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By Axel F. Sigurdsson, MD, PhD |

An interesting scientific paper on the efficacy of different dietary approaches in type 2 diabetes recently caught my eye. The study has not received much media coverage although it certainly addresses a question of importance to millions of people worldwide.

More than 20 million people in the US have type 2 diabetes. According to the International Diabetes Foundation (IDF), the number of people diagnosed with diabetes in the last the 1 last update 01 Jun 2020 twenty years has risen from 30 million to over 246 million, or about 7.3% of the world population. Approximately 90% of those have type 2 diabetes. Diet and nutrition play a central role in the well-being of all those people. 
More than 20 million people in the US have type 2 diabetes. According to the International Diabetes Foundation (IDF), the number of people diagnosed with diabetes in the last twenty years has risen from 30 million to over 246 million, or about 7.3% of the world population. Approximately 90% of those have type 2 diabetes. Diet and nutrition play a central role in the well-being of all those people. 

The study, which is a systematic review, was published in a recent issue of the American Journal of Clinical Nutrition. A systematic review is an unbiased survey of all the scientific evidence available on a given question. In this case, Ajala and coworkers from Plymouth UK addressed the efficacy of different diets to induce weight loss and improve glycemic control and lipid profile among people with type 2 diabetes.

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Type 2 Diabetes and Prediabetes

Before we go further, let me touch on few basic issues, just for the sake of clarification. Type 2 diabetes is a chronic condition that affects the way our body metabolizes sugar (glucose). Glucose is the body’s primary source of fuel. With type 2 diabetes, the body either resists the effects of for 1 last update 01 Jun 2020 insulin — a hormone that regulates the movement of sugar into our cells — or doesn’t produce enough insulin to maintain a normal glucose level.Before we go further, let me touch on few basic issues, just for the sake of clarification. Type 2 diabetes is a chronic condition that affects the way our body metabolizes sugar (glucose). Glucose is the body’s primary source of fuel. With type 2 diabetes, the body either resists the effects of insulin — a hormone that regulates the movement of sugar into our cells — or doesn’t produce enough insulin to maintain a normal glucose level.

Glucose comes from two major sources, food and the liver. Our liver produces and stores glucose. When glucose enters the blood stream, insulin is released from the pancreas. Insulin enables sugar to enter the cells of the body where it is used for energy production. Without insulin, or when insulin resistance is present, glucose builds up in the blood stream. This is what happens in diabetes. Elevated levels of blood glucose may cause a number of symptoms, and increase the risk of developing heart disease and stroke.

It is not fully understood why people develop type 2 diabetes, but certain factors increase the risk. Overweight is a risk factor. However, many overweight and obese individuals never have diabetes, and many people with type 2 diabetes are not overweight or obese. If our body stores fat primarily in the abdomen, the risk of diabetes is higher than if the body stores fat elsewhere such as on our hips and thighs. Family history and physical inactivity also increase the risk of diabetes.

The risk of type 2 diabetes increases with age. Lately, type 2 diabetes has become increasingly common in children, adolescents, and young adults. The main goals of therapy are to improve glucose metabolism and thereby reduce blood sugar levels and to mitigate the risk factors for the main complications of diabetes, heart disease, and stroke. Overweight often contributes significantly to the development of type 2 diabetes. Therefore weight loss often plays a large role in the treatment of the disorder.

Prediabetes is a condition in which blood sugar level is higher than normal, but not high enough to be classified as diabetes. Left untreated, prediabetes often progresses to type 2 diabetes. There is good evidence showing that dietary modification can prevent the progression from prediabetes to type 2 diabetes. Howvever, the optimal dietary approach to type 2 diabetes is less clear. Before I discuss the recent study by Ajala and coworkers, let’s have a look at the background stage.

What Is the Best Diet for Type 2 Diabetes?

