Fruit intake and incident diabetic retinopathy with type 2 diabetes. Epidemiology. 2013;24:204-211. [PMID: 23348071 DOI: 10.1097/ede.0b013e318281725e]

Effect of the Mediterranean Diet (MeDi) on the Progression of Retinal Disease: A Narrative Review

Worldwide, the number of individuals suffering from visual impairment, as well as those affected by blindness, is about 600 million and it will further increase in the coming decades. These diseases also seriously affect the quality of life in working-age individuals. Beyond the characterization of metabolic, genetic, and environmental factors related to ocular pathologies, it is important to verify how lifestyle may participate in the induction of the molecular pathways underlying these diseases. On the other hand, scientific studies are also contributing to investigations as to whether lifestyle could intervene in modulating pathophysiological cellular responses, including the production of metabolites and neurohormonal factors, through the intake of natural compounds capable of interfering with molecular mechanisms that lead to ocular diseases. Nutraceuticals are promising in ameliorating pathophysiological complications of ocular disease such as inflammation and neurodegeneration. Moreover, it is important to characterize the nutritional patterns and/or natural compounds that may be beneficial against certain ocular diseases. The adherence to the Mediterranean diet (MeDi) is proposed as a promising intervention for the prevention and amelioration of several eye diseases. Several characteristic compounds and micronutrients of MeDi, including vitamins, carotenoids, flavonoids, and omega-3 fatty acids, are proposed as adjuvants against several ocular diseases. In this review, we focus on studies that analyze the effects of MeDi in ameliorating diabetic retinopathy, macular degeneration, and glaucoma. The analysis of knowledge in this field is requested in order to provide direction on recommendations for nutritional interventions aimed to prevent and ameliorate ocular diseases.

The Role of Natural Products in Diabetic Retinopathy

Diabetic retinopathy (DR) is one of the most severe complications of diabetes mellitus and potentially leads to significant visual impairment and blindness. The complex mechanisms involved in the pathological changes in DR make it challenging to achieve satisfactory outcomes with existing treatments. Diets conducive to glycemic control have been shown to improve outcomes in diabetic patients, thus positioning dietary interventions as promising avenues for DR treatment. Investigations have demonstrated that natural products (NPs) may effectively manage DR. Many types of natural compounds, including saponins, phenols, terpenoids, flavonoids, saccharides, alkaloids, and vitamins, have been shown to exert anti-inflammatory, antioxidant, anti-neovascular, and antiapoptotic effects in vivo and in vitro. Nevertheless, the clinical application of NPs still faces challenges, such as suboptimal specificity, poor bioavailability, and a risk of toxicity. Prospective clinical studies are imperative to validate the therapeutic potential of NPs in delaying or preventing DR.

Effect of High-Sucrose Diet on the Occurrence and Progression of Diabetic Retinopathy and Dietary Modification Strategies

As the most serious of the many worse new pathological changes caused by diabetes, there are many risk factors for the occurrence and development of diabetic retinopathy (DR). They mainly include hyperglycemia, hypertension, hyperlipidemia and so on. Among them, hyperglycemia is the most critical cause, and plays a vital role in the pathological changes of DR. High-sucrose diets (HSDs) lead to elevated blood glucose levels in vivo, which, through oxidative stress, inflammation, the production of advanced glycation end products (AGEs) and vascular endothelial growth factor (VEGF), cause plenty of pathological damages to the retina and ultimately bring about loss of vision. The existing therapies for DR primarily target the terminal stage of the disease, when irreversible visual impairment has appeared. Therefore, early prevention is particularly critical. The early prevention of DR-related vision loss requires adjustments to dietary habits, mainly by reducing sugar intake. This article primarily discusses the risk factors, pathophysiological processes and molecular mechanisms associated with the development of DR caused by HSDs. It aims to raise awareness of the crucial role of diet in the occurrence and progression of DR, promote timely changes in dietary habits, prevent vision loss and improve the quality of life. The aim is to make people aware of the importance of diet in the occurrence and progression of DR. According to the dietary modification strategies that we give, patients can change their poor eating habits in a timely manner to avoid theoretically avoidable retinopathy and obtain an excellent prognosis.

Intake of Fruit and Glycemic Control in Korean Patients with Diabetes Mellitus Using the Korea National Health and Nutrition Examination Survey

BACKGRUOUND

Despite the well-recognized health benefits of fresh fruit consumption, there is still substantial uncertainty about its potential effects on glycemic control in patients with type 2 diabetes mellitus (T2DM).

