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Ma-PI 2 macrobiotic diet intervention in adults with type 2 diabetes mellitus

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Introduction Diet is a cornerstone of comprehensive treatment of diabetes mellitus. The macrobiotic diet is low in fat and rich in dietary fiber, vegetables and whole grains, and therefore may be a good therapeutic option. Objective Assess the influence of the Ma-Pi 2 macrobiotic diet on physical, hematologic and biochemical variables, as well as on hypoglycemic medication, in adults with type 2 diabetes mellitus. Materials and Methods A 6-month dietary intervention was carried out in 16 adults with type 2 diabetes mellitus and poor glucide metabolism control (glycosylated hemoglobin, HbA1 >8.5%) receiving treatment at the Diabetic Care Center in Colón, Matanzas province, Cuba. The diet was prepared and served daily by macrobiotic specialists. Type and amount of food consumed and nutritional content were assessed using a weighted food-consumption survey. At onset and termination of the intervention, anthropometric and body composition variables were measured, as were biochemical (glucide and lipid metabolism) and other nutritional safety variables, and hypoglycemic drug use. Results The diet provided sufficient energy and protein. It was low in fat, high in complex carbohydrates and dietary fiber, and provided adequate amounts of vitamins and minerals, except for vitamin B12. At 6 months, anthropometric variables were significantly lower, lean body mass was preserved, and glucide and lipid metabolism was controlled. All participants were able to eliminate insulin treatment, and 25% continued treatment with glibenclamide only. Mean total cholesterol, LDL cholesterol and triglyceride values dropped 16.4%, 22.7% and 37.0%, respectively, while mean HDL cholesterol rose 97.8%. Mean glycemia and HbA1 values also decreased 63.8% and 54.5%, respectively. According to lipid levels and ratios, cardiovascular risk was also considerably reduced. Hemoglobin, total protein, albumin and creatinin levels indicated that nutritional safety was maintained. There were no adverse events. Conclusions In the 6-month intervention, the Ma-Pi 2 macrobiotic diet had a positive influence on weight control, body fat, and glucide and lipid metabolism in patients with type 2 diabetes mellitus. Further research is needed to validate these encouraging results, particularly a clinical trial in which a control group receives the standard diet recommended for diabetic patients.
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MEDICC Review, Fall 2009, Vol 11, No 4
Original Scientic Articles
Research & Practice
Peer Reviewed
INTRODUCTION
Diabetes mellitus affects 246 million people in the world and is
predicted to reach 380 million by 2030.[1] In Latin America, the
number of diabetics is expected to increase more than 50%, from
13.3 million in 2002 to 32.9 million in 2030.[2]
According to the Pan American Health Organization, the “nutri-
tional transition” in Latin America and the Caribbean is character-
ized by very low intake of vegetables, whole grains and fruits,
combined with a relatively high intake of foods rich in saturated
fats, sugars and salt, such as milk, meats, rened grains and pro-
cessed foods.[3] This dietary conguration is a key factor in the
development of chronic diseases, particularly diabetes mellitus.
The magnitude of the diabetes mellitus epidemic also may have
an impact on economic growth.[4,5] The cost of health care for
people with diabetes is 2 to 3 times higher than for non-diabetics.
[6] For this reason the American Diabetes Association has called
for measures to increase efcacy of prevention, diagnosis and
treatment.[7]
Diet is a key factor in both prevention and treatment of type 2 dia-
betes mellitus. Although dietary recommendations for therapeutic
management of diabetes are constantly changing, most follow
these general guidelines: restrict the intake of foods with high
glycemic index and load; reduce fat intake (especially saturated
fats and trans fatty acids) and cholesterol; increase the intake of
whole grains and ber; limit protein and reduce salt.[8–10] Diets
low in fat and rich in dietary ber and whole grains have been
shown to be effective for maintaining body weight and reducing
glycemia and cholesterol levels.[10,11] The macrobiotic diet ful-
lls these requirements.
Macrobiotics was developed by George Ohsawa, based on two
ancient Asian theories (Yin/Yang and the Five Transformations).
[12] Mario Pianesi simplied the food regimens proposed by Oh-
sawa to make them more acceptable in Western cultures. Pianesi
proposed 5 “Ma-Pi” diets.[13] The Ma-Pi 2 diet was specically
designed for diabetes mellitus patients, particularly those with
metabolic disorders. The results ascribed to it are mainly anec-
dotal and testimonial but there is growing interest in conducting
scientic studies to determine its efcacy. Since 2001, Cuba’s
Finlay Institute has been studying the nutritional characteristics
and safety of the Ma-Pi diets, as well as their therapeutic effect
on several chronic diseases, particularly type 2 diabetes melli-
tus.[14–16] These studies are part of an international multicenter
project sponsored by the Italian organization Un Punto Macrobi-
otico (UPM), with research also being conducted in Thailand,[17]
Ivory Coast and China.
Given the positive results yielded by these studies and the seri-
ous epidemiological prole presented by diabetes mellitus, the
Finlay Institute proposed an intervention using the Ma-Pi 2 diet in
a group of adults with type 2 diabetes mellitus receiving treatment
at the Diabetic Care Center (CAD, its Spanish acronym) in Colón,
Matanzas province. CADs have been established by the Cuban
Ministry of Public Health (MINSAP, its Spanish acronym) in every
province to provide specialized services for all diabetic patients,
Ma-Pi 2 Macrobiotic Diet Intervention in Adults
with Type 2 Diabetes Mellitus
Carmen Porrata, MD, PhD, Julio Sánchez, MD, Violeta Correa, MD, Alfredo Abuín, MD, Manuel Hernández-Triana, MD, PhD,
Raúl Vilá Dacosta-Calheiros, MD, María Elena Díaz, PhD, Mayelín Mirabal, MS, Eduardo Cabrera, PhD, Concepción Campa,
MS, Mario Pianesi
ABSTRACT
Introduction Diet is a cornerstone of comprehensive treatment of diabe-
tes mellitus. The macrobiotic diet is low in fat and rich in dietary ber, veg-
etables and whole grains, and therefore may be a good therapeutic option.
