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Nutritional Therapy for Diabetes Mellitus

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A special issue of Nutrients (ISSN 2072-6643).

Deadline for manuscript submissions: closed (31 July 2019) | Viewed by 148681

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Prof. Dr. Matti Uusitupa

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Institute of Public Health and Clinical Nutrition, University of Eastern Finland, 70211 Kuopio, Finland
Interests: diabetes; metabolism; insulin resistance; nutritional medicine; abdominal obesity; lipid metabolism; metabolic diseases; glucose metabolism; nutrigenetics; nutrigenomics
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Dear Colleagues,

Diabetes mellitus is one of the biggest health burdens worldwide. At present, 425 million people are suffering from diabetes. Most of them have type 2 diabetes, which is known to be preventable by changing lifestyles, i.e., by permanently losing weight, increasing physical activity, and acquiring healthy dietary habits. Currently, type 1 diabetes is not preventable and needs permanent insulin therapy. Nutritional therapy is important in the management of both major types of diabetes. Recently, there has been a lot of discussion about the optimal quality of diet for diabetes. In particular, issues such as the role of protein vs. carbohydrates and the quality of fat have aroused debate among scientists and other experts in the field. The present Special Issue on the Nutritional Therapy for Diabetes Mellitus covers prevention of type 2 diabetes and the role of macronutrients, sugar, artificial sweeteners, and dietary fiber in the diet of diabetic patients. Furthermore, it deals with healthy dietary patterns that we can recommend for the patients with diabetes. Furthermore, the aim of the Special Issue is to dispel potential confusing beliefs related to so-called popular diets in the therapy of diabetes. The invited papers are based on a scientifically solid literature survey and grading of the publications quoted in individual papers.

Prof. Dr. Matti Uusitupa
Guest Editor

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Keywords

diabetes
prevention
dietary therapy
carbohydrates
protein
fatty acids
dietary fiber
sugar
sweeteners
dietary patterns
microbiota
biomarkers

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Published Papers (10 papers)

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Editorial

Jump to: Research, Review

4 pages, 187 KiB

Open AccessEditorial

Evolving Nutritional Therapy for Diabetes Mellitus

by Matti Uusitupa and Ursula Schwab

Nutrients 2020, 12(2), 423; https://doi.org/10.3390/nu12020423 - 6 Feb 2020

Cited by 6 | Viewed by 5897

Abstract

One of the special issues in Nutrients in 2020 focuses on the nutritional therapy for diabetes mellitus [...] Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

Research

Jump to: Editorial, Review

12 pages, 265 KiB

Open AccessCommunication

The Effects of Different Quantities and Qualities of Protein Intake in People with Diabetes Mellitus

by Andreas F.H. Pfeiffer, Eva Pedersen, Ursula Schwab, Ulf Risérus, Anne-Marie Aas, Matti Uusitupa, Anastasia Thanopoulou, Cyril Kendall, John L. Sievenpiper, Hana Kahleová, Dario Rahélic, Jordi Salas-Salvadó, Stephanie Gebauer and Kjeld Hermansen