METHODS

We examined the association of fresh fruit consumption and glycemic control in patients with T2DM using data from the 6th Korea National Health and Nutrition Examination Survey. The study sample was divided into three groups based on weekly fruit consumption frequency for the analysis.

RESULTS

Patients with the highest fruit intake were older than those in the other two groups, and women were more likely to consume fruits in general. Being a current smoker and weekly alcohol intake also showed negative correlations according to the fruit intake tertiles. Fruit consumption was positively correlated with better hemoglobin A1c (HbA1c) levels. Moreover, patients in the highest tertile of fruit intake were 3.48 times more likely to be in good glycemic control defined as HbA1c <7%.

CONCLUSION

We observed that fruit consumption can be helpful in glycemic control in Korean patients with T2DM.

A Mediterranean Diet May Be Protective in the Development of Diabetic Retinopathy

The Mediterranean diet is recognized as one of the healthiest available dietary patterns. This perception results from its beneficial effects on the cardiovascular system and, also, on hypertension, diabetes, and cancer compared with other diets. Its impact on the course of diabetes is assessed in the available scientific literature; however, little information is available about its impact on diabetic retinopathy. The MD is characterized mainly by the consumption of fish, seafood, foods of plant origin, and fresh fruit and vegetables. It is also recommended to consume legumes, which are a source of folic acid, magnesium, iron, and dietary fiber. High consumption of nuts and unrefined grains is also recommended in the MD. Marine fish provide polyunsaturated acids from the omega-3 group. Olive oil plays a very important role, especially olive oil obtained from mechanical pressing. Additionally, olive oil contains vitamins E, K, and polyphenols. Polyphenols, which are present in a diverse range of vegetables, fruits, and seeds, have the ability to decrease oxidative stress, inflammation, and insulin resistance. Resveratrol is naturally found in grape skins and seeds, as well as in peanuts and berries, and is a constituent of red wine. Resveratrol can inhibit increased vascular leakage and loss of pericytes and regulate the level of VEGF protein in the retina, thus inhibiting the development of DR. Consumption of fruits, vegetables, fish, and olive oil may be correlated with a lower risk of diabetic retinopathy. This paper presents the definition of the Mediterranean diet and its influence on the course of diabetes and diabetic retinopathy.

Diet and ideal food pyramid to prevent or support the treatment of diabetic retinopathy, age-related macular degeneration, and cataracts

Many eye diseases, such as diabetic retinopathy (DR), age-related macular degeneration (AMD), and cataracts are preventable and treatable with lifestyle. The objective of this review is to assess the most recent research on the ideal dietary approach to prevent or support the treatment of DR, AMD, and cataracts, as well as to construct a food pyramid that makes it simple for people who are at risk of developing these pathologies to decide what to eat. The food pyramid presented here proposes what should be consumed every day: 3 portions of low glycemic index (GI) grains (for fiber and zinc content), 5 portions (each portion: ≥200 g/day) of fruits and vegetables (spinach, broccoli, zucchini cooked, green leafy vegetables, orange, kiwi, grapefruit for folic acid, vitamin C, and lutein/zeaxanthin content, at least ≥42 μg/day, are to be preferred), extra virgin olive (EVO) oil (almost 20 mg/day for vitamin E and polyphenols content), nuts or oil seeds (20-30 g/day, for zinc content, at least ≥15.8 mg/day); weekly: fish (4 portions, for omega-3 content and eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) 0.35-1.4 g/day), white meat (3 portions for vitamin B12 content), legumes (2 portions for vegetal proteins), eggs (2 portions for lutein/zeaxanthin content), light cheeses (2 portions for vitamin B6 content), and almost 3-4 times/week microgreen and spices (saffron and curcumin). At the top of the pyramid, there are two pennants: one green, which indicates the need for personalized supplementation (if daily requirements cannot be met through diet, omega-3, and L-methylfolate supplementation), and one red, which indicates that certain foods are prohibited (salt and sugar). Finally, 3-4 times per week, 30-40 min of aerobic and resistance exercises are required.

Effect of fruit on glucose control in diabetes mellitus: a meta-analysis of nineteen randomized controlled trials

Objective

Diabetes mellitus is a worldwide health problem, and it remains unclarified whether fruit is beneficial in glycemic control. This study aimed to analyze evidence from randomized controlled trials evaluating the effect of fruit consumption on glucose control.