Objective Assess the inuence of the Ma-Pi 2 macrobiotic diet on
physical, hematologic and biochemical variables, as well as on hypo-
glycemic medication, in adults with type 2 diabetes mellitus.
Materials and Methods A 6-month dietary intervention was carried out
in 16 adults with type 2 diabetes mellitus and poor glucide metabolism
control (glycosylated hemoglobin, HbA1 >8.5%) receiving treatment at
the Diabetic Care Center in Colón, Matanzas province, Cuba. The diet
was prepared and served daily by macrobiotic specialists. Type and
amount of food consumed and nutritional content were assessed us-
ing a weighted food-consumption survey. At onset and termination of
the intervention, anthropometric and body composition variables were
measured, as were biochemical (glucide and lipid metabolism) and other
nutritional safety variables, and hypoglycemic drug use.
Results The diet provided sufcient energy and protein. It was low
in fat, high in complex carbohydrates and dietary ber, and provided
adequate amounts of vitamins and minerals, except for vitamin B12. At
6 months, anthropometric variables were signicantly lower, lean body
mass was preserved, and glucide and lipid metabolism was controlled.
All participants were able to eliminate insulin treatment, and 25% con-
tinued treatment with glibenclamide only. Mean total cholesterol, LDL
cholesterol and triglyceride values dropped 16.4%, 22.7% and 37.0%,
respectively, while mean HDL cholesterol rose 97.8%. Mean glycemia
and HbA1 values also decreased 63.8% and 54.5%, respectively. Ac-
cording to lipid levels and ratios, cardiovascular risk was also consider-
ably reduced. Hemoglobin, total protein, albumin and creatinin levels
indicated that nutritional safety was maintained. There were no ad-
verse events.
Conclusions In the 6-month intervention, the Ma-Pi 2 macrobiotic diet
had a positive inuence on weight control, body fat, and glucide and
lipid metabolism in patients with type 2 diabetes mellitus. Further re-
search is needed to validate these encouraging results, particularly a
clinical trial in which a control group receives the standard diet recom-
mended for diabetic patients.
Keywords: Type 2 diabetes mellitus; adult; macrobiotic diet; diet
therapy
MEDICC Review, Fall 2009, Vol 11, No 4
30
including consultations with medical specialists, nutritional coun-
seling, medication, health care, and hygiene.
The objective of this study was to evaluate the effects of the Ma-
Pi 2 diet on physical and body composition variables, glucide and
lipid metabolism, nutritional safety (hemoglobin, total protein and
albumin levels), and use of insulin and other hypoglycemic medi-
cation in a group of adults with type 2 diabetes mellitus and poor
glucide metabolism control (high glycosylated hemoglobin).
METHODS
Type of study and subjects A prospective intervention study
with the Ma-Pi 2 diet was conducted for 6 months beginning in
December 2004 and ending in May 2005. A convenience sample
was formed of patients with type 2 diabetes mellitus, attending
the CAD in Colón, Matanzas province, who responded to a call
for participants and who met the inclusion criteria established in
the research protocol. The group consisted of 16 adults: 3 men
(18.8%) and 13 women (81.3%), average age 60 years (range:
44–73 years) and 9–31 years disease evolution. All were being
treated with insulin (670 units/day total; average per capita: 42.4
units/day; 0.61 units/kg body weight) and 2 patients also used
glibenclamide (6 tablets/day total; 0.2 mg/kg body weight).
Inclusion criteria Conrmed diagnosis of type 2 diabetes mel-
litus with poor glucide metabolism control (glycosylated hemoglo-
bin, HbA1 >8.5%); voluntary participation with informed consent;
pharmacological treatment with insulin and hypo- or normo-glyce-
mic tablets, or both; aged 20–75 years; residence near the CAD
or with transportation; completion of a macrobiotic diet therapy
course, consisting of 28 hours of practical cooking classes (se-
lection of food items, amounts, combinations, proportions, eating
frequency, handling, cooking methods and food preservation) and
28 hours of theory (principles underlying the diet and its nutri-
tional and therapeutic potential). The course was given during
the pre-intervention period when patients were being evaluated
to determine if they complied with the remaining inclusion criteria
established in the protocol.
Exclusion criteria Presence of other diseases or use of drugs
interfering with carbohydrate metabolism, invalidating diseases
(terminal stage disease, mental impairment, etc.), addictions, he-
moglobin <10 mg/dl, or body mass index (BMI) <18.5.
Exit criteria Intolerance or non-acceptance of the diet, hemoglo-
bin <10 mg/dl, BMI <18.5, persistent signs or symptoms of nu-
tritional deciencies or excesses, interruption of the diet (more
than 2 days absence from the dining hall in one month), failure to
participate in medical evaluations established in the protocol, vol-
untary abandonment of the study, appearance of other diseases
or complications requiring hospitalization or medications interfer-
ing with study results.
Adverse events Any medical event occurring during the interven-
tion that may or may not be attributed to the diet. Anemia, low
weight, and signs and symptoms of nutritional deciencies or ex-
cesses were considered events possibly attributable to the diet.
Ethical considerations The study was conducted according to
the Helsinki Declaration.[18] All participants were informed of
the procedures and possible drawbacks of the study, and written
informed consent was obtained. The Scientic Council and the
Ethics Committee of the Matanzas Medical School approved the
study protocol.
Diet Total volume of the Ma-Pi 2 diet consisted of 40–50% whole
grains (rice, millet and barley), 30–40% vegetables (carrots, kale,
cabbage, broccoli, chicory, onions, red and white radish, parsley),
and 8% legumes (adzuki beans, chickpeas, lentils, black beans),
plus gomashio (roasted ground sesame seeds with unrened sea
salt), fermented products (miso, tamari, umeboshi) and seaweeds
(kombu, wakame, nori). Bancha tea (tannin-free green tea) was
the main source of liquid.
