fats instead of
carbohydrates. The carbohydrates contained in food are
normally converted into glucose, which is transported around
the body and is mainly important in fueling the brain
function. However, if little or no carbohydrate remains in the
diets, the liver converts fat into ketone bodies and fatty acids.
The ketone bodies pass into brain and replace glucose as
energy source. Elevated level of ketone bodies in blood,
known as ketosis, results in a reduction in frequency of the
epileptic seizures. Around 50% of children and young
individuals with epilepsy who have tried various form of this
diet had the number of seizures dropped by at least 50%, and
the effects persist even after discontinuing the diet [102].
Some evidence shows that adults with epilepsy can benefit
from the diet, and that less strict diets, such as modified
Atkins diet, is equally effective. Potential side effects may be
constipation, high cholesterol, acidosis, kidney stones, and
growth slowing.
The ketogenic diet, low in carbs and high in fat, can
potentially change the way body stores and uses energy,
easing the symptoms of diabetes. With the keto diet, body
converts fat, rather than sugar, into energy. The keto diet was
made in 1924 as treatment for epilepsy. The effects of this
pattern of eating are also being studied for diabetes type 2.
The ketogenic diet may improve blood glucose level while at
the same time reducing the requirement for insulin in diabetic
people. However, the diet comes with risks. Ketogenic diet
has been studied for the potential therapeutic use in
numerous neurological disorders other than epilepsy:
amyotrophic lateral sclerosis (ALS), autism, Alzheimer's
disease (AD), headache, pain, Parkinson's disease (PD),
neurotrauma, and sleep disorders [103].
3. Conclusion
Diabetes mellitus, a group of metabolic disorders, is
characterized by a high blood sugar level over a prolonged
period. If left untreated, diabetes mellitus can cause many
complications. The acute complications can include
hyperosmolar hyperglycemic state, diabetic ketoacidosis, or
even death. Serious long-term complications include chronic
kidney disease, foot ulcers, cardiovascular disease, damage to
the eyes, and stroke. Diabetes is due to either the cells of the
body not responding properly to insulin produced or the
pancreas not producing enough insulin. Three main types of
diabetes mellitus are Type 1, Type 2, and Gestational diabetes.
Type 1 diabetes results from the failure of pancreas to produce
enough insulin due to loss of beta cells. The loss of the beta cells
is caused by autoimmune response. The cause of the
autoimmune response is unknown. Type 2 diabetes begins with
the resistance of insulin, a condition in which the cells fail to
properly respond to insulin. As the disease progresses, lack of
insulin may develop. The most common cause is combination of
insufficient exercise and excessive body weight. Gestational
diabetes is the third major form, and occurs when pregnant
women without previous history of diabetes develop a high
blood sugar level. Prevention and treatment of diabetes involve
maintaining healthy diet, normal body weight, regular physical
exercise, and avoiding use of tobacco. Maintaining a healthy diet,
low-fat diet, low-calorie diet, paleolithic diet, very low
carbohydrate diet, raw foodism, and/or ketogenic diet can help
prevent or manage diabetes.
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... Elimination of food allergens using food processing is an effective means of preventing allergens. Though most antigenic determinants and allergens can tolerate several food processing techniques and methods to some extent, studies have demonstrated that specific food processing processes can have effects on allergenicity (Fu et al. 2019;Chinaza et al. 2020a;Awuchi, Hannington et al. 2020;. In food processing, fermentation, enzymatic, chemical, and physical methods can alter the allergens' activity. ...
... These strategies have been reported as recording huge success in producing peanuts and soybeans cultivars with decreased protein allergens (ibid.). Heat treatment, irradiation, ultrasound, ultrahigh-pressure treatment, pulsed ultraviolet technology, chemical modification, fermentation, glycosylation, etc. have also been shown to eliminate several allergens in foods (Fu et al. 2019;Chinaza et al. 2020a;Awuchi, Hannington et al. 2020;). ...