For some years, experts and scientists have debated what dietary approach is best to control and treat type 2 diabetes. Most regulatory authorities, like the for 1 last update 01 Jun 2020 British Diabetic Association, European Association for the Study of Diabetes (EASD), American Diabetes Association (ADA), Canadian Diabetes Association and many more usually recommend a carbohydrate intake of 50-60% of total energy intake, total fat intake less than 30% of energy, with restriction of saturated and trans fat intake. Some experts believe there is insufficient evidence to justify these recommendations.For some years, experts and scientists have debated what dietary approach is best to control and treat type 2 diabetes. Most regulatory authorities, like the British Diabetic Association, European Association for the Study of Diabetes (EASD), American Diabetes Association (ADA), Canadian Diabetes Association and many more usually recommend a carbohydrate intake of 50-60% of total energy intake, total fat intake less than 30% of energy, with restriction of saturated and trans fat intake. Some experts believe there is insufficient evidence to justify these recommendations.

reverses diabetes type 2 blood sugar levels (🔴 song) | reverses diabetes type 2 biologyhow to reverses diabetes type 2 for Almost five years ago, an international group of scientists and experts on diabetes, nutrition and carbohydrate metabolism published an overview paper suggesting a critical appraisal of the role of carbohydrate restriction in type 2 diabetes mellitus and the metabolic syndrome. The authors pointed out that current nutritional approaches often emphasized a reduction in dietary fat.

They believed that such approaches often were ineffective, leading to more reliance on drug therapy. They argued that carbohydrate restricted diets were at least as effective for weight-loss as low-fat diets and that the substitution of fat for carbohydrate was beneficial for the risk of cardiovascular disease. Furthermore, they provided evidence suggesting that carbohydrate restriction improved control of blood glucose and reduced insulin fluctuations. They believed the recommendation to reduce the intake of saturated fat in type 2 diabetes lacked scientific evidence.

The authors concluded: “Finally, while no systematic study of clinical practice has been done, anecdotal evidence suggests that carbohydrate restriction is a common clinical recommendation for diabetes. We believe that there is a need to codify these recommendations in light of current evidence.”

In the recent systematic review by Ajala and coworkers, data was collected from all studies published up to July 2011 that compared low carbohydrate, vegetarian, vegan, low glycemic index (GI), high fiber, Mediterranean, and high protein diets with control diets including low-fat, high-GI, ADA diet, EASD diet, and low-protein diets. Only randomized controlled trials with an intervention lasting longer than six months were selected. A total of 20 studies including 3073 individuals fulfilled the defined criteria and were selected for the metaanalysis. Measured outcomes were HbA1c (which reflects glucose control), difference in weight loss, and changes in HDL-cholesterol (“good cholesterol”), LDL-cholesterol (“bad cholesterol”) and triglycerides.

The low carbohydrate, low-GI, Mediterranean, and high protein diets all led to a greater improvement in blood glucose control (HbA1c) compared with their respective control diets, with the largest effect seen with the Mediterranean diet. Low-carbohydrate and Mediterranean diets led to a greater weight loss compared with their control diets. Low carbohydrate, low-GI, and Mediterranean diets all led to an elevation of HDL-cholesterol. Only the Mediterranean diet led to a significant reduction in triglycerides. High protein diets had no effects on markers of lipid profile. One study from their review compared the effects of a vegan diet to the low-fat ADA diet. The vegan arm had a significantly lower levels of total cholesterol, LDL-cholesterol, and HbA1c, indicating better glycemic control by the vegan diet. Similar results were obtained in one study that compared the effect of a vegan diet with the EASD diet, with more weight loss on the vegan diet.

Ajala and coworkers conclude that their review provides evidence that modifying the amount of macronutrients can improve glycemic control, weight, and lipids in type 2 diabetes. In their analysis, low carbohydrate diets appeared to provide superior weight loss, better control of blood glucose, and better lipid profile, compared with low-fat diets. The authors also conclude that vegan and vegetarian diet may improve glucose control and promote weight loss in type 2 diabetes.

The Mediterranean diet is rich in olive oil, legumes, unrefined cereals, fruit, and vegetables, low in meat and meat products, and with moderate contents of dairy products (mostly cheese and yogurt), fish and wine. The total fat in this diet is typically 25-35% of calories, with saturated fat less than 8% of calories. The meta-analysis indicates that a Mediterranean diet provides better control of blood glucose, greater weight loss, and a more favorable lipid profile compared with a conventional diet and ADA diet.

A meta-analysis of such widely different studies may be problematic. For example, the control diets differed significantly between studies and the duration of the studies ranged between six months and four years. The definition of a low carbohydrate diet varies between studies. While the authors acknowledge the limitations of their study, they believe that low carbohydrate, low-GI, Mediterranean and high-protein diets should be considered in the overall strategy of diabetes management.