Food intake was measured using the weight method for 7 consecu-
tive days in the 2nd and 4th months of the intervention. Average
nutritional content was calculated using internationally recognized
chemical composition charts for food[19–22] and was compared
with daily intake allowances recommended by the Joint FAO/WHO
Expert Consultation group and the US Academy of Sciences Food
and Nutrition Board.[23,24] Recommended intake of protein, fat
and carbohydrates was set at 15%, 20% and 65% of total energy,
respectively. Tolerable upper intake levels of vitamins and miner-
als were established. The protein amino acid score was assessed
using the adult amino acid requirements proposed by Millward,[25]
corrected for 80% digestibility, since all proteins were vegetable.
Statistical data and methods Anthropometric measurements
and blood samples were taken at onset and termination of the
intervention (0 and 6 months, respectively). All participants’ body
weight, height, waist and hip circumferences, and skin folds (bi-
ceps, triceps, subscapular and suprailiac) were measured.[26]
Durnin/Womersly equations were used to estimate body density.
[27] Percentage of body fat was calculated using Siri’s equation.
[28] All measurements were made by specialized technicians
from the Nutrition and Food Hygiene Institute (INHA, its Spanish
acronym).
Original Scientic Articles
Peer Reviewed
Ma-Pi 2 Diet Typical Composition
Food* (Source) Grams Per Person Per Day
Brown rice (MINAGRI, Cuba) 350
Husked barley (La Salvia, Italy) 25
Millet (La Salvia, Italy) 25
Chicory (Urban Agriculture, Cuba) 50
Broccoli (Urban Agriculture, Cuba) 100
Onion (MINAGRI, Cuba) 200
Kale (Urban Agriculture, Cuba) 100
Parsley (Urban Agriculture, Cuba) 10
Radish (Urban Agriculture, Cuba) 40
Carrots (MINAGRI, Cuba) 200
Chickpeas (MINAGRI, Cuba) 30
Black beans (MINAGRI, Cuba) 30
Sesame seeds (Urban Agriculture,
Cuba) 45
Kombu seaweed (La Salvia, Japan) 2
Nori seaweed (La Salvia, Japan) 6
Wakame seaweed (La Salvia, Japan) 2
Miso (La Salvia, Italy) 6
Tamari (La Salvia, Italy) 6
Unrened sea salt (MINBAS, Cuba) 2
Bancha tea (La Salvia, Japan) 1000 ml
* Raw food, ready for processing
31
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Original Scientic Articles
The following 12-hour fasting blood tests were also performed:
total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides,
glucose, glycosylated hemoglobin (HbA1), C-peptide, hemoglo-
bin, total proteins, albumin and creatinin. Glucose, lipids, and
other hematologic and biochemical variables were measured us-
ing internationally established techniques,[29–31] in the Faustino
Pérez Provincial Hospital laboratory in Matanzas. A Hitachi 902
Automatic Analyzer (Roche Diagnostics GmbH, Germany) was
used with HELFA-Diagnostics commercial kits (Cuba).
C-peptide and HbA1 were measured in the National Endocrinol-
ogy Institute laboratory in Havana. Solid-phase radioimmuno-
assay (Schering AG CIS Bio International, France) was used
to measure C-peptide concentrations (normal values 1.07–
3.51 ng/ml), and the ion-exchange resin separation method
was used to determine HbA1 levels (Human Gesellschaft für
Biochemic und Diagnostic GmbH, Germany) (normal values
4.5–7.0%). Diagnostic cut-off points for metabolic control were
set as follows: good, 4.5–7.5%; acceptable, 7.5%–8.5%; poor,
>8.5%.[32] Cardiovascular risk was estimated according to se-
rum lipid values.[33]
Quantitative variables at 0 and 6 months were compared, and
results were described using stadigraphs, mean and median. Stu-
dent’s t-test and the Wilcoxon test were used for comparison of
matched pairs with a signicance level of p ≤0.05.
Procedure A logbook was specically designed for this interven-
tion, and data on each patient was collected and recorded daily
for the rst month, every other day during the second month, and
twice a week for the remaining months. Patient evolution data
included clinical signs and symptoms, heart rate, blood pressure,
glycemic prole, tolerance and acceptance of the diet, adverse
events, and amounts of medication used. Body weight was re-
corded monthly. Capillary glycemic proles were evaluated regu-
larly using a glucometer (Roche, USA).
As glycemia values declined, hypoglycemic medicine doses were
reduced.
Patients received full food service daily (breakfast, lunch, din-
ner and snacks) in the CAD macrobiotic dining hall. Food was
prepared by expert macrobiotic cooks from UPM. Patients could
have more than one serving as long as proportions of grains, veg-
etables and legumes were maintained.
RESULTS
The diet supplied adequate energy and was highly lling, low
in energy density and high in complex carbohydrates (Table 1).
Total energy composition was 12% protein, 16% fat and 72%
carbohydrate.
All nutrients fullled >90% of recommended daily allowances,
except vitamin B12, which met only 23%, well below the recom-
mended amount. Nutritional content of dietary ber, vitamin A
from β-carotenes, folates, vitamin C, thiamine, pyridoxine, niacin,
manganese and magnesium was notably high (Table 1). Despite
the absence of dairy and animal products in the diet, intake of
calcium and iron was adequate. The amino acid score was 99%,
corrected for 80% digestibility, with methionine + cysteine as the
limiting amino acids, indicating adequate proportions of grains,
legumes and sesame seeds in the protein mix.
