How To Prevent Diabetes Mellitus Type 2 – Nutrition Science and Policy Analysis Dietary and Nutritional Approaches to Preventing and Treating Type 2 Diabetes 2018; 361 doi: https://doi.org/10.1136/.k2234 (Published 2018-06-13) Cite as: 2018;361:k2234 Food for thought To read other articles in this collection, click here
Nita G Forouhi and her colleagues argue that it is possible to find common ground in nutrition for the prevention, treatment and eventual remission of type 2 diabetes.
Dietary factors are extremely important in the treatment and prevention of type 2 diabetes. Despite advances in evidence-based dietary guidelines, controversy and uncertainty remain. In this article, we examine the evidence for areas of consensus as well as ongoing uncertainty or controversy regarding dietary guidelines for type 2 diabetes. What is the best way to eat? Can remission of type 2 diabetes be achieved through lifestyle behavior changes, or is it inevitably a condition that leads to progressive health deterioration? We also explore the implications of dietary transitions and population-specific factors in a global context and discuss future directions for and implementation of effective dietary and nutritional approaches to type 2 diabetes.
Diabetes mellitus is one of the major global public health problems: the prevalence is estimated to increase from 425 million people in 2017 to 629 million by 2045, with health, social and economic costs.1 Urgent solutions to slow or even reverse this situation . trends, particularly in relation to investment in modifiable factors including diet, physical activity and weight. According to the Global Burden of Disease Study conducted in 188 countries, diet is a major factor in morbidity and mortality worldwide.2 The importance of diet in the treatment and prevention of type 2 diabetes is clear through its effects on body weight and metabolic control. However, diet is also one of the most controversial and difficult aspects of treating type 2 diabetes.
The idea of dieting for a chronic, lifelong disease like diabetes is enough to deter many people, as knowing what to eat and maintaining an optimal eating pattern is a challenge. Medical nutrition therapy was introduced to guide a systematic and evidence-based approach to the management of diabetes through diet, and its effectiveness has been demonstrated 3 , but difficulties remain. Although most diabetes guidelines recommend starting pharmacotherapy only after lifestyle changes in diet and physical activity, this is not always followed in practice worldwide. Most physicians are not trained in nutritional interventions, and this hinders patient counseling.45 In addition, talking to patients about nutrition is time-consuming. In many places outside of dedicated diabetes centers with trained nutritionists/teachers, diabetes nutrition counseling is at best a printed menu given to the patient. In resource-poor settings, when type 2 diabetes is diagnosed, the patient often leaves the clinic with new medications and little else. The use of dietary modification alone in the management of type 2 diabetes varies greatly: for example, it is estimated that less than 5–10% of patients with type 2 diabetes in India6 and 31% in the UK, despite patients being treated with lifestyle. measures may be less carefully managed than in patients treated for type 2 diabetes.7 Although systems for recording and tracking steps in the diabetes care process in the medical record are generally in place, nutritional information is often overlooked, although diet receives at least a small amount of attention. attention. . necessary to achieve adequate glycemic control. GPs and hospital clinics should routinely collect this information, but how to do so is a challenge.58
Progress has been made in understanding the best dietary recommendations for diabetes, but there are broader challenges. For example, most dietary guidelines recommend increasing the consumption of vegetables and fruits, but their costs are prohibitively high in many situations: the cost of two servings of fruit and three servings of vegetables per day per person (to meet the “5-a-day” guideline) was 52%, 18 %, 16% and 2% of household income in low, low to middle, upper to middle and high income countries.9 Expensive market for foods labeled for consumption. people with diabetes whose products are often no healthier and sometimes less healthy than regular foods. Following new European Union legislation, food regulations in some countries, including the UK, were only updated in July 2016 to ban such misleading labels. Elsewhere, however, this is not the case, and what will happen to such regulation after the UK leaves the European Union is unclear, underscoring the importance of the political environment.