Methods

We searched the PubMed, EMBASE, Ovid, Web of Science, and Cochrane Central Register of Controlled Trials databases from the respective database inception dates to December 30, 2022, to identify randomized controlled trials that evaluated the effects of fruit consumption on glucose control. Two researchers independently screened the studies in accordance with the inclusion and exclusion criteria, and performed the literature quality evaluation and data extraction. RevMan 5.4 software was used to perform the data analysis.

Results

Nineteen randomized controlled trials with 888 participants were included. Fruit consumption significantly decreased the fasting blood glucose concentration (MD -8.38, 95% CI -12.34 to -4.43), but it showed no significant difference in the glycosylated hemoglobin (MD -0.17, 95% CI -0.51 to 0.17). Subgroup analyses further suggested that the consumption of both fresh and dried fruit decreased the fasting blood glucose concentration.

Conclusions

Increasing the fruit intake reduced fasting blood glucose concentration. Therefore, we recommend that patients with diabetes eat more fruits while ensuring that their total energy intake remains unchanged.

The use of medicinal plants in common ophthalmic disorders: A systematic review with meta-analysis

Purpose

This study aimed to assess and compile the available research articles about medicinal plants used for ocular diseases.

Principal results

A total of 2949 articles were retrieved, 35 full-text articles were assessed for eligibility, and seven studies (4 observational and three experimental) with low to moderate quality were eligible and involved in the systematic review, with a total of 600 plants from 4 countries. Among the 600 plants, only 24 (4%) were used to assess the status. Both the fixed and random models of the studies showed that the included studies tended to predict the results for the observational studies (OR = 0.062, CI = 0.043-0.090 OR = 0.039, CI = 0.012-0.122) for different plants used for ocular diseases. High heterogeneity (estimated as I2 = 87.078, Tau2 = 1.161 and Q-value = 23.217 with a p-value of 0.000), while for experimental studies (I2 = 94.928, Tau2 = 23.211 and Q-value = 39.434 with a p-value of 0.000) and publication bias were reported.

Conclusion

Few articles representing approximately 600 plants of low to moderate quality reported using medicinal plants for ocular diseases. The meta-analysis confirmed the systematic review findings regarding the plants' traditional use with high heterogeneity and publication bias. A considerable gap was proven in the use of medicinal plants in ocular diseases requiring intensive research.

Blood pressure control for diabetic retinopathy

BACKGROUND

Diabetic retinopathy is a common complication of diabetes and a leading cause of visual impairment and blindness. Research has established the importance of blood glucose control to prevent development and progression of the ocular complications of diabetes. Concurrent blood pressure control has been advocated for this purpose, but individual studies have reported varying conclusions regarding the effects of this intervention.

OBJECTIVES

To summarize the existing evidence regarding the effect of interventions to control blood pressure levels among diabetics on incidence and progression of diabetic retinopathy, preservation of visual acuity, adverse events, quality of life, and costs.

SEARCH METHODS

We searched several electronic databases, including CENTRAL, and trial registries. We last searched the electronic databases on 3 September 2021. We also reviewed the reference lists of review articles and trial reports selected for inclusion.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which either type 1 or type 2 diabetic participants, with or without hypertension, were assigned randomly to more intense versus less intense blood pressure control; to blood pressure control versus usual care or no intervention on blood pressure (placebo); or to one class of antihypertensive medication versus another or placebo.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently reviewed the titles and abstracts of records identified by the electronic and manual searches and the full-text reports of any records identified as potentially relevant. The included trials were independently assessed for risk of bias with respect to outcomes reported in this review.