The only adverse event observed during the intervention was
slight carotinemia when carrots and green leaf vegetables were
more abundant. No participants abandoned the study, although
the diet differs greatly from most Cubans’ tastes and preferences
in food [34] and was hard to accept at rst, particularly for partici-
pants unaccustomed to eating vegetables. They adapted quickly,
however, and acceptability noticeably improved.
After 6 months of Ma-Pi 2 dietary intervention, statistically signi-
cant reductions in mean body weight (9.0%), BMI (9.1%), waist
circumference (6.7%), hip circumference (5.1%), skin folds (tri-
ceps 24.2%, subscapular 24.1%, suprailiac 28.0%) and body fat
(9.7%) were found, as well as a statistically signicant increase
lean body mass (6.9%) (Table 2).
Changes in mean levels of total protein, albumin and creatinin
were not statistically signicant, while mean hemoglobin and lipid
variables all showed statistically signicant changes. Reductions
in higher hemoglobin values accounted for the 7.4% drop in mean
hemoglobin (10.1 g/dl–19.6 g/dl at onset vs 11.2 g/dl–13.6 g/dl at
termination). Total cholesterol, LDL cholesterol and triglycerides
decreased 16.4%, 22.7% and 37.0%, respectively, while HDL
Peer Reviewed
Table 1: Average Daily Nutritional Content, Ma-Pi 2 Diet vs.
Recommended Intake
Nutrient Average Daily Intake Per Person
Ma-Pi 2 Diet Recommendation
Energy (kcal) 2202 2000
Protein (g)
-Tryptophan*
-Threonine*
-Isoleucine*
-Leucine*
-Lysine*
-Methionine + Cysteine*
-Phenylalanine + Tyrosine*
-Valine*
66
13
35
41
73
42
34
78
50
75
7
29
34
50
35
31
38
26
Total fat (g) 39 44
Carbohydrates (g) 396 325
Fiber (g) 55 30–55
Vitamin C (mg) 153 45–2000
Folic acid (µg) 781 400–1000
Vitamin B1 (mg) 3.50 1.2–NA
Vitamin B2 (mg) 1.31 1.3–NA
Vitamin B6 (mg) 5.46 1.4–NA
Niacin (mg) 25 16–35
Vitamin B12 (µg) 0.45 2.0–NA
Vitamin E (mg) 9.0 9–1000
Vitamin A (µg) 3376 550–3000**
Potassium (mg) 3756 2000–3500
Manganese (mg) 16.0 2–11
Iron (mg) 24.0 18–53
Calcium (mg) 978 750–2500
Phosphorus (mg) 1632 800–4000
Zinc (mg) 15.2 12–40
Magnesium (mg) 754 250–350***
Sodium (mg) 1724 500–2300
NA: Data not available
* mg of amino acid per gram of protein
** preformed vitamin A only
*** tablets only
Source: Study data
MEDICC Review, Fall 2009, Vol 11, No 4
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Original Scientic Articles
Peer Reviewed
cholesterol increased 97.8%, doubling its onset value. Lipid ratios
also improved: Total cholesterol/HDL cholesterol dropped 57.9%,
from 11.9 mmol/l to 5.0 mmol/l, and LDL/HDL decreased 60.3%,
from 7.8 mmol/l to 3.1 mmol/l (Table 3).
The 63.8% reduction in mean glycemia and 54.5% reduction
in HbA1 were also statistically signicant, although the 13% in-
crease in C-peptide was not (Table 3). HbA1 values at termination
(mean value 5.73%; 4.5%–7.5%) indicated that all participants
had achieved good control of glucide metabolism, compared to a
mean of 12.60% (10%–16%) at onset.
Risk of cardiovascular disease associated with lipoprotein and tri-
glyceride levels decreased notably in almost all patients (Table 4).
At intervention onset, only 5 patients (31.3%) had desirable total
cholesterol (≤5.18 mmol/1) and 3 patients (18.8%) were classied
as high risk (≥6.2 mmol/1). Six months later, at termination, 13
patients (81.3%) had achieved desirable cholesterol levels and
zero participants were considered high risk.
At termination of the intervention, insulin administration had been
eliminated in all patients, and 12 patients (75.0%) were receiving
the Ma-Pi 2 macrobiotic diet as their only therapy. Overall glib-
enclamide use increased from 6 to 15 tablets daily (0.76
mg/kg weight), since 4 patients initiated glibenclamide
therapy when they stopped taking insulin.
DISCUSSION
Therapeutic diets for diabetes mellitus all have the
same goals: adequate body weight, normal glycemia
and lipid values, reduced oxidative stress, and pre-
served or improved endogenous insulin secretion.[8]
Results of this study show that the Ma-Pi 2 diet inter-
vention met these objectives. Preliminary assessment
of its nutritional characteristics suggest that this mac-
robiotic diet fully meets functional requirements; how-
ever, further research on its physiological, biochemi-
cal and metabolic mechanisms is required to confirm
that claim.
Results of this study also support evidence that a diet
rich in ber, complex carbohydrates, whole grains and le-
gumes improves glycemia control, lowers insulin require-
ments, slows glucose absorption, increases peripheral
tissue sensitivity to insulin, reduces cholesterol and se-
rum triglyceride levels, controls body weight and lowers
blood pressure.[35]
Causes of decreased insulin secretion in type 2 dia-
betic patients have not been fully determined. Amyloid
protein deposits in pancreatic ß-cells, as well as glu-
cotoxicity and lipotoxicity resulting from elevated con-
centrations of glucose and circulating free fatty acids,
are among factors involved.[36] The benecial effects
of the Ma-Pi 2 diet observed in the study may be par-
tially attributed to the high content of complex carbo-
hydrates, total and soluble ber, and resistant starch,
resulting in high satiety and therefore higher energy
intake without negative metabolic effects. Large quan-
tities of chicory and onion used in the Ma-Pi diet are
rich sources of inulin, a soluble dietary ber, shown
to have a marked hypoglycemic effect in obese and
dyslipidemic individuals.[37] The botanical structure (structural
quality) of whole grains in the diet may also have a direct effect
on glucose and insulin metabolism.[38]
The low fat content of the Ma-Pi 2 diet may also contribute to
improved anthropometric and glucide and lipid metabolism indica-
tors. Low fat diets encourage weight loss, whereas high fat diets
are strongly associated with obesity, glucose intolerance and in-
creased insulin resistance.[11] Additionally, adipose tissue mass
is directly related to insulin resistance as well as peripheral and
central sensitivity to insulin and leptin.[39] In the present study,
weight loss and reduction in total body fat and abdominal fat with
preservation of lean body mass were among the rst effects of the
diet observed in participants.