Chapter
Food safety is one of the most important aspects of food manufacturing that needs to be considered in order to avoid any foodborne illnesses for consumers. Some foodborne illnesses are caused by the normal constituent of food itself, not because it is a contaminant but because the person is allergic to it. An allergy is caused by some specific protein molecules which act as antigens to trigger a vigorous immune response in the body. Usually, these protein molecules are harmless but the body perceives them as dangerous. Food allergies are very common and are usually self-diagnosable but are not deadly, however, in some cases, the allergy may prove to be fatal, as in the case of anaphylaxis. A food allergy is mainly caused by the ingestion of the allergen, even if it is in a small amount. The common symptoms which are seen in the allergy include itching (eczema) skin, swelling, nasal congestion, trouble in breathing, abdominal or stomach pain, diarrhea, nausea, vomiting, and dizziness. To prevent food allergies, the best way is to avoid eating the food with that particular allergen as the main constituent. Reading the constituents in the nutrition table of ready-to-eat food and semi-processed food may reduce the chances of allergy. Genetically modified plants can be prepared to have genetically modified proteins which do not have allergic properties. Hypoallergenic foods production may help to eliminate allergic reactions to food. Rapid detection of allergens in food while on the production line to eliminate the chances of introducing allergens while processing would be a great help. The guidelines given by USFDA and other regulatory bodies regarding food allergens during the food manufacturing processes can reduce the cases of food allergy. Food allergies, types, and safety measures are discussed in detail in this chapter.
... Nhiều nghiên cứu trên thế giới đã được thực hiện để chứng minh vai trò của dinh dưỡng trong bệnh đái tháo đường như: Nghiên cứu của tác giả Awuchi và cộng sự đưa ra kết quả: Ăn kiêng đầy đủ, dinh dưỡng tốt và tập thể dục thường xuyên là rất quan trọng trong việc ngăn ngừa hoặc kiểm soát bệnh đái tháo đường đặc biệt là đái tháo đường type 2 [3]. Trong nghiên cứu của mình tác giả Wagas Sami và cộng sự cho rằng: Mức HbA1c có thể kiểm soát thông qua quản lý chế độ ăn uống [2]. ...
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Mục tiêu: Xác định một số yếu tố liên quan đến tình trạng dinh dưỡng của người bệnh đái tháo đường type 2 điều trị tại bệnh viện Đa khoa tỉnh Nam Định năm 2022. Đối tượng và phương pháp nghiên cứu: Nghiên cứu mô tả cắt ngang trên 98 người bệnh được chẩn đoán đái tháo đường type 2 đang được điều trị tại Bệnh viện Đa khoa tỉnh Nam Định từ tháng 3 đến tháng 5 năm 2022. Kết quả: Tình trạng dinh dưỡng của người bệnh đái tháo đường type 2 theo SGA: Có 81,6% người bệnh có tình trạng dinh dưỡng SGA A, 18,4% người bệnh có tình trạng dinh dưỡng SGA B, 0% người bệnh có tình trạng dinh dưỡng SGA C. Chưa tìm thấy mối liên quan giữa giới tính, tuổi, trình độ học vấn, nghề nghiệp, với tình trạng dinh dưỡng của người bệnh đái tháo đường theo SGA (p > 0,05). Thói quen ăn uống, hút thuốc lá, hoạt động thể chất, khẩu phần ăn 24h có mối liên quan với tình trạng dinh dưỡng của người bệnh đái tháo đường type 2 đang điều trị tại Bệnh viện Đa khoa tỉnh Nam Định. Kết luận: Đa số người bệnh có tình trạng dinh dưỡng tốt (81,6%). Cần tăng cường các hoạt động tuyên truyền, tư vấn cho người bệnh đái tháo đường về chế độ dinh dưỡng bệnh lý, hành vi lối sống.
... The result obtained in the table above shows that the weight parameters affect patient which have T2DM and that could be because the rise in the BMI causes a defect in the work of enzymes and hormones controlling. The metabolism of glucose in the body and as a result causes T2DM, another fact that the elevated (BMI, WC and WHpR ) means that there is a rise in the body fat which made the whole concentration of the bodywork lower the body Fat and this cause a less work on the glucose digestion (17). According to other studies, having a high BMI is linked to an increased risk of all DM complications. ...
