Diabetes Management: Dietary Interventions

Diabetes, the word, is loosely derived from a Greek translation of “one that straddles,” probably referring to a person who urinates frequently. You already know this is considered a metabolic disease of several types, marked by frequent urine discharge, persistent thirst, and the inability to process sugars in the diet due to a decrease in, or absence of, insulin production. There also may be target tissue insulin resistance. Type 1 diabetes mellitus is one of the two major types. Here, the symptoms arise abruptly, often in early adolescence, and the person relies on exogenous insulin to sustain life. Onset may occur at any age, though. Among other miseries, type 1 affects blood vessel health (especially the tiny ones), and manifests in the retina, kidneys, and the underlying connective layer of arterioles. Type 2 diabetes often strikes between ages thirty and forty, with gradual onset that shows few symptoms of metabolic disturbance, at least not right away. With good fortune and careful management, there may be no need for exogenous insulin; diet and perhaps oral hypoglycemic medications can do the trick. Insulin response in type 2 is delayed or reduced, but insulin secretion is not necessarily absent. In this disorder blood vessels of various sizes are affected, particularly the large ones. This can lead to premature atherosclerosis, sometimes followed by myocardial infarction and stroke. Neither of these types of diabetes is to be taken lightly. There is also a third type of diabetes, diabetes insipidus, usually caused by hormone or kidney anomalies.

You might have heard people refer to themselves as having “a touch of diabetes.”  That’s the equivalent of being a little bit pregnant. Either you are, or you aren’t. Maybe you’ll hear folks say their sugar is “a little high.”  Either expression hints that diabetes is not a serious matter. That is wrong. Managing diabetes may not be the easiest thing in the world, but it certainly is achievable, and in the long run it’s well worth the effort. When your blood sugar is normal, you feel better—you have more energy, are less tired and thirsty, have fewer skin or bladder infections, you heal faster, and you have fewer problems with your vision, teeth and feet. Taking care of yourself will avoid heart attack and stroke, the possibility of blindness, nerve damage that causes tingling and numbness in hands and feet, kidney disease that may kill you, and gum disease that causes tooth loss. Hmm, this is serious business.

Unfortunately, the body is not modular in that an organ can be removed and replaced when the warranty is near expiration. It’s not like rotating tires. Even artificial joints don’t come with grease fittings. We have to make parts last as long as possible, despite that some can be replaced…an uncomfortable though to many of us. Prevention is still the best cure. Diabetes can lead to cardiovascular damage. Yes, eyesight and nerves can be damaged, too, but space restricts us to one topic at a time. Changes in the body don’t necessarily happen independently. The cycle of progressive vascular damage from diabetes affects the heart. Changing how we eat can manage glucose levels and prevent heart disease.  One dietary technique follows the glycemic index (GI), which is a measure of how fast blood sugar rises in response to a certain food.  The index estimates how much a gram of carbohydrate elevates blood sugar after consumption, relative to consumption of pure glucose, which is given an index value of 100. Subjects with diabetes managed only by a diet focusing on optimal glycemic control were found to have reduced postprandial glucose levels, accompanied by lower markers of inflammation, notably C-reactive protein (CRP), and improved lipid panels (Wolever, 2008). From time to time, meta-analyses are employed to examine relationships among disease-causing variables. Scrutinizing the GI relationship to CVD, Australian scientists, whose colleagues are credited with designing the GI, discovered a reduction in the risk for cardiovascular disease among diabetes patients who complied with the low GI regimen (Barclay, 2008). The low GI has such potential in the management of chronic disease that those who are morbidly obese may find heart-healthy value in following the plan (Ebbeling, 2005). Even in cases where diabetes is poorly controlled, adhering to the low GI diet has merit when combined with reduced carbohydrate intake in modulating CVD risk factors, including glycated hemoglobin, called HbA1c ( Afaghi, 2012) (Eskesen, 2013) (Zhang, 2012).  Glycated hemoglobin is formed through a non-enzyme pathway when hemoglobin is exposed to high plasma levels of glucose. Glycation forms end products that cause extreme oxidative stress on the body, affecting nearly every cell and molecule. The advanced glycation end products, termed AGE’s, increase vascular permeability, inhibit vascular dilation (and elevate blood pressure), interfere with nitric oxide production (which allows blood vessels to dilate), oxidize LDL, and excite excretion of cytokines. These pathological states invite cardiac entanglement, but can be managed successfully through dietary modification.