Other nutrients contained in substantial quantities in the Ma-Pi 2
diet also may have contributed to the benecial effects found in
this intervention. Research has shown, for example, that magne-
sium and manganese are essential to metabolic control of diabe-
tes mellitus.[40,41]
The Ma-Pi 2 diet also resulted in statistically signicant control
of serum lipids, indicating recovery of energy homeostasis and
Table 3: Hematologic and Biochemical Variables in Diabetic Patients at Onset
and Termination of 6-Month Ma-Pi 2 Dietary Intervention
Variable Onset 6 months p
Mean Median Mean Median
Hemoglobin (g/dl) 13.38 13.40 12.39 12.05 0.02329*
Total proteins (g/l) 77.73 77.45 74.79 76.15 0.2979
Albumin (g/l) 41.26 41.00 41.57 41.00 0.6601
Creatinin (μmol/l) 62.69 64.00 63.06 59.00 0.8908
Total cholesterol (mmol/l) 5.37 5.46 4.49 4.55 0.002279*
HDL cholesterol (mmol/l) 0.45 0.46 0.89 0.85 0.000480*
LDL cholesterol (mmol/l) 3.52 3.90 2.72 2.81 0.002145*
Triglycerides (mmol/l) 2.97 2.40 1.87 1.91 0.001092*
Glycemia (mmol/l) 14.03 12.55 5.08 4.70 0.000214*
HbA1 (%) 12.60 12.00 5.73 5.70 0.000481*
C-peptide (ng/ml) 2.15 2.21 2.43 2.47 0.3052
* p <0.05
Source: Study data
Table 2: Physical Variables in Diabetic Patients at Onset and Termination of
6-Month Ma-Pi 2 Dietary Intervention
Variable Onset 6 months p
Mean Median Mean Median
Weight (kg) 69.28 69.40 63.03 59.90 0.001470*
Waist Circumference (cm) 89.79 86.30 83.75 80.50 0.004101*
Hip Circumference (cm) 98.93 96.55 93.86 92.60 0.003478*
Triceps Skin Fold (mm) 26.81 23.00 20.31 21.50 0.000317*
Subscapular Skin Fold (mm) 32.88 30.00 24.94 25.50 0.000439*
Biceps Skin Fold (mm) 16.19 14.50 14.63 14.00 0.1313
Suprailiac Skin Fold (mm) 31.88 28.00 22.94 22.00 0.001511*
BMI (kg/m2)27.97 28.41 25.43 25.10 0.000255*
Fat (%) 41.82 41.51 37.78 39.54 0.000723*
Lean Body Mass (%) 58.18 58.49 62.22 60.46 0.000481*
* p <0.05
Source: Study data
33
MEDICC Review, Fall 2009, Vol 11, No 4 Peer Reviewed
Original Scientic Articles
greater protection against cardiovascular and other complications
of diabetes. High levels of total and LDL cholesterol, along
with low levels of HDL cholesterol, are atherogenic risk factors
associated with premature coronary disease and diabetic
macroangiopathy.[42]
Statistically signicant reductions in glycemia and glycosylated
hemoglobin in this study indicate the Ma-Pi 2 diet’s positive in-
uence on carbohydrate metabolism control. Interventions that
improve glycemic control, reected by glycosylated hemoglobin,
are associated with reduced risk of diabetic complications. Hyper-
glycemic intake is a major cause of microvascular complications;
reducing glycemia levels through diet or other therapeutic agents
can therefore have long-term benets.[43]
Pancreatic ß-cell failure is common in type 1 and type 2 diabetes
mellitus, although the responsible mechanism may be different. Re-
storing or protecting their function is a desirable therapeutic effect.
C-peptide determination under standardized conditions is a sensi-
tive, well-accepted and clinically validated indicator of ß-cell function,
and moderate increases in this indicator may represent potential for
clinical improvement.[43] The 13% increase in C-peptide levels in
this study was not signicant, suggesting that more than 6 months
of sustained diet therapy may be necessary to improve pancreatic
ß-cell function. Elimination of insulin use in all patients in this study,
however, may indicate some recovery of pancreatic function, lower
peripheral resistance to insulin or lower insulin demand.
One of the main effects of the Ma-Pi 2 diet may be its potential
to supply alkalis to metabolism. The amount of acid residue
generated by the typical Western diet (mainly sulfuric amino
acids contained in animal proteins) is currently under debate.