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The study focused on evaluating proximate compositions and functional properties of different flour blends. Three representative flour samples were produced from each mixture of maize-millet, soybean-wheat, and rice-wheat in the ratios of 70:30, 50:50, and 30:70 percent for all combinations. The proximate composition and functional properties of flour blends were determined using the methods of AOAC. There was significant difference in the proximate compositions of the flours (p =0.05). The moisture content of the blends was highest at 5.41% for maize-millet blend ratio of 70:30% and lowest at 1.8% for soybean-wheat blend ratio of 30:70%. The crude protein content of the grain flour samples ranged from 16.32% to 44.10%. Soybean-wheat flour blend had the highest fat content of 7.34% for 70:30% and maize-millet blend had the least fat content of 1.30 for 50:50%. Maize-millet flour blend had the highest ash content of 4.02% for 30:70% and lowest for rice-wheat with 0.35% for 50:50%. The percent carbohydrate content of the flours ranged from 42.60% to 65.01%. The percent crude fibre content of the flours ranged from 2.13% to 10.01%. Soya bean-wheat flour blend had the highest average crude fibre content. There was significant difference in the functional properties of the flour blends (p =0.05). The oil absorption capacity (OAC) of the flours ranged from 1.00 to 2.25 ml/g. The rice-wheat flour blend had the highest water absorption capacity (WAC) of 2.60 ml/g for 30:70% blend ratio, while the lowest WAC was 0.50 ml/g for soybean-wheat blend. The foaming capacity (FC) of the flour blends ranged from 10.83 to 15.40%, while the emulsion capacity ranged from 35.05% to 50.95%. The swelling index ranged from 1.13% to 1.98%. The high emulsion capacity of soybean-wheat flour blend suggested that it was more digestible and therefore could be suitable for use as ingredient in infant food formulations.The high swelling index indicates that rice-wheat flour blend could be more suitable in food systems where swelling is required. The high emulsion capacity of soybean-wheat flour blend suggested that it was more digestible and therefore could be suitable for use as ingredient in infant food formulations.
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The research discussed the current developments in the chemistry, nutrition, and medical and health concerns of sugar alcohols, particularly sorbitol, xylitol, glycerol, arabitol, inositol, maltitol, and lactitol. Sugar alcohols (also called glycitols, polyols, polyhydric alcohols, polyalcohols, or alditols) are organic compounds, typically derived from sugars, containing one hydroxyl group attached to each carbon atom. Sugar alcohols are widely used as thickeners and sweeteners in the food industry. In commercial foods, sugar alcohols are commonly used in place of sucrose, usually in combination with high-intensity artificial sweeteners, in order to offset their low sweetness. Sorbitol is a sugar substitute, and is about 60% as sweet as sucrose (table sugar). Inositol is half as sweetness as sucrose, and is made naturally in humans from glucose. Glycerol is also widely used as a sweetener in the food industry and as a humectant in pharmaceutical formulations. Xylitol naturally occur in small amounts in plums, strawberries, pumpkin, and cauliflower; and can be produced industrially from lignocellulosic biomass from which xylan is extracted. Arabitol can be formed by reduction of either lyxose or arabinose. Lactitol is used as a laxative, and also as a replacement in bulk sweetener for low calorie foods with roughly 40% of the sugar sweetness. The high sweetness of maltitol allows its solitaire use without mixing with other sweeteners. Like other sugar alcohols, foodstuffs containing sorbitol may cause gastrointestinal distress. Sorbitol acts as laxative by drawing water into large intestine, stimulating bowel movements. Inositol is used in managing preterm babies who are at a risk of (or have) infant respiratory distress syndrome. Glycerol may pose very low toxicity when consumed. At high doses, xylitol and other polyols can cause gastrointestinal discomfort, including irritable bowel syndrome, flatulence, and diarrhea. Arabitol is associated with ribose-5-phosphate isomerase deficiency and Alzheimer's disease. Like other sugar alcohols, lactitol may cause diarrhea, cramping, and flatulence in some individuals who consume it.