Nutrients 2020, 12(2), 365; https://doi.org/10.3390/nu12020365 - 30 Jan 2020

Cited by 44 | Viewed by 10327

Abstract

The recommended amount and quality of protein in diets of diabetic patients are highly controversial. In order to provide evidence-based information, the Diabetes Nutrition Study Group (DNSG) used a grading procedure used for quality of evidence and strength of recommendations (GRADE). A protein intake of 10% to 20% of energy intake (E%) or about 0.8 to 1.3 g/kg body weight in people below 65 years of age, and 15% to 20% of E% in people above 65 years of age appeared safe in weight-stable conditions. There were no intervention studies addressing metabolic effects, mortality, or cardiovascular events over prolonged periods. Body weight is closely linked to metabolic control and high protein diets are often recommended. Weight-loss diets that include 23% to 32% of E% as protein for up to one year reduced blood pressure and body weight slightly but significantly more than lower protein diets, whereas blood lipids, fasting blood glucose, and HbA1c improved similarly with higher or lower protein intakes in participants with a glomerular filtration rate (GFR) >60 mL/min/1.73 m². Patients with a GFR <60 mL/min/1.73 m² did not show a faster decline of GFR or kidney function with protein intakes around 0.8 g/kg body weight as compared with lower intakes, thereby arguing against a restriction. The effects of protein intake on diabetic eye or nerve disease have not been reported. There are a number of studies that have compared different types of animal proteins (milk, chicken, beef, pork, and fish) or compared animal with plant protein in diabetic patients and have reported a greater reduction of serum cholesterol with plant protein. In summary, the suggested range of protein intake appears to be safe and can be adapted according to personal dietary preferences. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

15 pages, 1969 KiB

Open AccessArticle

Efficacy of Arabica Versus Robusta Coffee in Improving Weight, Insulin Resistance, and Liver Steatosis in a Rat Model of Type-2 Diabetes

by Pedram Shokouh, Per B Jeppesen, Christine B Christiansen, Fredrik B Mellbye, Kjeld Hermansen and Søren Gregersen

Nutrients 2019, 11(9), 2074; https://doi.org/10.3390/nu11092074 - 3 Sep 2019

Cited by 19 | Viewed by 5852

Abstract

The effects of chronic coffee exposure in models of type 2 diabetes mellitus (T2D) is scarcely studied, and the efficacy of the main coffee species has never been compared. We tested the hypothesis that long-term consumption of arabica and robusta coffee may differentially delay and affect T2D development in Zucker diabetic fatty rats. Three study groups received either chow mixed with arabica or robusta instant coffee (1.8% w/w) or unsupplemented chow food for 10 weeks. Both coffee species reduced liver triglyceride content and area under the curve of fasting and postprandial insulin. At study end, plasma adiponectin, total cholesterol and high density lipoprotein levels were higher in the robust group compared with both arabica and control groups. The liver gene expression of Glucose-6-phosphatase, catalytic subunit (G6pc) and Mechanistic target of rapamycin (mTOR) in robusta and Cpt1a in both coffee groups was downregulated. In conclusion, long-term consumption of both coffee species reduced weight gain and liver steatosis and improved insulin sensitivity in a rat model of T2D. Robusta coffee was seemingly superior to arabica coffee with respect to effects on lipid profile, adiponectin level and hepatic gene expression. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

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10 pages, 1099 KiB

Open AccessArticle

Life Style Intervention Improves Retinopathy Status—The Finnish Diabetes Prevention Study

by A. Aro, A. Kauppinen, N. Kivinen, T. Selander, K. Kinnunen, J. Tuomilehto, S. Keinänen-Kiukaanniemi, J. Lindström, M. Uusitupa and K. Kaarniranta

Nutrients 2019, 11(7), 1691; https://doi.org/10.3390/nu11071691 - 23 Jul 2019

Cited by 28 | Viewed by 6409

Abstract

The aim of the study was to find out whether participation in earlier intervention had an effect on the occurrence of retinopathy in study participants. We also examined risk factors (age, sex, weight, fasting and 2 h glucose, fasting insulin, blood pressure, serum lipids) for early retinal changes. The study included 522 individuals (mean 55 years old, range 40–64 years) with impaired glucose tolerance who were randomized into intervention (weight loss, healthy diet, and physical activity, N = 265) and control groups (N = 257). Intervention lasted for median of four years in 1993–2000, after which annual follow-up visits at study clinics were conducted. In the years 2002–2006 (at least five years after stopping intervention), fundus photography was offered for all study participants in four of five study clinics. Photographs were assessed by two experienced ophthalmologists (A.A. and K.K.), masked for the group assignment. After exclusion of poor quality photographs, the data of 211 individuals (N = 113 for intervention and N = 98 for control group) were included in the present study. The occurrence of microaneurysms was significantly higher in the control (37/98, 38%) than in the intervention group (27/113, 24%; p = 0.029). In the model, including age, sex, diabetes diagnosis before the retinal assessment, body mass index (BMI), and treatment group, the odds ratio for microaneurysms was markedly lower in intervention group (OR 0.52; 0.28–0.97, p = 0.039). The only risk factor that predicted the occurrence of microaneurysms was serum triglycerides at baseline (mean ± SD 1.9 ± 0.9 vs. 1.6 ± 0.7, mmol/L, with and without microaneurysms, respectively, p = 0.003). Triglycerides associated with decreased microaneurysms in regression analysis for age, sex, fasting glucose, and intervention group (OR 1.92, p = 0.018). Lifestyle intervention in overweight and obese individuals with impaired glucose tolerance showed decreased occurrence of retinal microaneurysms. Elevated serum triglycerides were associated to the development of early diabetic microangiopathy. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