It may be argued that such residue surpasses the capacity
of homeostatic mechanisms, producing an increase in blood
acidication, resulting in lowered plasma bicarbonate concen-
tration.[44] One effect of this low level chronic acidosis may be
increased insulin resistance.[45] Epidemiological studies re-
ported in the literature also suggest that sustained high protein
intake is associated with higher incidence of type 2 diabetes
mellitus.[44]
A strong association has also been shown between diabetes mel-
litus and oxidative stress. It has been suggested that high oxida-
tive stress due to hyperglycemia leads to diabetic complications
and may be a major cause of cell damage.[46] Nutri-
ents such as vitamins E and C, β-carotene and other
phytochemical compounds with antioxidant effects
contained in the whole grains, vegetables, legumes,
green tea and fermented soy products used in the Ma-
Pi diet may therefore have inuenced the results of the
intervention.[14,47]
The only negative effect of the diet observed during the
intervention was the vitamin B12 deciency, resulting
from the lack of animal foods in the Ma-Pi 2 diet and
indicating a potential long-term risk. Given the size and
type of sample studied, results cannot be extrapolated
to the rest of the diabetic population, nor can the diet
be recommended for longer than 6 months, the maxi-
mum period for which its nutritional safety in diabetic
patients has been demonstrated.[15,16]
Dietary intervention studies are difcult, particularly those de-
signed to assess therapeutic effects. Research involving mac-
robiotic diets has the added drawback of rejection by most of
the medical and scientic community, which considers them too
restrictive and even elitist, because they prioritize organic foods
and use a range of products uncommon in Western diets.
The results of this and related studies[14–17] provide important
preliminary data and indicate that further research is warranted
to explain the mechanisms inuencing the diet’s therapeutic po-
tential and to establish recommendations for its use. In Cuba,
we have proposed conducting a clinical trial using a control
group receiving the standard diet approved for diabetics by the
Ministry of Public Health.
An important aspect to consider is acceptability, independent of
the diet’s therapeutic potential. In the present study, availability of
the diet was a major factor, since patients received all meals fully
prepared and without cost. The objectives of the course required
for inclusion in the study were to motivate participants to stick
to the diet during the intervention, enable them to prepare food
themselves if they were absent from the dining hall, and continue
the diet as much as possible on their own, following termination
of the intervention. After a period of adaptation, acceptability was
high. Further research on patient behavior is needed, however,
to assess acceptance and continuation with the diet outside the
intervention setting.
Although economic factors were not among the objectives of
this study, it is worth noting that the cost of the imported prod-
ucts used (miso, tamari, seaweeds and green tea) was about
0.20 Euros per day per patient, according to the Ministry of the
Food Industry (MINAL, its Spanish acronym), which procured
the items.
This suggests that the cost of the Ma-Pi 2 diet per person may
be lower than that of the standard recommended diet for di-
abetics in Cuba, consisting of several daily portions of dairy
products, meat, eggs, sausages, fruits, fat and root vegetables,
apart from vegetables, legumes and grains consumed in both
diets. Studies are also recommended to compare actual costs
of diabetic patient care taking into account type of diet, medica-
tion, health care utilization, productivity, absenteeism and other
factors.
Table 4: Lipoproteins and Cardiovascular Risk in Diabetic Patients at Onset and
Termination of 6-Month Ma-Pi 2 Dietary Intervention
Variable Cut-off Values Onset 6 months
n % n %
Total Cholesterol (mmol/l) Desirable ≤ 5.2
Borderline 5.2–6.19
High ≥ 6.20
5 31.25 13 81.25
8 50.00 3 18.75
3 18.75 0 0
LDL Cholesterol (mmol/l) Acceptable ≤ 3.39
Borderline 3.4–4.1
High ≥ 4.12
7
4
5
43.75
25.00
31.25
14
1
1
87.50
6.25
6.25
HDL Cholesterol (mmol/l) Desirable > 1.6
Acceptable 1.0-1.6
Undesirable ≤ 0.9
0 0 5 31.25
0 0 5 31.25
16 100.00 637.50
Triglycerides (mmol/l) Acceptable ≤ 2.29
High 2.3–5.6
Very high ≥ 5.65
5
10
1
31.25
62.50
6.25
15
1
0
93.75
6.25
0
Source: Study data
MEDICC Review, Fall 2009, Vol 11, No 4
34
Original Scientic Articles
Peer Reviewed
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The Finlay Institute is actively working across sectors in Cuba
to improve availability of Ma-Pi diet ingredients in order to fulll
an ethical obligation to study participants who beneted from the
intervention, help them and other diabetics follow the diet inde-
pendently, meet rising consumer demand and supply its own pro-
grams. Through collaboration between the Ministry of Agriculture,
the National Urban Agriculture Movement and the Institute for
Rice Research, production of whole grains (particularly brown rice
and millet), vegetables and oleaginous seeds is being expanded
throughout the country.
CONCLUSIONS
Results of the 6-month intervention using the Ma-Pi 2 macrobiotic
diet in adults with type 2 diabetes mellitus suggest this diet may be
a good alternative for comprehensive treatment of diabetes mellitus
in Cuba. Further studies are recommended, specically a clinical trial
using a control group receiving the standard diet recommended by
the Cuban Ministry of Public Health. Broader multi-sector collabora-
tion is also needed to increase availability and accessibility of whole
grains and other products essential to achieving the nutrient content
potentially inuencing the benecial effects of the Ma-Pi 2 diet.
35
MEDICC Review, Fall 2009, Vol 11, No 4
Original Scientic Articles
Peer Reviewed
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47. González Montesino D. Capacidad antioxidante y
aporte de polifenoles de las dietas macrobióticas
Ma-Pi implementadas en el Instituto Finlay
[master’s thesis]. Havana (CU): University of
Havana; 2009.
THE AUTHORS
Carmen Porrata Maury (Corresponding
author: cporrata@nlay.edu.cu). Physiolo-
gist. Head of the Ma-Pi Macrobiotic Group,
Finlay Institute, Havana, Cuba.
Julio Sánchez Cruz, endocrinologist,
Diabetic Care Center, Colón, Matanzas,
Cuba.
Violeta Correa Corrales, family medicine
specialist, Diabetic Care Center, Colón,
Matanzas, Cuba.
Alfredo Abuín Landín, biochemist, Matan-
zas Medical School, Matanzas, Cuba.
Manuel Hernández-Triana, biochemist.
Head of the Biochemistry and Physiology
Department, Nutrition and Food Hygiene
Institute, Havana, Cuba.
