|Review Article (Open access)|
SSR Inst. Int. J. Life Sci., 8(1): 2931-2939, January 2022
Effects of Different Dietary Approaches on Type 2 Diabetes Mellitus: A Review
Dipan Samanta1*, Amarendra Haldar2, Zeeshan Ali3, Jyothsna Volisha Cardoza3, Muhammad Rehan Arif4, Muhammad Qasim Ali5
1Junior Resident, Department of Obstetrics and Gynaecology, Dali University, Yunnan, China
2Student, Department of Nutrition and Dietetics, Mount Carmel College (Autonomous), Bengaluru, India
3Assistant Professor, Department of Physiotherapy Krupanidhi groups of institutions, College of Physiotherapy, Bangalore, India
4Institute of Food and Nutritional Sciences, PirMehr Ali Shah Arid Agriculture University Rawalpindi, Punjab, Pakistan
5Institute of Food Science and Nutrition, University of Sargodha, Punjab, Pakistan
*Address for Correspondence: Dr. Dipan Samanta, Junior Resident, Department of Obstetrics and Gynaecology, Dali University, Yunnan-671000, China
ABSTRACT- Type 2 diabetes (T2D) is a metabolic disorder that occurs due to various etiologies including lifestyle. One of the significant contributors in causing Type-2 diabetes is diet. For high-risk individuals, diet is way more significant in causing Type-2 diabetes. This present study discussed several published papers comprising of various food categories and their effects on type-2 diabetes or its role in causing the disorder. The study revealed the advantages of functional foods and their role in the prevention of T2D. The study has elaborated the outcome of T2D due to consumption of fats, carbohydrates, protein, dietary fibres, red meat, fried food, common beverages like carbonated drinks, and a few other foods. The authors also reviewed T2D from the aspect of religion, region, specific lifestyles, smoking and drinking habit and body weight. Overall, the study has successfully drawn a map of the spectrum of dietary role in T2D including its prevention, increasing the risk of T2D, its causation and affecting the outcome of the disorder.
Keywords: Diabetes mellitus, Glycaemicindex, Hyperglycaemia, Metabolic disorder, Type 2 diabetes
INTRODUCTION- Definition and epidemiology- Type 2 diabetes (T2D) is the most well-known and clinically significant metabolic issue which has turned into a worldwide contagion late and a serious medical burden since the past few years. According to global figures, there were about 382 million patients in 2013 , which is expected to reach 350 million by the year 2025 [1,2]. The World Health Organization (WHO) characterizes diabetes as a disease that disrupts the normal metabolism of the body having numerous etiology and presents conditions like persistent hyperglycaemia, which interferes with normal breakdown and assimilation of 3 basic and major components of food (carbohydrate, fat, and protein) because of deformities in either insulin production or functioning, or both . Out of all forms of diabetes, type 2 is the most prevalent (around 90%)  and the rest 10% of patients have either type 1 diabetes (T1D), or its other uncommon types . There are two main causes of T2D. They are defective pancreatic beta-cells working (responsible for insulin production); resistance towards insulin exhibited by peripheral tissue [5,6]. As about ~90% of patients suffering from T2D are also seen to be obese, the etiology of T2D gets frequently linked with foods consumed entirely for taste and flavour rather than for getting nutrition accompanied with inadequate energy expenditure . There is a scope of compelling drugs that diminish hyperglycaemia in T2D patients, which are said to be the reason behind insulin emission or diminishing peripheral tissue Insulin Resistance . In defiance of all this T2D presents lifelong impediments and is considered as the dominant cause of visual impairment, end-stage renal deterioration (leaving with only 2 last options for survival dialysis or transplant of the kidney), confiscation of lower appendages (up to 25% more than normal people) and cardiovascular diseases .
Relationship of T2D with diet- The pervasiveness of T2D is expanding at a disturbing rate around the world, causing a huge expansion in premature bereavement, co-morbidity and expanded cost of healthcare . The future forecasts are likewise miserable given that 1 of every 10 individuals present on the planet is estimated to be its sufferer by 2030 . Normal determinants incorporate obesity, unbalanced eating rituals, sedentary lifestyle, hypertension, and family background of diabetes . But studies have shown globally that if people with pre-diabetes and high-risk population concentrate on diet-change and carry out regular exercise, then there can be 58% reduction in risk of T2DM incidence rate as opposed to using metformin alone where only 28% risk reduction occurs when compared to controls [11-14]. This evidence lead to the necessity of exploring the precautionary and beneficiary role of healthy foods, which can be coined as functional foods (FnFs). FnFs are logically demonstrated to have potential medical advantages.