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Background It remains uncertain which diet is best for people with type 2 diabetes (T2D). Objective We compared the effects of dietary carbohydrate restriction with fat restriction on markers of metabolic syndrome and quality of life in people with T2D. Design This systematic review of randomized controlled trials (RCTs) and controlled clinical trials (CCTs) compares the effects of a low-carbohydrate [≤40% of energy (%)] diet with those of a low-fat (≤30%) diet over a period of ≥4 wk in patients with T2D. Two investigators independently selected studies, extracted data, and assessed risk of bias. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was used to assess the certainty of evidence. Pooled mean differences (MDs) and 95% CIs were calculated with the use of a random-effects model. Results Thirty-three RCTs and 3 CCTs (n = 2161) were included. Glycated hemoglobin declined more in people who consumed low-carbohydrate food than in those who consumed low-fat food in the short term (MD: –1.38%; 95% CI: –2.64%, –0.11%; very-low-certainty evidence). At 1 y, the MD was reduced to –0.36% (95% CI: –0.58%, –0.14%; low-certainty evidence); at 2 y, the difference had disappeared. There is low to high (majority moderate) certainty for small improvements of unclear clinical importance in plasma glucose, triglycerides, and HDL concentrations favoring low-carbohydrate food at half of the prespecified time points. There was little to no difference in LDL concentration or any of the secondary outcomes (body weight, waist circumference, blood pressure, quality of life) in response to either of the diets (very-low- to high-certainty evidence). Conclusions Currently available data provide low- to moderate-certainty evidence that dietary carbohydrate restriction to a maximum of 40% yields slightly better metabolic control of uncertain clinical importance than reduction in fat to a maximum of 30% in people with T2D.
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Dietary management has been a mainstay of care in Type 1 diabetes since before the discovery of insulin when severe carbohydrate restriction was advocated. The use of insulin facilitated re‐introduction of carbohydrate into the diet. Current management guidelines focus on a healthy and varied diet with consideration of glycaemic load, protein and fat. As a result of frustration with glycaemic outcomes, low‐carbohydrate diets have seen a resurgence in popularity. To date, low‐carbohydrate diets have not been well studied in the management of Type 1 diabetes. Studies looking at glycaemic outcomes from low‐carbohydrate diets have largely been cross‐sectional, without validated dietary data and with a lack of control groups. The participants have been highly motivated self‐selected individuals who follow intensive insulin management practices, including frequent blood glucose monitoring and additional insulin corrections with tight glycaemic targets. These confounders limit the ability to determine the extent of the impact of dietary carbohydrate restriction on glycaemic outcomes. Carbohydrate‐containing foods including grains, fruit and milk are important sources of nutrients. Hence, low‐carbohydrate diets require attention to vitamin and energy intake to avoid micronutrient deficiencies and growth issues. Adherence to restricted diets is challenging and can have an impact on social normalcy. In individuals with Type 1 diabetes, adverse health risks such as diabetic ketoacidosis, hypoglycaemia, dyslipidaemia and glycogen depletion remain clinical concerns. In the present paper, we review studies published to date and provide clinical recommendations for ongoing monitoring and support for individuals who choose to adopt a low‐carbohydrate diet. Strategies to optimize postprandial glycaemia without carbohydrate restriction are presented. This article is protected by copyright. All rights reserved.
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Meta‐analysis was conducted to clarify the effect of low carbohydrate diet (LCD) on renal function in patients with type 2 diabetes mellitus (T2DM). An extensive literature search was conducted on scientific databases including PubMed, Scopus, and Cochrane Library until September 2017. Only controlled trials on human subjects written in English were included in this meta‐analysis. Several markers of renal function were compared between subjects who adopted a LCD or control diet, including estimated glomerular filtration rate (eGFR), creatinine clearance, urinary albumin, serum creatinine, and serum uric acid. Random effect model was used in the analysis of each marker. In this meta‐analysis, 12 controlled trials were selected, which involved 942 participants (500 received LCD and 442 received a control diet). The pooled standardized mean difference (SMD) of eGFR from LCD vs. control diet was not different (Pooled SMD: 0.26; 95% CI:‐0.03, 0.55; p=0.08). Investigation on creatinine clearance also showed no significant difference (Pooled SMD: 0.53; 95% CI: ‐0.38, 1.44; p=0.26). Other comparisons from urinary albumin (Pooled SMD: ‐0.04; 95% CI: 0.75, 0.67; p=0.90), serum creatinine (Pooled SMD: ‐0.57; 95% CI: ‐1.51, 0.38; p=0.24), and serum uric acid (Pooled SMD: ‐8.86; 95% CI: ‐4.00, 2.28; p=0.59) also showed insignificant difference in the results. In the present meta‐analysis, no effect on markers of renal function was found after provision of a low carbohydrate diet compared with a control diet in patients with T2DM.