Raúl Vilá Dacosta-Calheiros, fam-
ily medicine specialist, Ma-Pi Macrobiotic
Group, Finlay Institute, Havana, Cuba.
María Elena Díaz Sánchez, anthropolo-
gist. Head of the Anthropology Laboratory,
Nutrition and Food Hygiene Institute, Ha-
vana, Cuba.
Mayelín Mirabal Sosa, mathematician,
Clinical Trials Department, Finlay Institute,
Havana, Cuba.
Eduardo Cabrera Rode, biologist, Nation-
al Endocrinology Institute, Havana, Cuba.
Concepción Campa Huergo, pharmacist
and biochemist. President and General Di-
rector, Finlay Institute, Havana, Cuba.
Mario Pianesi, President and founder, Un
Punto Macrobiótico International Associa-
tion, Italy.
Submitted: March 19, 2009
Approved for publication: September 27, 2009
... Therefore, if we consider this new role for food, we can make dietary recommendations to promote health or treat specific diseases, taking into account that until now macronutrients have been classified according to their energy-yielding biochemical properties and not by their shown that consumption of the diet for 3 or 6 mo resulted in statistically significant improvements from baseline in indicators of metabolic control, including fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), the serum lipid profile [including reductions in total cholesterol, LDL cholesterol and triglyceride values, and the LDL:high-density lipoprotein (HDL) cholesterol ratio], BMI, and insulin resistance, as well as body weight and blood pressure (P < 0.001) (Table 2) [79,[80][81][82][83][84] . These results were apparent even in patients with poor glycemic control (HbA1c > 8.5%) [85] . In patients being treated with insulin, use of this agent fell during the intervention [79,85] . ...
... These results were apparent even in patients with poor glycemic control (HbA1c > 8.5%) [85] . In patients being treated with insulin, use of this agent fell during the intervention [79,85] . Similar results were obtained later in short-term (21-d) intervention studies [86,87] , thus demonstrating the ability of the diet to achieve rapid metabolic control. ...
... Special concern should be given to possible deficiencies of vitamin B-12 [77] , even though clinical evidences for deficiency in this vitamin are described only after several years of insufficient consumption [91] . The MA-PI 2 diet was especially conceived for the treatment of T2DM and studies in adults with T2DM consistently showed that a 3 or 6-mo consumption of the Ma-Pi 2 diet was nutritionally safe, at least for the evaluated time [79][80][81][82][83]85] . These evidences suggest that Ma-Pi 2 diet can be used as a short-and medium-term treatment, aimed to achieve a good metabolic control and that further research is needed to demonstrate the safety of this diet in the long-term. ...
Article
Full-text available
In the past 10 years the prevalence of type 2 diabetes mellitus (T2DM) has increased hugely worldwide, driven by a rise in the numbers of overweight and obese individuals. A number of diets have been shown to be effective for the management of T2DM: the Mediterranean diet, the vegetarian diet and the low-calorie diet. Results of studies clearly indicate, however, that the efficacy of these diets is not solely related to the biochemical structure of the individual nutrients they contain. This review discusses this point with reference to the potential role of the intestinal microbiota in diabetes. The macrobiotic Ma-Pi 2 diet is rich in carbohydrates, whole grains and vegetables, with no animal fat or protein or added sugar. In short- and medium-term trials conducted in patients with T2DM, the Ma-Pi 2 diet has been found to significantly improve indicators of metabolic control, including fasting blood glucose, glycosylated hemoglobin, the serum lipid profile, body mass index, body weight and blood pressure. The diet may also alter the gut microbiota composition, which could additionally affect glycemic control. As a result, the Ma-Pi 2 diet could be considered a valid additional short- to medium-term treatment for T2DM.
... Todos los datos de la investigación se registraban en los respectivos Cuadernos de Recogida de Datos (CRD), usados solamente por los investigadores involucrados en el estudio. (27,9) 32,8 9) ‫٭11-‬ Hemoglobina, g/dL 14,2 (10,(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18) 13,5 (10,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)5) -4,9 ...
... Todos los datos de la investigación se registraban en los respectivos Cuadernos de Recogida de Datos (CRD), usados solamente por los investigadores involucrados en el estudio. (27,9) 32,8 9) ‫٭11-‬ Hemoglobina, g/dL 14,2 (10,(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18) 13,5 (10,(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)5) -4,9 ...
... Leucocitos, 10 3 /mm 3 7,9 (4,5-13,1) 6,3 (4)(5)(6)(7)(8)(9)(10) ‫٭02-‬ Urea 5,7 (3,3-10,7) 4,5 (2,(2)(3)(4)(5)(6)8) ‫٭12-‬ TGP 20,9 (9,4) 16,6 (7,4) ‫٭12-‬ Glucosa, mmol/L 9,1 (6)(7)(8)(9)(10)(11)(12)(13)(14)6) 5,8 (2,(4)(5)(6)(7)(8)(9)9) ‫٭63-‬ HbA1c, % 9,9 (7,(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)8) 7,4 (5,8) ‫٭52-‬ Colesterol total, mmol/L 6,4 (3,(7)(8)(9)7) 5,2 (2,(3)(4)(5)(6)9) ‫٭91-‬ Colesterol-LDL, mmol/L 4,6 (1,(2)(3)(4)(5)(6)2) 3,5 ( ‫٭14-‬ Glucosa 2 horas después del almuerzo 10,9 (3,9) 6,3 ( Los síntomas subjetivos de astenia, mareos, irritabilidad, dolor muscular, depresión, ansiedad, agresividad, insomnio, cefaleas, dolores articulares, digestiones lentas, plenitud postpandrial, pérdida de la fuerza muscular, constipación, lipotimias y dificultad para la locomoción, mostraron una reducción evidente al final del estudio, así como gripe y otros procesos infecciosos frecuentes. Los pacientes informaron, además, experimentar menos fatiga y astenia, mayor capacidad ante el esfuerzo físico y para hacer frente a las tareas normales cotidianas. ...