Functional Foods are all food sources that comprise biologically dynamic components and may be helpful in prevention/ delaying of numerous chronic illnesses like T2D, a parallel term to FnFs is "nutraceuticals" that alludes to components found in FnFs and is related to derivation and making them available to use .
Fats- Diminishing the ingestion of saturated fat (SF) and cholesterol with intention of bringing down diminishing plasma lipid levels have been a practically all-inclusive solution for individuals with a risk of diabetes. There has been debate regarding what should supersede SF- carbohydrate (CHO) or monounsaturated fat (MUFAs); since evidence from studies proposed that foods containing MUFAs might be better than low-fat and high CHO ones .
Diet with high MUFA can be replaced by a Mediterranean diet comprising of vegetables, coarse and whole grains, fruits, nuts, and olive oil and keep a strict check on the level of SF from meat, poultry, and dairy items . Several investigations have illustrated that the Mediterranean diet regulates plasma lipid levels without causing unfavourable changes in triglyceride and HDL cholesterol .
Preclinical information supports the idea that high incorporation of MUFA, (like oleate), may exert physiological benefits. It has been proved that exposure of pancreatic islets to the excess amount of fatty acids diminishes insulin discharge , and saturated fatty acid (SFAs) (like palmitate) aggravates cell death, while oleate has a defensive/ neutral impact . Moreover, although persistently raised circulating fatty acids cause insulin resistance (Insulin Resistance), this impact is by all accounts more articulated with SFAs than with MUFA . In this manner, current evidence from in vitro and animal studies upholds the replacement of MUFA for SFAs in diabetic people .
Thus, living with T2D on a high MUFA diet are a better option than traditional low-fat, high-CHO foods with similar advantageous consequences on body weight, body composition, cardiovascular danger factors, and glycemic control. Also, study has shown MUFA rich diet has done wonders on T2D even in Non-Mediterranean locales .
Carbohydrates- It has been discovered from many explorations that in the population suffering from diabetes, glycaemic control showed signs of improvement as carbohydrate intake in daily food regime got enhanced proving that earlier studies  in this context stand true that a diet composed of relatively high carbohydrate is beneficial in diabetes, in contrast to a low (typically around 40% of total energy) carbohydrate diet . Yet another conclusion was that only those high carbohydrate foods that are also impregnated with dietary fibre [26,27] will lead to better glycaemic control. Two latest reviews, the former speaking of effects of viscous fibre , and the latter which was an umbrella review did not have any new insights of relevance . However, these benefits were only apparent, when the carbohydrate-containing foods were rich in dietary fibre [26,27]. There have been 2 more recent reviews, one related to the effects of viscous fibre, and the other was an umbrella review that did not provide any new analyses .
Proteins- Legumes (including soy foods) have remarkable beneficiary dietary elements being low in glycemic index, full of nutritional ingredients like proteins etc., and the icing is their antibody-diabetic potential; thus validates daily ingestion of legumes and soy products for prophylaxis and management of T2D [30,31]. Although this school of thought has dual viewpoints: few explorations reportage builds an inverse connotation amid legumes/soy diet and the perils of T2D [32-35]; while a mosaic of others testifying a null [36-42] or a positive [22,23] connection.
A meta-analysis  concluded that the amount of legume in the diet has no direct linkage with T2D risks and that different varieties of soy foods have a variable impact; but it also recommended that augmenting a normal food course with 10 g soy protein and 10 mg soy is flavone can result in 9% and 4% reduced chances of T2D, respectively, regardless of little evidence in favour .
Soy milk a kind of liquid food with added sugar may lose its antibody diabetic potency because sweetened beverages are notorious for risk of type 2 diabetes , thus confirming findings of a cohort study that declared that unsweetened soy is inversely and its sugared-counterpart is directly linked to T2D .