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11 pages, 867 KiB

Open AccessArticle

Pre-Exercise Blood Glucose Levels Determine the Amount of Orally Administered Carbohydrates during Physical Exercise in Individuals with Type 1 Diabetes—A Randomized Cross-Over Trial

by Othmar Moser, Max L. Eckstein, Alexander Mueller, Philipp Birnbaumer, Felix Aberer, Gerd Koehler, Caren Sourij, Harald Kojzar, Peter Pferschy, Pavel Dietz, Richard M. Bracken, Peter Hofmann and Harald Sourij

Nutrients 2019, 11(6), 1287; https://doi.org/10.3390/nu11061287 - 6 Jun 2019

Cited by 20 | Viewed by 7251

Abstract

The aim of the study was to assess the amount of orally administered carbohydrates needed to maintain euglycemia during moderate-intensity exercise in individuals with type 1 diabetes. Nine participants with type 1 diabetes (four women, age 32.1 ± 9.0 years, BMI 25.5 ± 3.9 kg/m², HbA_1c 55 ± 7 mmol/mol (7.2 ± 0.6%)) on insulin Degludec were randomized to cycle for 55 min at moderate intensity (63 ± 7% VO_2peak) for five consecutive days on either 75% or 100% of their regular basal insulin dose. The impact of pre-exercise blood glucose concentration on the carbohydrate requirement was analyzed by one-way ANOVA stratified for pre-exercise blood glucose quartiles. The effect of the basal insulin dose on the amount of orally administered carbohydrates was evaluated by Wilcoxon matched-pairs signed-rank test. The amount of orally administered carbohydrates during the continuous exercise sessions was similar for both trial arms (75% or 100% basal insulin) with median [IQR] of 36 g (9–62 g) and 36 g (9–66 g) (p = 0.78). The amount of orally administered carbohydrates was determined by pre-exercise blood glucose concentration for both trial arms (p = 0.03). Our study elucidated the importance of pre-exercise glucose concentration related orally administered carbohydrates to maintain euglycemia during exercise in individuals with type 1 diabetes. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

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11 pages, 1280 KiB

Open AccessArticle

A Plant-Based Meal Stimulates Incretin and Insulin Secretion More Than an Energy- and Macronutrient-Matched Standard Meal in Type 2 Diabetes: A Randomized Crossover Study

by Hana Kahleova, Andrea Tura, Marta Klementova, Lenka Thieme, Martin Haluzik, Renata Pavlovicova, Martin Hill and Terezie Pelikanova