MAIN RESULTS

We included 29 RCTs conducted in North America, Europe, Australia, Asia, Africa, and the Middle East that had enrolled a total of 4620 type 1 and 22,565 type 2 diabetic participants (sample sizes from 16 to 4477 participants). In all 7 RCTs for normotensive type 1 diabetic participants, 8 of 12 RCTs with normotensive type 2 diabetic participants, and 5 of 10 RCTs with hypertensive type 2 diabetic participants, one group was assigned to one or more antihypertensive agents and the control group to placebo. In the remaining 4 RCTs for normotensive participants with type 2 diabetes and 5 RCTs for hypertensive type 2 diabetic participants, methods of intense blood pressure control were compared to usual care. Eight trials were sponsored entirely and 10 trials partially by pharmaceutical companies; nine studies received support from other sources; and two studies did not report funding source. Study designs, populations, interventions, lengths of follow-up (range less than one year to nine years), and blood pressure targets varied among the included trials. For primary review outcomes after five years of treatment and follow-up, one of the seven trials for type 1 diabetics reported incidence of retinopathy and one trial reported progression of retinopathy; one trial reported a combined outcome of incidence and progression (as defined by study authors). Among normotensive type 2 diabetics, four of 12 trials reported incidence of diabetic retinopathy and two trials reported progression of retinopathy; two trials reported combined incidence and progression. Among hypertensive type 2 diabetics, six of the 10 trials reported incidence of diabetic retinopathy and two trials reported progression of retinopathy; five of the 10 trials reported combined incidence and progression. The evidence supports an overall benefit of more intensive blood pressure intervention for five-year incidence of diabetic retinopathy (11 studies; 4940 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.73 to 0.92; I2 = 15%; moderate certainty evidence) and the combined outcome of incidence and progression (8 studies; 6212 participants; RR 0.78, 95% CI 0.68 to 0.89; I2 = 42%; low certainty evidence). The available evidence did not support a benefit regarding five-year progression of diabetic retinopathy (5 studies; 5144 participants; RR 0.94, 95% CI 0.78 to 1.12; I2 = 57%; moderate certainty evidence), incidence of proliferative diabetic retinopathy, clinically significant macular edema, or vitreous hemorrhage (9 studies; 8237 participants; RR 0.92, 95% CI 0.82 to 1.04; I2 = 31%; low certainty evidence), or loss of 3 or more lines on a visual acuity chart with a logMAR scale (2 studies; 2326 participants; RR 1.15, 95% CI 0.63 to 2.08; I2 = 90%; very low certainty evidence). Hypertensive type 2 diabetic participants realized more benefit from intense blood pressure control for three of the four outcomes concerning incidence and progression of diabetic retinopathy. The adverse event reported most often (13 of 29 trials) was death, yielding an estimated RR 0.87 (95% CI 0.76 to 1.00; 13 studies; 13,979 participants; I2 = 0%; moderate certainty evidence). Hypotension was reported in two trials, with an RR of 2.04 (95% CI 1.63 to 2.55; 2 studies; 3323 participants; I2 = 37%; low certainty evidence), indicating an excess of hypotensive events among participants assigned to more intervention on blood pressure.

AUTHORS' CONCLUSIONS

Hypertension is a well-known risk factor for several chronic conditions for which lowering blood pressure has proven to be beneficial. The available evidence supports a modest beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to five years, particularly for hypertensive type 2 diabetics. However, there was a paucity of evidence to support such intervention to slow progression of diabetic retinopathy or to affect other outcomes considered in this review among normotensive diabetics. This weakens any conclusion regarding an overall benefit of intervening on blood pressure in diabetic patients without hypertension for the sole purpose of preventing diabetic retinopathy or avoiding the need for treatment for advanced stages of diabetic retinopathy.

Association between Systemic Factors and Vitreous Fluid Cytokines in Proliferative Diabetic Retinopathy

Proliferative diabetic retinopathy (PDR) is a vision-threatening complication of diabetes mellitus (DM). Systemic and intraocular factors are intricately related to PDR, and vitreous fluid (VF) cytokines are representative intraocular biomarkers. However, the associations between systemic factors and VF cytokines and their influence on PDR pathology are unclear. This study aimed to examine the correlation between systemic factors and VF cytokines and analyze their contributions to the pathology of PDR using multivariate analyses. We conducted a retrospective observational study on 26 PDR eyes of 25 patients with type 2 DM, and 30 eyes of 30 patients with idiopathic macular hole or epiretinal membrane as controls. Fifteen systemic and laboratory tests including blood pressure (BP) and body mass index (BMI), and 27 cytokines in VF were analyzed. BP and BMI correlated positively with VF levels of IL-6 and IP-10 in PDR patients, while no significant correlation was found between systemic factors and VF cytokines in controls. MCP-1 and VEGF-A in VF separately clustered with different systemic factors in controls, but these cytokines lost the property similarity with systemic factors and acquired property similarity with each other in PDR. Systemic factors contributed to only 10.4%, whereas VF cytokines contributed to 42.3% out of 52.7% variance of the whole PDR dataset. Our results suggest that intraocular factors play a major role in the pathology of PDR, whereas systemic factors may have limited effects, and that BP and BMI control in PDR could be useful interventions to improve intraocular immune condition.