... Overweight and obesity have been shown to be positively associated with higher levels of chronic inflammation (56). A recent article reported a positive protective effect of the MBD on outcomes related to diabetes mellitus (57). Participants eating a MBD saw a favorable change in body weight and lipid values, reduced oxidative stress, and improved insulin secretion. ...
... After 6 mo of the macrobiotic intervention, significant reductions were seen in body weight (9.0%), total cholesterol (16.4%), LDL cholesterol (22.7%), and triglycerides (37.0%); and an increase was seen in HDL (97.8%) (57). Findings from our study add to this literature indicating the MBD, when consumed as recommended, has the potential to aid in disease prevention and control, in part through its potential to be low in calories while high in nutrient density, an important consideration of any dietary recommendation, given the emphasis placed on reducing caloric intake in order to lose weight by various disease-prevention recommendations (58). ...
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... This diet consists of 40-50% whole grains, 30-40% vegetables, and 8% legumes, plus roasted ground sesame seeds with unrefined sea salt, fermented products, and seaweeds. Tannin-free green tea is the main source of liquid [72,73]. Interventions employing this diet demonstrated promising results, including those of the aforementioned study [72]. ...
... This diet consists of 40-50% whole grains, 30-40% vegetables, and 8% legumes, plus roasted ground sesame seeds with unrefined sea salt, fermented products, and seaweeds. Tannin-free green tea is the main source of liquid [72,73]. Interventions employing this diet demonstrated promising results, including those of the aforementioned study [72]. ...
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... reduction of fasting blood glucose, plasma lipid fractions, plasma insulin, and energy homeostasis by implementing the Ma-Pi 2 diet supporting the role of intestinal dysbiosis in the development of diabetes mellitus and that manipulation of the gut microbiome may be a promising therapeutic option. Subsequent studies have also demonstrated the Ma-Pi 2 diet to reduce markers of insulin resistance, inflammation, and insulin growth factor-1, supporting its use in patients with T2DM (21)(22)(23). None of these studies aimed to understand the link between the intestinal dysbiosis and the metabolic derangements found. ...
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The obesity epidemic drastically impacted the state of health care in the United States. Paralleling this epidemic is the incidence of diabetes mellitus, with a notable shift to much younger ages of onset. While central to the pathogenesis of diabetes associated with obesity is the role of inflammation attributed to “adiposopathy” it is now emerging that changes in sympathetic/parasympathetic balance regulated by the brain precedes changes in the inflammatory cascade. It has now been established that gut microflora may contribute significantly to the activation and inhibition of autonomic control and impact the set of the neuroinflammatory inhibitory reflex mediated by the cholinergic nervous system. There has been a paradigm shift towards further investigating commensal bacteria in the gut/brain in the pathogenesis of obesity and diabetes mellitus and its complications, as dysbiosis is thought to play a significant if not pivotal role in diabetic associated disorders. This paper is intended to evaluate the role of intestinal dysbiosis in the pathogenesis of diabetes mellitus and examine the potential for restoration of balance via use of probiotics.
... In our review of literature, there is no diet proposal in which results with such a high and fast impact on carbohydrate metabolism and insulin medication have been reported, as those obtained in the present intervention and those of this multicentered UPM project previously carried out with the same Ma-Pi 2 diet in type 2 diabetic patients, either at short, [16,17] medium [27] or long term [28,29]. ...
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http://www.hoajonline.com/journals/pdf/2052-6954-2-3.pdf ISSN 2052-6954 Background: Acceptable results have been observed in Cuban, and Chinese diabetic type 2 patients treated during 21 days with Ma-Pi 2 vegetarian macrobiotic diet. The study aim was to evaluate the reproducibility of these results in Tamale, Ghana, as a part of the multicenter study promoted by UPM, A Macrobiotic Point, Italy. Methods: A 21 day dietary intervention was carried out in 23 adult patients with type 2 diabetes mellitus.The diet consisted of whole cereals, vegetables, legumes, sesame seeds, seaweeds, soy fermented products and green tea. Patients were hospitalized during the study in the Tamale Teaching Hospital. In order to evaluate the effect of the diet, records of anthropometric measurements, body composition, biochemical indicators, blood pressure, clinical evaluation and medication adjustments, were carried out. Data at onset and at termination were compared. Results: Despite the limitations of the intervention (small and non random selected sample, physical inactivity, and vegetable scarcities), significant reductions were recorded on: glycosemia, 47%; fructosemia, 27%; leukocytes, 20%; blood urea, 23%; and insulin consumption, 44%. The urine pH increased by 10%, which was evidence of a lower metabolic acidosis level after the diet. Conclusions: The fast improvement of the glucose metabolic control, parallel to the significant reduction in insulin consumption evidenced the therapeutic benefit of the Ma-Pi 2 diet. These encouraging results, though preliminary, should be additionally extended in further research addressed to describe the underlying metabolic mechanisms. An additional study with a control group receiving the prescribed standard diet for type 2 diabetic patients is recommended. Internal Medicine Inside, 2014;2(3):1-9 ISSN 2052-6954 | Volume 2 | Article 3 http://www.hoajonline.com/journals/pdf/2052-6954-2-3.pdf doi: 10.7243/2052-6954-2-3
... The Ma-Pi 2 diet, conceived by Mario Pianesi, is a kind of macrobiotic diet; it is high in dietary fiber, which is in line with dietary recommendations by the Academy of Nutrition and Dietetics [13]. High-fiber diet may induced several health benefits such as prevention or reduction of bowel disorders and decreased risk of the development of coronary heart disease and type 2 diabetes [14,15]. The Ma-Pi 2 diet is also rich in complex carbohydrates, whole grains, vegetables and legumes, fermented products, sea salt and green tea, without fat or protein from animal sources (including milk and dairy products) and no added sugars. ...
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