What is the best diet for type 2 diabetes?  Although there is probably not a simple answer, the question reflects one of the main challenges of modern medicine. It is likely that our dietary recommendations will have to be tailored to the needs of the individual. A one-size-fits-all approach is unrealistic. Although not providing any definitive answers, the study by Ajala and coworkers is an important contribution to our understanding of this highly important issue.

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Guest

“It is likely that our dietary recommendations will have to be tailored to the needs of the individual.” Swedes have done this already. In the Swedish dietary recommendation for diabetes (2011),low GI, moderately low carb, Mediterranean diet and “traditional diabetes diet” are all included as possible and viable options. I think this is the way to go. The long term addherence to any version of healthy diets is the key. People have different food aversion, different preferences, activity levels, so forth, and thus may prefer one of these dietary patterns more easy and attractive to follow in the long run.… Read more »

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7 years ago
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Richard

Doc wrote: “What is the best diet for type 2 diabetes? Although, there is probably not a simple answer, the question reflects one of the main challenges of modern medicine” I think the solution is simple: my perspective comes from the global epidemiology and atherosclerosis research. I will provide a direct quote from the chief inspector of Framingham study, William Castelli: “You know, we know that if I can get your total cholesterol down around let’s say 100 to 130 or so, and I have maybe not quite a billion people on the earth like that, and those people cannotreverses diabetes type 2 vbid (⭐️ normal) | reverses diabetes type 2 nutritionhow to reverses diabetes type 2 for … Read more »

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7 years ago
Guest

reverses diabetes type 2 blood sugar levels (🔥 pathophys) | reverses diabetes type 2 eatinghow to reverses diabetes type 2 for Thanks for pointing us toward the Ajala review. I concur with your conclusions Axel, and not only because they conform to my own bias about diet. Many patients tell me that unlike prior diets they have tried, the Mediterranean Diet is easy to follow and delicious. I just wonder when, if ever, the AHA and all the other august bodies that have been preaching the low-fat gospel for years will retract their erroroneous advice and admit that they have done harm.

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7 years ago
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Martin Almgren

Thank you Axel for your summary of the meta study and your recommendation. I seem to be on the right track, considering I am in the risk zone for diabetes. /Martin

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7 years ago
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Axel F Sigurdsson

Thanks for your comment Martin, and thanks for reading my blog. From what I have seen on FB in the last year I assume you are under the influence of the Mediterranean diet/lifestyle. From a health perspective that is a good choice. My best regards to you and your family in Sweden.

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7 years ago
the 1 last update 01 Jun 2020 GuestGuest

reverses diabetes type 2 charts (👍 nice) | reverses diabetes type 2 yeast infectionhow to reverses diabetes type 2 for Doc, you say ‘The Mediterranean diet is rich in olive oil, legumes, unrefined cereals, fruit and vegetables, low in meat and meat products, and with moderate contents of dairy products (mostly cheese and yogurt), fish and wine.’ I’ve never eaten, or seen, an unrefined cereal in Spain, Italy or Greece, so I don’t know whether the version of a Mediterranean diet used for the research used whole grains or whether this is a misunderstanding somewhere. Although there is white pasta (as a separate course) in Italy, there’s not much of it in Spanish or Greek food, but white rice and… Read more »

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Richard

Jan C wrote: “I don’t know whether the version of a Mediterranean diet used for the research used whole grains or whether this is a misunderstanding somewhere”. The contemporary med diet has nothing to do with the sort of med diet that was being consumed by the poor peasants of Crete and Southern Italy in the 1950s. Keys observed already in 1950s that rich napolinians that were part of the Rotary club were not healthy and had high cholesterol levels. Rockefeller institute conducted a large epidemiological survey study on Crete during late 1940s. The diet was plant-based one, quite high… Read more »

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7 years ago
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Mie

the 1 last update 01 Jun 2020 Richard:Richard:

“I think the solution is simple: my perspective comes from the global epidemiology and atherosclerosis research. I will provide a direct quote from the chief inspector of Framingham study, William Castelli:”

This question cannot be approached by anecdotes but by analysing the available research literature that meets the properly set inclusion criteria. As such, the current review points out that a multitude of approaches work.

More focus on the essentials, less copy/pasting.

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7 years ago