Nutrients 2019, 11(3), 486; https://doi.org/10.3390/nu11030486 - 26 Feb 2019

Cited by 29 | Viewed by 17804

Abstract

Diminished postprandial secretion of incretins and insulin represents one of the key pathophysiological mechanisms behind type 2 diabetes (T2D). We tested the effects of two energy- and macronutrient-matched meals: A standard meat (M-meal) and a vegan (V-meal) on postprandial incretin and insulin secretion in participants with T2D. A randomized crossover design was used in 20 participants with T2D. Plasma concentrations of glucose, insulin, C-peptide, glucagon-like peptide-1 (GLP-1), amylin, and gastric inhibitory peptide (GIP) were determined at 0, 30, 60, 120, and 180 min. Beta-cell function was assessed with a mathematical model, using C-peptide deconvolution. Repeated-measures ANOVA was used for statistical analysis. Postprandial plasma glucose responses were similar after both test meals (p = 0.64). An increase in the stimulated secretion of insulin (by 30.5%; 95% CI 21.2 to 40.7%; p < 0.001), C-peptide (by 7.1%; 95% CI 4.1 to 9.9%; p < 0.001), and amylin (by 15.7%; 95% CI 11.8 to 19.7%; p < 0.001) was observed following consumption of the V-meal. An increase in stimulated secretion of GLP-1 (by 19.2%; 95% CI 12.4 to 26.7%; p < 0.001) and a decrease in GIP (by −9.4%; 95% CI −17.3 to −0.7%; p = 0.02) were observed after the V-meal. Several parameters of beta-cell function increased after the V-meal, particularly insulin secretion at a fixed glucose value 5 mmol/L, rate sensitivity, and the potentiation factor. Our results showed an increase in postprandial incretin and insulin secretion, after consumption of a V-meal, suggesting a therapeutic potential of plant-based meals for improving beta-cell function in T2D. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

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Review

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22 pages, 2330 KiB

Open AccessReview

Prevention of Type 2 Diabetes by Lifestyle Changes: A Systematic Review and Meta-Analysis

by Matti Uusitupa, Tauseef A. Khan, Effie Viguiliouk, Hana Kahleova, Angela A Rivellese, Kjeld Hermansen, Andreas Pfeiffer, Anastasia Thanopoulou, Jordi Salas-Salvadó, Ursula Schwab and John L. Sievenpiper

Nutrients 2019, 11(11), 2611; https://doi.org/10.3390/nu11112611 - 1 Nov 2019

Cited by 246 | Viewed by 40787

Abstract

Prevention of type 2 diabetes (T2D) is a great challenge worldwide. The aim of this evidence synthesis was to summarize the available evidence in order to update the European Association for the Study of Diabetes (EASD) clinical practice guidelines for nutrition therapy. We conducted a systematic review and, where appropriate, meta-analyses of randomized controlled trials (RCTs) carried out in people with impaired glucose tolerance (IGT) (six studies) or dysmetabolism (one study) to answer the following questions: What is the evidence that T2D is preventable by lifestyle changes? What is the optimal diet (with a particular focus on diet quality) for prevention, and does the prevention of T2D result in a lower risk of late complications of T2D? The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess the certainty of the trial evidence. Altogether seven RCTs (N = 4090) fulfilled the eligibility criteria and were included in the meta-analysis. The diagnosis of incident diabetes was based on an oral glucose tolerance test (OGTT). The overall risk reduction of T2D by the lifestyle interventions was 0.53 (95% CI 0.41; 0.67). Most of the trials aimed to reduce weight, increase physical activity, and apply a diet relatively low in saturated fat and high in fiber. The PREDIMED trial that did not meet eligibility criteria for inclusion in the meta-analysis was used in the final assessment of diet quality. We conclude that T2D is preventable by changing lifestyle and the risk reduction is sustained for many years after the active intervention (high certainty of evidence). Healthy dietary changes based on the current recommendations and the Mediterranean dietary pattern can be recommended for the long-term prevention of diabetes. There is limited or insufficient data to show that prevention of T2D by lifestyle changes results in a lower risk of cardiovascular and microvascular complications. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

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28 pages, 2859 KiB

Open AccessReview

Dietary Patterns and Cardiometabolic Outcomes in Diabetes: A Summary of Systematic Reviews and Meta-Analyses

by Hana Kahleova, Jordi Salas-Salvadó, Dario Rahelić, Cyril WC Kendall, Emilie Rembert and John L Sievenpiper