Other important foods
Dietary fibre- A Study that incorporated 14 RCTs (Randomized controlled trials) (covering all three categories of people viz. healthy, pre-diabetic, and diabetic) unearthed that intake of both insoluble or soluble fibre, when gets scoffed with diets that compose plentiful of coarse grains and vegetables, and also vegan followers showed honed glucose metabolism and the upsurge insensitivity towards insulin. The best improvement in blood lipids, body weight, and Hemoglobin A1C (HbA1c) level happened in members People who religiously followed a low-fat, plant-based eating regime pictured overwhelming restoration related to blood lipids, body weight, and HbA1c levels. Meals laden with grains, veggies and both kinds of fibres were equally beneficial for diabetic and healthy subjects. Glucose equilibrium and insulin sensitivity were rather better exhibited by people on a more plant-based diet rather than a conventional diet . It has been claimed that more consumption of dietary fibre has a direct linkage with the reduced rate of premature mortality and chances of acquiring diverse kinds of non-communicable diseases. Thus it suggested to people of these 3 categories (pre-diabetes and having either type of diabetes) that they should have up to 35 g daily dose of fibre and this can easily be achieved by preferring whole grains over processed ones .
Red meat and Fried food- Having more amount of red meat, desserts and fat-laden food will eventually increase the risk of Insulin Resistance (IR) and T2DM . And, a converse relationship is seen between consuming vegetables and T2DM as utilization of leafy foods (as they are laden with nutrients, fibre and antioxidants) might restrict the advancement of T2D, by forming a defensive obstruction against the diseases . Red meat and excess oil/fat cooked foods are a common feature of a diet of males when contrasted with females. Also, they have been seen to take in more daily rice-helpings than their female counterparts . A contrasting study on Japanese ladies uncovered that a high amount of white rice was related to an increased risk of T2DM .
Carbonated drinks- Novel studies have proposed a connection between the ingestion of soda pops with obesity and diabetes, as they come loaded with a high concentration of fructose corn syrup that causes blood rise of glucose levels and BMI to hazardous levels. It has also come to the limelight that expressed that diet sodas contain glycated synthetics that particularly promote Insulin Resistance .
Tea- Epidemiological investigations have exhibited different positive relationships amid daily usage of herbal tea as a good prophylactic measure in T2D [52,53]. Herbal teas including dark and green concoctions and yet another variety of yerba maté, (native to South America) have spread their wings to North America, and portions of Europe and the Levant [53,54]. Populaces who are at diabetes risk may essentially gain from the utilization of locally available natural tea ingestions like Mauritian people (potential suspects of T2D) seem to benefit from their teas (high in polyphenolics) .
Ø A systematic review and meta‐analysis (7 trials, 350 respondents) confirmed that the addition of pomegranate in the daily diet of diabetic associates laid no remarkable effect on "metabolic status and oxidative stress biomarkers” of the volunteers, also no publication bias was inked .
Ø There has been observed a linkage amid deficiency of vitamin D and T2D but there is no apparent clarity that whether its supplements are capable of diminishing chances of acquiring T2D. But in people with pre-diabetes, Vit-D supplements condenses the possibility of T2D and proliferate the chances of reversion from pre-diabetes to normoglycemia. This retreat might be limited to those subjects who were otherwise not obese .
Ø Studies have revealed that regular incorporation of walnut in diet may enhance serum leptin and adiponectin. But showcased no changes in fasting blood glucose (FBG) or insulin and glycatedhaemoglobin (HbA1c) levels thus has no impact in improving glycemic biomarkers .
Religion specific study on T2D- Practicing the ritual of fasting during the month of Ramadan is one of the five mainstays of Islam [59,60] and requires shunning eating, drinking and the utilization of oral or parenteral drugs from dawn to nightfall for 29–30 continuous days once per year [59,61]. It is prohibited to patients with Type 1 diabetes and restricted to an enormous extent of patients with T2D [62,63]. But, a new review of 38,000 patients with diabetes from 39 nations found that 39% went fasting during Ramadan, other ones supported it by stating that 43% of patients with type 1 diabetes and 79% with type 2 diabetes kept fast during Ramadan [64,65]. Fasting might prompt prescription non-adherence  and complexities including lack of hydration, hyperglycemia, diabetic ketoacidosis [59,61,64] and hypoglycemia .