Diabetic retinopathy as the leading cause of blindness and early predictor of cascading complications-risks and mitigation

Proliferative diabetic retinopathy (PDR) the sequel of diabetic retinopathy (DR), a frequent complication of diabetes mellitus (DM), is the leading cause of blindness in the working-age population. The current screening process for the DR risk is not sufficiently effective such that often the disease is undetected until irreversible damage occurs. Diabetes-associated small vessel disease and neuroretinal changes create a vicious cycle resulting in the conversion of DR into PDR with characteristic ocular attributes including excessive mitochondrial and retinal cell damage, chronic inflammation, neovascularisation, and reduced visual field. PDR is considered an independent predictor of other severe diabetic complications such as ischemic stroke. A "domino effect" is highly characteristic for the cascading DM complications in which DR is an early indicator of impaired molecular and visual signaling. Mitochondrial health control is clinically relevant in DR management, and multi-omic tear fluid analysis can be instrumental for DR prognosis and PDR prediction. Altered metabolic pathways and bioenergetics, microvascular deficits and small vessel disease, chronic inflammation, and excessive tissue remodelling are in focus of this article as evidence-based targets for a predictive approach to develop diagnosis and treatment algorithms tailored to the individual for a cost-effective early prevention by implementing the paradigm shift from reactive medicine to predictive, preventive, and personalized medicine (PPPM) in primary and secondary DR care management.

Dietary Intake and Diabetic Retinopathy: A Systematic Review of the Literature

Diabetic retinopathy (DR) is a common microvascular complication of diabetes mellitus. The evidence connecting dietary intake and DR is emerging, but uncertain. We conducted a systematic review to comprehensively summarize the current understanding of the associations between dietary consumption, DR and diabetic macular edema (DME). We systematically searched PubMed, Embase, Medline, and the Cochrane Central Register of Controlled Trials between January 1967 to May 2022 for all studies investigating the effect of diet on DR and DME. Of the 4962 articles initially identified, 54 relevant articles were retained. Our review found that higher intakes of fruits, vegetables, dietary fibers, fish, a Mediterranean diet, oleic acid, and tea were found to have a protective effect against DR. Conversely, high intakes of diet soda, caloric intake, rice, and choline were associated with a higher risk of DR. No association was seen between vitamin C, riboflavin, vitamin D, and milk and DR. Only one study in our review assessed dietary intake and DME and found a risk of high sodium intake for DME progression. Therefore, the general recommendation for nutritional counseling to manage diabetes may be beneficial to prevent DR risk, but prospective studies in diverse diabetic populations are needed to confirm our findings and expand clinical guidelines for DR management.

Certain Dietary Nutrients Reduce the Risk of Eye Affliction/Retinopathy in Individuals with Diabetes: National Health and Nutrition Examination Survey, 2003-2018

As the global trend of diabetes intensifies, the burden of vision-threatening retinopathy, particularly diabetic retinopathy (DR), is increasing. There is an urgent need to seek strategies for early prevention and control of DR. This study attempted to comprehensively evaluate the relationship between dietary nutrient intake and the risk of DR to provide assistance for doctors in guiding the diet of diabetic patients. Data from eligible participants with diabetes from the US National Health and Nutrition Examination Survey (NHANES) from 2003-2018 were analyzed. Univariate logistic regression was used to assess the association between 58 dietary nutrient intakes and self-reported eye disease risk. Multivariate logistic regression model was used to further evaluate the relationship between the two groups after adjusting relevant confounding factors. A total of 4595 diabetic patients were included. People with self-reported eye affliction/retinopathy had lower dietary fiber, butanoic, octanoic, vitamin A, alpha-carotene, folate, magnesium, copper and caffeine intake compared to those without self-reported eye affliction/retinopathy. The pooled ORs (95% CIs) were 0.78 (0.62-0.98), 0.79 (0.63-0.99), 0.72 (0.58-0.91), 0.74 (0.59-0.93), 0.70 (0.55-0.88), 075 (0.60-0.95), 0.79 (0.64-0.99), 0.67 (0.54-0.84) and 0.80 (0.64-0.99). Dietary cholesterol and hexadecenoic intake were higher, with the pooled ORs (95% CIs) of 1.26 (1.01-1.58) and 1.27 (1.02-1.59), respectively. Our research found that among dietary nutrients, dietary fiber, butanoic, octanoic, vitamin A, alpha-carotene, folate, magnesium, copper and caffeine intake reduced the occurrence of DR. Cholesterol and hexadecenoic intake promoted the occurrence of DR. This suggests that certain dietary nutrients should be paid more attention in the prevention of DR.