The Mediterranean Diet has been touted for its cardiovascular benefits, but little attention has been paid to its effect on diabetes issues.  This diet is a relative newcomer to us, although it’s been a way of life in the Mediterranean for years, generally in the less opulent areas of southern Italy, parts of Greece and a few islands. Despite being called such, this diet is not typical of the entire area. For instance, wine is avoided by the Muslims of the region, and butter, lard and other animal fats comprise part of the cuisine of various indigenous groups. One thing that is easily identifiable about this regional lifestyle is ambulation—everybody walks everywhere. You know very well that accounts for a lot. The diet is abundant in plant foods. Fruit is dessert, as opposed to the sugary stuff Americans eat. The main fat is olive oil; cheese and yogurt are the chief dairy products; red meat is more an accoutrement than a feature. Legumes, unrefined non-GMO cereals, huge amounts of fruits and vegetables, moderate consumption of fish and poultry, and little saturated fat are the norm.

A cohort of more than thirteen thousand Spanish university graduates was followed for four years to assess an association of diet and diabetes. Participants who followed the Mediterranean protocol had a lower risk of disease (Martinez-Gonzalez, 2008) (Dominguez, 2012). There was no beating about the bush in this report. The conclusion was stated with conviction. At the same time, it was noted that seduction by the typical Western diet of fast and prepared foods leads to increases in cardiovascular and metabolic complications (Tarabusi, 2010).

In all the controlled trials reviewed in recent years, those that featured low GI, low carbohydrate and Mediterranean diets all led to greater improvement in glycemic control, with the Mediterranean having the most profound influence on both glucose control and weight loss, enhanced by increases in HDL (Ajala, 2013). Reduction in markers of inflammation and decreases in AGE’s are among the goals in the management of blood glucose and coronary health. AGE’s affect the physiological profiles of proteins by creating cross-links, and they induce vascular dysfunction by stiffening blood vessels and myocardial tissue. Keeping HbA1c where your doctor wants it will keep you alive long enough to be chastised for decades.

Abiemo EE, Alonso A, Nettleton JA, Steffen LM, Bertoni AG, Jain A, Lutsey PL. Relationships of the Mediterranean dietary pattern with insulin resistance and diabetes incidence in the Multi-Ethnic Study of Atherosclerosis (MESA). Br J Nutr. 2012 Aug 30:1-8.

Afaghi A, Ziaee A, Afaghi M. Effect of low-glycemic load diet on changes in cardiovascular risk factors in poorly controlled diabetic patients. Indian J Endocrinol Metab. 2012 Nov;16(6):991-5.

Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013 Mar;97(3):505-16.

Anastasios S Dontas, Nicholas S Zerefos, Demosthenes B Panagiotakos, and Dimitrios A Valis Mediterranean diet and prevention of coronary heart disease in the elderly Clin Interv Aging. 2007 March; 2(1): 109–115.

Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, Brand-Miller JC. Glycemic index, glycemic load, and chronic disease risk--a meta-analysis of observational studies. Am J Clin Nutr. 2008 Mar;87(3):627-37.

Bédard A, Riverin M, Dodin S, Corneau L, Lemieux S. Sex differences in the impact of the Mediterranean diet on cardiovascular risk profile. Br J Nutr. 2012 Oct 28;108(8):1428-34.

Chiu CJ, Liu S, Willett WC, Wolever TM, Brand-Miller JC, Barclay AW, Taylor A. Informing food choices and health outcomes by use of the dietary glycemic index. Nutr Rev. 2011 Apr;69(4):231-42.

Domínguez LJ, Bes-Rastrollo M, de la Fuente-Arrillaga C, Toledo E, Beunza JJ, Barbagallo M, Martínez-González MA. Similar prediction of decreased total mortality, diabetes incidence or cardiovascular events using relative- and absolute-component Mediterranean diet score: The SUN cohort. Nutr Metab Cardiovasc Dis. 2012 Mar 6.

Due A, Larsen TM, Mu H, Hermansen K, Stender S, Astrup A. Comparison of 3 ad libitum diets for weight-loss maintenance, risk of cardiovascular disease, and diabetes: a 6-mo randomized, controlled trial. Am J Clin Nutr. 2008 Nov;88(5):1232-41.

Ebbeling CB, Leidig MM, Sinclair KB, Seger-Shippee LG, Feldman HA, Ludwig DS. Effects of an ad libitum low-glycemic load diet on cardiovascular disease risk factors in obese young adults. Am J Clin Nutr. 2005 May;81(5):976-82.

K. Eskesen, M. T. Jensen, S. Galatius, H. Vestergaard, P. Hildebrandt, J. L. Marott, J. S. Jensen Glycated haemoglobin and the risk of cardiovascular disease, diabetes and all-cause mortality in the Copenhagen City Heart Study Journal of Internal Medicine. Vol 273, Iss 1, pp 94–101, January 2013

Hartog JW, Voors AA, Bakker SJ, Smit AJ, van Veldhuisen DJ. Advanced glycation end-products (AGEs) and heart failure: pathophysiology and clinical implications. Eur J Heart Fail. 2007 Dec;9(12):1146-55.

Konstantinidou V, Covas MI, Sola R, Fitó M. Up-to date knowledge on the in vivo transcriptomic effect of the Mediterranean diet in humans. Mol Nutr Food Res. 2013 Feb 18. doi: 10.1002/mnfr.201200613.