Nutrients 2019, 11(9), 2209; https://doi.org/10.3390/nu11092209 - 13 Sep 2019

Cited by 82 | Viewed by 12464

Abstract

The Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD) conducted a review of existing systematic reviews and meta-analyses to explain the relationship between different dietary patterns and patient-important cardiometabolic outcomes. To update the clinical practice guidelines for nutrition therapy in the prevention and management of diabetes, we summarize the evidence from these evidence syntheses for the Mediterranean, Dietary Approaches to Stop Hypertension (DASH), Portfolio, Nordic, liquid meal replacement, and vegetarian dietary patterns. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence. We summarized the evidence for disease incidence outcomes and risk factor outcomes using risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs), respectively. The Mediterranean diet showed a cardiovascular disease (CVD) incidence (RR: 0.62; 95%CI, 0.50, 0.78), and non-significant CVD mortality (RR: 0.67; 95%CI, 0.45, 1.00) benefit. The DASH dietary pattern improved cardiometabolic risk factors (P < 0.05) and was associated with the decreased incidence of CVD (RR, 0.80; 95%CI, 0.76, 0.85). Vegetarian dietary patterns were associated with improved cardiometabolic risk factors (P < 0.05) and the reduced incidence (0.72; 95%CI: 0.61, 0.85) and mortality (RR, 0.78; 95%CI, 0.69, 0.88) of coronary heart disease. The Portfolio dietary pattern improved cardiometabolic risk factors and reduced estimated 10-year coronary heart disease (CHD) risk by 13% (−1.34% (95%CI, −2.19 to −0.49)). The Nordic dietary pattern was correlated with decreased CVD (0.93 (95%CI, 0.88, 0.99)) and stroke incidence (0.87 (95%CI, 0.77, 0.97)) and, along with liquid meal replacements, improved cardiometabolic risk factors (P < 0.05). The evidence was assessed as low to moderate certainty for most dietary patterns and outcome pairs. Current evidence suggests that the Mediterranean, DASH, Portfolio, Nordic, liquid meal replacement and vegetarian dietary patterns have cardiometabolic advantages in populations inclusive of diabetes. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

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21 pages, 2454 KiB

Open AccessReview

Effect of Steviol Glycosides on Human Health with Emphasis on Type 2 Diabetic Biomarkers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

by Camilla Christine Bundgaard Anker, Shamaila Rafiq and Per Bendix Jeppesen

Nutrients 2019, 11(9), 1965; https://doi.org/10.3390/nu11091965 - 21 Aug 2019

Cited by 48 | Viewed by 10184

Abstract

The natural sweetener from Stevia rebaudiana Bertoni, steviol glycoside (SG), has been proposed to exhibit a range of antidiabetic properties. The objective of this systematic review was to critically evaluate evidence for the effectiveness of SGs on human health, particularly type 2 diabetic (T2D) biomarkers, collecting data from randomized controlled trials (RCTs). Electronic searches were performed in PubMed and EMBASE and the bibliography of retrieved full-texts was hand searched. Using the Cochrane criteria, the reporting quality of included studies was assessed. Seven studies, nine RCTs, including a total of 462 participants were included. A meta-analysis was performed to assess the effect of SGs on following outcomes: BMI, blood pressure (BP), fasting blood glucose (FBG), lipids, and glycated hemoglobin (HbA1c). The meta-analysis revealed an overall significant reduction in systolic BP in favour of SGs between SG and placebo, mean difference (MD): −6.32 mm Hg (−7.69 to 0.46). The overall effect of BMI, diastolic BP, FBG, total cholesterol, and high-density lipoprotein cholesterol (HDL-C) was a non-significant reduction in favour of SGs, and a non-significant increase in low-density lipoprotein cholesterol and triglyceride, while no significant effect of HbA1c was found. Heterogeneity was significant for several analyses. More studies investigating the effect of SGs on human health, particularly T2D biomarkers, are warranted. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