Association of Dietary Fiber Intake with All-Cause Mortality and Cardiovascular Disease Mortality: A 10-Year Prospective Cohort Study

Although previous studies have established that dietary fiber (DF) intake reduces the total cardiovascular disease (CVD) mortality in general populations, limited studies have been conducted in individuals with pre-existing chronic conditions, especially in Asian countries. We aimed to investigate the association of DF intake with all-cause and CVD mortality in the general population and in the subpopulation with hypertension, diabetes, and dyslipidemia. We examined the relationship between DF intake and all-cause and CVD mortality using the Korean genome and epidemiology study. Diet was assessed using a food-frequency questionnaire at baseline. Cox proportional hazard models were used to estimate the hazard ratio (HR) and 95% confidence intervals (CIs) after adjusting for confounders. During the mean 10.1 years of follow-up, higher DF intake was significantly associated with a lower risk of all-cause mortality after adjusting for confounders (HR and 95% CIs for Q5 vs. Q1: 0.84 (0.76−0.93); p < 0.001). DF intake was inversely associated with a lower risk of CVD mortality after adjusting for the same confounders (HR and 95% CIs for Q5 vs. Q1: 0.61 (0.47−0.78); p < 0.001). Total DF intake was inversely associated with all-cause and CVD mortality in middle-aged and older adults.

Micronutrients and Diabetic Retinopathy: Evidence From The National Health and Nutrition Examination Survey and a Meta-analysis

PURPOSE

To investigate the associations between circulating micronutrients (vitamins A, C, D, E, and carotenoids) and risk of diabetic retinopathy (DR).

DESIGN

Cross-sectional study and meta-analysis.

METHODS

The cross-sectional study included 517 diabetic participants aged ≥40 years in the 2005-2006 National Health and Nutrition Examination Survey. Serum vitamin D was converted to liquid chromatography-tandem mass spectrometry-equivalent results, while other micronutrients were measured using high-performance liquid chromatography. Presence of DR was determined based on non-mydriatic fundus photographs. A meta-analysis was subsequently performed, which included relevant studies published from January 01, 1990 to December 31, 2020.

RESULTS

Of the 517 included participants, DR was identified in 159 participants (25.17%). After adjusting for multiple confounders, only serum vitamin C was associated with a lower risk of DR (odds ratio [OR]: 0.60; 95% confidence interval [CI]: 0.38-0.95). A total of 35 studies were included in the subsequent meta-analysis. Comparing 1056 participants with DR to 920 controls, the pooled weighted mean difference (WMD) of vitamin C was -11.01 (95% CI: -19.35 to -2.67). Regarding vitamins D and E, the pooled WMD was -3.06 (95% CI: -5.15 to -0.96) and -3.03 (95% CI: -4.24 to -1.82), respectively. No associations were identified between DR and circulating vitamin A or carotenoids.

CONCLUSIONS

Lower levels of circulating vitamins C, D, and E were found in DR patients than those without. More high-quality studies are required to assess the real effects of micronutrients on DR.

Dietary intake and physical activity in Japanese patients with type 2 diabetes: the Japan Diabetes Complication and its Prevention prospective study (JDCP study 8)

Medical nutrition therapy and exercise therapy are the cornerstones of treatment for patients with type 2 diabetes; however, there has not been a nationwide study on the actual dietary intake and physical activity status of patients since the 2000s. We aimed to clarify this in Japanese patients with type 2 diabetes using data from the Japan Diabetes Complication and its Prevention prospective (JDCP), a nationwide study launched in 2007. A total of 1992 patients with type 2 diabetes, aged 40-75 years, completed either the Brief-type, self-administered Diet History Questionnaire (1643 patients) or International Physical Activity Questionnaire (1834 patients), and their data were analyzed in this study. Mean daily energy intake for all participants was 1686.8 kcal/day, and the mean proportions of carbohydrate, protein, and fat comprising total energy intake were 60.2, 16.2, and 23.6%, respectively. The patients in this study had similar energy and nutrient intake status to patients in the 1996 Japan Diabetes Complications Study; however, Japanese patients still had higher carbohydrate and lower fat consumption than patients with diabetes in Western countries. The physical activity questionnaire reported that 31.0% of patients did not have exercise habits; this was particularly noticeable in female patients and patients under the age of 65. BMI increased from 22.7 to 24.1 kg/m² in men and 23.2 to 24.8 kg/m² in women from 1996 to 2007, respectively. Further research is required to investigate how dietary intake and physical activity associates with the risk of developing complications in type 2 diabetes patients.