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Description: The American College of Physicians developed this guidance statement to guide clinicians in selecting targets for pharmacologic treatment of type 2 diabetes. Methods: The National Guideline Clearinghouse and the Guidelines International Network library were searched (May 2017) for national guidelines, published in English, that addressed hemoglobin A1c (HbA1c) targets for treating type 2 diabetes in nonpregnant outpatient adults. The authors identified guidelines from the National Institute for Health and Care Excellence and the Institute for Clinical Systems Improvement. In addition, 4 commonly used guidelines were reviewed, from the American Association of Clinical Endocrinologists and American College of Endocrinology, the American Diabetes Association, the Scottish Intercollegiate Guidelines Network, and the U.S. Department of Veterans Affairs and Department of Defense. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to evaluate the guidelines. Guidance statement 1: Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care. Guidance statement 2: Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes. Guidance statement 3: Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%. Guidance statement 4: Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.
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Importance: Diabetes prevention is imperative to slow worldwide growth of diabetes-related morbidity and mortality. Yet the long-term efficacy of prevention strategies remains unknown. Objective: To estimate aggregate long-term effects of different diabetes prevention strategies on diabetes incidence. Data Sources: Systematic searches of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases. The initial search was conducted on January 14, 2014, and was updated on February 20, 2015. Search terms included prediabetes, primary prevention, and risk reduction. Study Selection: Eligible randomized clinical trials evaluated lifestyle modification (LSM) and medication interventions (>6 months) for diabetes prevention in adults (age ≥18 years) at risk for diabetes, reporting between-group differences in diabetes incidence, published between January 1, 1990, and January 1, 2015. Studies testing alternative therapies and bariatric surgery, as well as those involving participants with gestational diabetes, type 1 or 2 diabetes, and metabolic syndrome, were excluded. Data Extraction and Synthesis: Reviewers extracted the number of diabetes cases at the end of active intervention in treatment and control groups. Random-effects meta-analyses were used to obtain pooled relative risks (RRs), and reported incidence rates were used to compute pooled risk differences (RDs). Main Outcomes and Measures: The main outcome was aggregate RRs of diabetes in treatment vs control participants. Treatment subtypes (ie, LSM components, medication classes) were stratified. To estimate sustainability, post-washout and follow-up RRs for medications and LSM interventions, respectively, were examined. Result: Forty-three studies were included and pooled in meta-analysis (49 029 participants; mean [SD] age, 57.3 [8.7] years; 48.0% [n = 23 549] men): 19 tested medications; 19 evaluated LSM, and 5 tested combined medications and LSM. At the end of the active intervention (range, 0.5-6.3 years), LSM was associated with an RR reduction of 39% (RR, 0.61; 95% CI, 0.54-0.68), and medications were associated with an RR reduction of 36% (RR, 0.64; 95% CI, 0.54-0.76). The observed RD for LSM and medication studies was 4.0 (95% CI, 1.8-6.3) cases per 100 person-years or a number-needed-to-treat of 25. At the end of the washout or follow-up periods, LSM studies (mean follow-up, 7.2 years; range, 5.7-9.4 years) achieved an RR reduction of 28% (RR, 0.72; 95% CI, 0.60-0.86); medication studies (mean follow-up, 17 weeks; range, 2-52 weeks) showed no sustained RR reduction (RR, 0.95; 95% CI, 0.79-1.14). Conclusions and Relevance: In adults at risk for diabetes, LSM and medications (weight loss and insulin-sensitizing agents) successfully reduced diabetes incidence. Medication effects were short lived. The LSM interventions were sustained for several years; however, their effects declined with time, suggesting that interventions to preserve effects are needed.