Kuhlmann M., Levin N. Interaction between Nutrition and Inflammation in Hemodialysis Patients. in “Cardiovascular Disorders in Hemodialysis” Ronco C. Vicenza and Brendolan A. Vicenza, editors. Basel, Karger, 2005, vol 149, pp 200-207

Lagiou P, Sandin S, Weiderpass E, Lagiou A, Mucci L, Trichopoulos D, Adami HO. Low carbohydrate-high protein diet and mortality in a cohort of Swedish women. J Intern Med. 2007 Apr;261(4):366-74.

Lagiou P, Sandin S, Lof M, Trichopoulos D, Adami HO, Weiderpass E. Low carbohydrate-high protein diet and incidence of cardiovascular diseases in Swedish women: prospective cohort study. BMJ. 2012 Jun 26;344:e4026. doi: 10.1136/bmj.e4026.

Lajous M, Boutron-Ruault MC, Fabre A, Clavel-Chapelon F, Romieu I. Carbohydrate intake, glycemic index, glycemic load, and risk of postmenopausal breast cancer in a prospective study of French women. Am J Clin Nutr. 2008 May;87(5):1384-91.

Talya Lavi, RD, Avraham Karasik, MD, Nira Koren-Morag, PHD, Hannah Kanety, PHD, Micha S. Feinberg, MD, Michael Shechter, MD, MA The Acute Effect of Various Glycemic Index Dietary Carbohydrates on Endothelial Function in Nondiabetic Overweight and Obese Subjects College of Cardiology Vol. 53, No. 24, 2009: 2283-2287

Martínez-González MA, de la Fuente-Arrillaga C, Nunez-Cordoba JM, Basterra-Gortari FJ, Beunza JJ, Vazquez Z, Benito S, Tortosa A, Bes-Rastrollo M. Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study. BMJ. 2008 Jun 14;336(7657):1348-51

Martínez-González MA, García-López M, Bes-Rastrollo M, Toledo E, Martínez-Lapiscina EH, Delgado-Rodriguez M, Vazquez Z, Benito S, Beunza JJ. Mediterranean diet and the incidence of cardiovascular disease: a Spanish cohort. Nutr Metab Cardiovasc Dis. 2011 Apr;21(4):237-44.

Massaro M, Carluccio MA, De Caterina R. Direct vascular antiatherogenic effects of oleic acid: a clue to the cardioprotective effects of the Mediterranean diet. Cardiologia. 1999 Jun;44(6):507-13.

Peppa M, Raptis SA. Advanced glycation end products and cardiovascular disease Curr Diabetes Rev. 2008 May;4(2):92-100.

Rose Marie Robertson, MD; Lynn Smaha, MD, PhD Can a Mediterranean-Style Diet Reduce Heart Disease? Circulation. 2001; 103: 1821-1822

Valeria Tarabusi, Carla Cavazza, Francesca Pasqui, Alessandra Gambineri, Renato Pasquali Quality of diet, screened by the Mediterranean diet quality index and the evaluation of the content of advanced glycation endproducts, in a population of high school students from Emilia Romagna Mediterranean J Nutrition and Metabolism. Sep 2010, Vol 3, Iss 2, pp 153-157

Temelkova-Kurktschiev TS, Koehler C, Henkel E, Leonhardt W, Fuecker K, Hanefeld M. Postchallenge plasma glucose and glycemic spikes are more strongly associated with atherosclerosis than fasting glucose or HbA1c level. Diabetes Care. 2000 Dec;23(12):1830-4.

Uchiki T, Weikel KA, Jiao W, Shang F, Caceres A, Pawlak D, Handa JT, Brownlee M, Nagaraj R, Taylor A. Glycation-altered proteolysis as a pathobiologic mechanism that links dietary glycemic index, aging, and age-related disease (in nondiabetics). Aging Cell. 2012 Feb;11(1):1-13.

Wolever TM, Gibbs AL, Mehling C, Chiasson JL, Connelly PW, Josse RG, Leiter LA, Maheux P, Rabasa-Lhoret R, Rodger NW, Ryan EA. The Canadian Trial of Carbohydrates in Diabetes (CCD), a 1-y controlled trial of low-glycemic-index dietary carbohydrate in type 2 diabetes: no effect on glycated hemoglobin but reduction in C-reactive protein. Am J Clin Nutr. 2008 Jan;87(1):114-25.

Yurong Zhang, Gang Hu, Zuyi Yuan, Liwei Chen Glycosylated Hemoglobin in Relationship to Cardiovascular Outcomes and Death in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis PLoS ONE 7(8): e42551

Ziaee A, Afaghi A, Sarreshtehdari M. Effect of low glycemic load diet on glycated hemoglobin (HbA1c) in poorly-controlled diabetes patients. Glob J Health Sci. 2011 Dec 29;4(1):211-6.

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