In some, mostly developed countries, dietary guidelines for the treatment of diabetes have evolved from a focus on a low-fat diet to a recognition that macronutrient quality (ie, type and amount of macronutrients), processed foods (especially processed starches) are more important considerations. and sugars) as well as overall dietary patterns. Many systematic reviews and national dietary guidelines have evaluated the evidence for optimal dietary advice, and we will not repeat the evidence review.101112131415161718 In the following sections, we will instead focus on some important principles for which there is broad consensus in the scientific and clinical community and highlight areas. uncertainty, but let’s begin by outlining three key features.
First, understanding of a healthy diet for the prevention and treatment of type 2 diabetes is largely derived from long-term prospective studies and limited evidence from randomized controlled trials in general populations, supplemented by evidence from people with type 2 diabetes. Many published guidelines and reviews have applied assessment criteria, and this evidence is often of moderate quality in a hierarchy of evidence topped by randomized controlled trials. Elsewhere, it is argued that evidence-based dietary guidelines should use a body of evidence that assesses consistency across multiple study designs, including large population-based prospective clinical outcome studies, controlled interim pathway studies, and, where possible, randomized clinical outcome trials. . 19
Second, it is now recognized that dietary recommendations for both prevention and treatment of type 2 diabetes should be consistent and should not be considered as separate entities (Figure 1). However, in patients with type 2 diabetes, the degree of glycemic control and the type and dose of antidiabetic agents must be coordinated with the diet.12 Some dietary interventions, such as very low-calorie or low-carbohydrate diets, should generally be discontinued in diabetics. or reduce diabetes medications and should be closely monitored as described in the next section.
Third, recognizing the importance of nutrition in weight control, the various ways in which dietary factors affect health through both obesity-dependent and obesity-independent mechanisms are now better understood 10 . Dietary effects on body weight, glycemia, and glucose-insulin homeostasis are directly related to glycemic control in diabetes, while other outcomes, such as cardiovascular complications, are further influenced by dietary effects on blood lipids, apolipoproteins, blood pressure, endothelial function, and thrombosis. , coagulation, systemic inflammation and vascular adhesion. The effects of food and nutrients on the gut microbiome may also be important in the pathogenesis of diabetes, but further research is needed. Therefore, the quality and quantity of nutrition is important in the long term for the prevention and treatment of diabetes and its complications as a result of various metabolic and physiological processes.
Type 2 diabetes is most often associated with being overweight or obese and insulin resistance. Therefore, weight loss and maintenance of a healthy body weight are central to clinical management. Weight loss is also associated with improvements in glycemia, blood pressure, and lipid levels, and thus may delay or prevent complications, especially cardiovascular events.
Most guidelines recommend promoting weight loss in overweight or obese people by reducing energy intake. Portion control is one strategy for limiting energy intake along with a healthy eating pattern that focuses on whole or unprocessed foods with physical activity and ongoing support.
The evidence suggests that eating vegetables, fruits, whole grains, legumes, nuts and dairy products such as yogurt is recommended, but with some precautions. First, some diets (such as low-carb diets) recommend limiting fruits, whole grains, and legumes because of their sugar or starch content. The opinions of scientists and doctors about the use of fruit in the diet are divided, especially among people with diabetes (see appendix). However, many guidelines recommend fruit because fructose intake from fruit is better than isocaloric intake from sucrose or starch because fruit contains additional micronutrients, phytochemicals, and fiber. Second, despite evidence from randomized controlled trials and prospective studies10 that nuts may help prevent type 2 diabetes, there are (potentially misplaced) concerns about their high energy content. Further research in people with type 2 diabetes should help clarify this.
There is also consensus on the benefits of certain dietary habits, such as the Mediterranean diet, in the prevention and treatment of type 2 diabetes. Expert guidelines also support other healthy eating habits that take into account local socio-cultural factors and personal preferences.
There is consensus on reducing or avoiding processed red meat and refined grains
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