While a few examinations have shown no effect of this religious fasting on factors related to metabolism in patients with diabetes , different other investigations have shown an improvement in glycemia and lipids in those have controlled baseline-level of sugar; yet the condition was deteriorating in patients with poor glycemic control . A few examinations have exhibited a huge decrease  while others have shown no huge change in HbA1c, weight or BMI .
Educative sessions on how to fast while being diabetic were an advantage in Type 1 diabetes  and lesser significant in Type 2 diabetes . This one-of-a-kind detailed meta-analysis exhibits that Ramadan explicit knowledge sharing gives benefits by tending to lower HbA1c and LDL; causing body weight and TG to shoot up; while remaining safe with null impact on TC, HDL, blood pressure or hypoglycemia .
Region-specific diet- A special kind of diet called Mediterranean diet (MD) has become the real hot potato in the medical field as it comprises of high consumption of plant-based foods, moderate quantity of fish and dairy items, and least intake of red meat and red wine . In it, the salt intake can be replaced by the utilization of spices . Due to its potential benefits, MD is flowing across international borders in non-Mediterranean areas as well .
Main eatables of the Mediterranean diet - like plant-based salads, fishes with high oil content, olive oil, are a few components of FnFs and nutraceuticals that are embedded with “polyphenols (PPs), terpenoids, flavonoids, alkaloids, sterols, pigments, and unsaturated fatty acids”. PPs and associated herbs rich in it like coffee, tea (both green and black) and yerba mate have exhibited promising results in decreasing CH and FBS levels, taking care of various metabolic and micro-vascular mechanisms and acting as anti-inflammatory and anti-oxidative agents in people suffering from T2D or those, who are much prone to it .
Lifestyle specific–various patterns and incidences of T2D- It has now been unveiled that embracing a fit and active way of life (for example keeping a sound body weight, following a balanced eating routine, regular exercise, abstaining from smoking and keeping away from unsafe liquor drinking) is a 'best purchase' mediation for keeping T2D at bay . Many large Randomized Controlled Trials validate that thoughtful and well-planned life leading ways can be successful for the avoidance of T2D .
Comparative study  has concluded that vivacious people with a lithesome life would have a 75% lower hazard of occurrence T2D than most torpid and sluggard individuals, and it applies to populaces from various financial foundations and benchmark attributes. Also, such a lifestyle has been related with 56%, 49%, 31% and 52% lesser deaths due to all causes, CVD, cancer and chances of occurrence of CVD in T2D individuals . Excessive consumption of salt and sugar or less consumption of antioxidant vitamins like vitamin C play an important role in causing hypertension and diabetes . Some studies have concluded decreased serum levels of vitamin C in hyperglycaemic individuals. These studies have also found that anti-oxidants like Vitamin C has resulted in the free radical formation and has shown beneficial effects on glycaemic status, when vitamin C is given therapeutically .
Smoking and drinking- Smoking is only evil gets yet another proof as current smokers have been seen to experience a 37% higher danger of T2D contrasted with never smokers . But alcohol gets a narrow escape here as it was found that moderate drinking (10–14 g liquor each day) is related to an 18% lower hazard of T2D contrasted to teetotalers .
Bodyweight- The most grounded affiliation was seen between body weight and occurrence type 2 diabetes: overweight and people struck with obesity showed a 133% and 510% higher danger of T2D, paralleled, with their equal weight partners .
Overall, the study elaborated the dietary strategy in the management of type-2 diabetes from various aspects, which can also be considered as one of the most significant inclusions in the treatment plan of T2D.
CONTRIBUTION OF AUTHORS
Research concept- Dipan Samanta
Research design- Dipan Samanta, Amarendra Haldar, Zeeshan Ali, Jyothsna Volisha Cardoza
Supervision- Dipan Samanta
Literature search- Zeeshan Ali, Jyothsna Volisha Cardoza
Writing article- Zeeshan Ali, Jyothsna Volisha Cardoza
Critical review- Dipan Samanta, Zeeshan Ali, Jyothsna Volisha Cardoza
Article editing- Dipan Samanta
Final approval- Dipan Samanta
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