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28 pages, 1125 KiB

Open AccessReview

DASH Dietary Pattern and Cardiometabolic Outcomes: An Umbrella Review of Systematic Reviews and Meta-Analyses

by Laura Chiavaroli, Effie Viguiliouk, Stephanie K Nishi, Sonia Blanco Mejia, Dario Rahelić, Hana Kahleová, Jordi Salas-Salvadó, Cyril WC Kendall and John L Sievenpiper

Nutrients 2019, 11(2), 338; https://doi.org/10.3390/nu11020338 - 5 Feb 2019

Cited by 329 | Viewed by 30404

Abstract

Background: The Dietary Approaches to Stop Hypertension (DASH) dietary pattern, which emphasizes fruit, vegetables, fat-free/low-fat dairy, whole grains, nuts and legumes, and limits saturated fat, cholesterol, red and processed meats, sweets, added sugars, salt and sugar-sweetened beverages, is widely recommended by international diabetes and heart association guidelines. Objective: To summarize the available evidence for the update of the European Association of the Study of Diabetes (EASD) guidelines, we conducted an umbrella review of existing systematic reviews and meta-analyses using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach of the relation of the DASH dietary pattern with cardiovascular disease and other cardiometabolic outcomes in prospective cohort studies and its effect on blood pressure and other cardiometabolic risk factors in controlled trials in individuals with and without diabetes. Methods: MEDLINE and EMBASE were searched through 3 January 2019. We included systematic reviews and meta-analyses assessing the relation of the DASH dietary pattern with cardiometabolic disease outcomes in prospective cohort studies and the effect on cardiometabolic risk factors in randomized and non-randomized controlled trials. Two independent reviewers extracted relevant data and assessed the risk of bias of individual studies. The primary outcome was incident cardiovascular disease (CVD) in the prospective cohort studies and systolic blood pressure in the controlled trials. Secondary outcomes included incident coronary heart disease, stroke, and diabetes in prospective cohort studies and other established cardiometabolic risk factors in controlled trials. If the search did not identify an existing systematic review and meta-analysis on a pre-specified outcome, then we conducted our own systematic review and meta-analysis. The evidence was summarized as risk ratios (RR) for disease incidence outcomes and mean differences (MDs) for risk factor outcomes with 95% confidence intervals (95% CIs). The certainty of the evidence was assessed using GRADE. Results: We identified three systematic reviews and meta-analyses of 15 unique prospective cohort studies (n = 942,140) and four systematic reviews and meta-analyses of 31 unique controlled trials (n = 4,414) across outcomes. We conducted our own systematic review and meta-analysis of 2 controlled trials (n = 65) for HbA1c. The DASH dietary pattern was associated with decreased incident cardiovascular disease (RR, 0.80 (0.76–0.85)), coronary heart disease (0.79 (0.71–0.88)), stroke (0.81 (0.72–0.92)), and diabetes (0.82 (0.74–0.92)) in prospective cohort studies and decreased systolic (MD, −5.2 mmHg (95% CI, −7.0 to −3.4)) and diastolic (−2.60 mmHg (−3.50 to −1.70)) blood pressure, Total-C (−0.20 mmol/L (−0.31 to −0.10)), LDL-C (−0.10 mmol/L (−0.20 to −0.01)), HbA1c (−0.53% (−0.62, −0.43)), fasting blood insulin (−0.15 μU/mL (−0.22 to −0.08)), and body weight (−1.42 kg (−2.03 to −0.82)) in controlled trials. There was no effect on HDL-C, triglycerides, fasting blood glucose, HOMA-IR, or CRP. The certainty of the evidence was moderate for SBP and low for CVD incidence and ranged from very low to moderate for the secondary outcomes. Conclusions: Current evidence allows for the conclusion that the DASH dietary pattern is associated with decreased incidence of cardiovascular disease and improves blood pressure with evidence of other cardiometabolic advantages in people with and without diabetes. More research is needed to improve the certainty of the estimates. Full article

(This article belongs to the Special Issue Nutritional Therapy for Diabetes Mellitus)

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