The Effect of Diet and Lifestyle on the Course of Diabetic Retinopathy-A Review of the Literature

Diabetes is a major social problem. As shown by epidemiological studies, the world incidence of diabetes is increasing and so is the number of people suffering from its complications. Therefore, it is important to determine possible preventive tools. In the prevention of diabetic retinopathy, it is essential to control glycemia, lipid profile and blood pressure. This can be done not only by pharmacological treatment, but first of all by promoting a healthy lifestyle, changing dietary habits and increasing physical activity. In our work, we present a review of the literature to show that physical exercise and an adequate diet can significantly reduce the risk of diabetes and diabetic retinopathy.

Association between Dietary Calcium and Potassium and Diabetic Retinopathy: A Cross-Sectional Retrospective Study

Background: Micronutrients are considered to have an important role in metabolic process. The relationships between micronutrients and diabetic complication, such as retinopathy, are rarely discussed. The main purpose of the current study was to investigate the relationship between dietary micronutrients and diabetic retinopathy in an adult population. Methods: 5321 participants from National Health and Nutritional Examination Survey (NHANES) 2005–2008 were included in this cross-sectional study. Diabetic retinopathy was diagnosed by the severity scale of the Early Treatment Diabetic Retinopathy Study (ETDRS) using nonmydriatic fundus photography. Micronutrients were assessed by 24-h dietary recall. The relationship between dietary micronutrients and the occurrence of diabetic retinopathy was analyzed by a logistic regression model. Results: Dietary calcium and potassium were inversely associated with diabetic retinopathy (OR: 0.729, 95%CI: 0.562–0.945; OR: 0.875, 95%CI: 0.787–0.973). Higher quartile of dietary calcium and potassium was associated with lower occurrence of diabetic retinopathy (OR: 0.664, 95%CI: 0.472–0.933; OR: 0.700, 95%CI: 0.495–0.989). Furthermore, increased amounts of dietary calcium and potassium were significantly associated with reduced occurrence of diabetic retinopathy (OR: 0.701, 95%CI: 0.546–0.900; OR: 0.761, 95%CI: 0.596–0.972). Conclusions: Higher levels of dietary calcium and potassium are suggested to reduce the risk of diabetic retinopathy with dose–response effect. The evaluation of dietary micronutrients might be a part of treatment for patients with diabetic complications.

Joint associations of fresh fruit intake and physical activity with glycaemic control among adult patients with diabetes: a cross-sectional study

OBJECTIVE

To investigate the joint associations of fresh fruit intake and physical activity with glycaemic control in adult patients with diabetes mellitus (DM).

DESIGN

It was an observational study involving adult patients with DM through a face-to-face questionnaire survey, physical measurements and laboratory examinations. Data were analysed by introducing a generalised linear mixed model, and a significant difference was set at p<0.05.

SETTING

Nanjing, Jiangsu, China.

PARTICIPANTS

A total of 5663 adult patients with DM from the 2017 Nanjing Chronic Disease and Risk Factor Surveillance were recruited.

RESULTS

Based on the food frequency questionnaire, fresh fruit intake was classified as 'not eat', '1~99 g/day' and '≥100 g/day'. Physical activity level was calculated based on the data of Global Physical Activity Questionnaire and classified into insufficient physical activity (<600 MET-min/week) and sufficient physical activity (≥600 MET-min/week). The likelihood of glycaemic control in adult patients with DM with fresh fruit intake ≥100 g/day was 37.8% (OR: 1.378; 95% CI: 1.209 to 1.571) higher than those with fresh fruit intake <100 g/day, which was 26% (OR: 1.260; 95% CI: 1.124 to 1.412) higher in adult patients with DM with sufficient physical activity than those with insufficient physical activity. Adult patients with DM with fresh fruit intake ≥100 g/day and sufficient physical activity presented the greatest likelihood of glycaemic control (OR: 1.758; 95% CI: 1.471 to 2.102) compared with those with both fresh fruit intake <100 g/day and insufficient physical activity.

CONCLUSIONS

Fresh fruit intake ≥100 g/day combined with sufficient physical activity is associated with a significantly higher likelihood of glycaemic control in adult patients with DM.

Effects of a Mediterranean diet on the development of diabetic complications: A longitudinal study from the nationwide diabetes report of the National Program for Prevention and Control of Diabetes (NPPCD 2016-2020)

OBJECTIVE

To evaluate the effectiveness of a Mediterranean dietary pattern on the incidence of macrovascular and microvascular complications of diabetes, namely cardiovascular disease (CVD), diabetic foot disorders, diabetic retinopathy, nephropathy, and neuropathy.

METHODS

This longitudinal study was conducted among 71392 adults with diabetes who attended academic tertiary-care outpatient clinics from February 2016 to March 2020 across Iran using the National Program for Prevention and Control of Diabetes database. Among them, 22187 patients with diabetes (type 1 and type 2) completed 2-11 follow-up visits after baseline registration. The association between adherence to a Mediterranean diet and diabetic complications was assessed using pooled logistic regression models. This association was adjusted for potential confounders. The effect of time was assessed using fractional polynomials.

RESULTS

A total of 22187 participants were included in the analysis (30.22% men and 69.78% women) with either type 1 (mean age 50.7 years) or type 2 (mean age 59.9 years) diabetes. After adjustment for confounding variables, there was a negative correlation between adherence to a Mediterranean diet and the incidence of CVD among patients with type 1 diabetes (T1D) and 2 diabetes (T2D) (OR= 0.53, 95% CI: 0.37 - 0.75, p-value <0.001 and OR= 0.61, 95% CI: 0.57 - 0.89, p-value <0.001, respectively). Also, the diet had a statistically significant protective effect against incident symptomatic neuropathy (OR= 0.32, 95% CI: 0.23 - 0.43, p-value <0.001, and OR= 0.68, 95% CI: 0.64 - 0.72, p-value <0.001, respectively), nephropathy (OR= 0.42, 95% CI: 0.30 - 0.58, p-value <0.001, and OR= 0.88, 95% CI: 0.80 - 0.96, p-value= 0.007, respectively), and retinopathy (OR= 0.32, 95% CI: 0.24 - 0.44, p-value <0.001, and OR= 0.68, 95% CI: 0.61 - 0.71, p-value <0.001, respectively) in T1D and T2D.

CONCLUSION

The Mediterranean dietary pattern is associated with a lower incidence of CVD and microvascular complications (i.e. diabetic retinopathy, nephropathy, and neuropathy) among a cohort of patients with T1D and T2D in Iran.

Secular Trends in Dietary Intake over a 20-Year Period in People with Type 2 Diabetes in Japan: A Comparative Study of Two Nationwide Registries; Japan Diabetes Complications Study (JDCS) and Japan Diabetes Clinical Data Management Study (JDDM)

Background: In order to provide effective dietary guidance, it is necessary to consider dietary intake, which can change over time. This study analyzed changes in the diet of Japanese patients with type 2 diabetes over a 20-year period. Methods: We compared the results of two dietary surveys that used the food frequency questionnaire format. The first was conducted in 1996 by the Japan Diabetes Complications Study (JDCS) (n = 1509; males 53.3%), and the second in 2014–2018 by the Japan Diabetes Clinical Data Management Study (JDDM) (n = 1145; males 65.6%). Both are nationwide representative registries of outpatients with type 2 diabetes in Japan. Results: Over a 20-year period, both men and women with type 2 diabetes had a significant increase in body mass index (BMI). Nonetheless, there was only a small change in energy intake. Conversely, there was a significant increase in fat intake and thus in the fat-to-energy ratio. With regard to food groups, there was a significant increase in meat intake and a decrease in the intake of fish, soybeans/soy products, vegetables, and fruits, with a particularly significant decrease in vegetables. Conclusions: Even in Japan, an industrialized country with a stable socioeconomic environment, there were many significant changes in the dietary intake of patients with type 2 diabetes over the 20-year period.

Sodium Intake and Incidence of Diabetes Complications in Elderly Patients with Type 2 Diabetes-Analysis of Data from the Japanese Elderly Diabetes Intervention Study (J-EDIT)

This study investigates the associations between sodium intake and diabetes complications in a nationwide cohort of elderly Japanese patients with type 2 diabetes aged 65–85. Data from 912 individuals regarding their dietary intake at baseline is analyzed and assessed by the Food Frequency Questionnaire based on food groups. Primary outcomes are times to diabetic retinopathy, overt nephropathy, cardiovascular disease (CVD), and all-cause mortality during six years. We find that mean sodium intake in quartiles ranges from 2.5 g to 5.9 g/day. After adjustment for confounders, no significant associations are observed between sodium intake quartiles and incidence of diabetes complications and mortality, except for a significant trend for an increased risk of diabetic retinopathy (p = 0.039). Among patients whose vegetable intake was less than the average of 268.7 g, hazard ratios (HRs) for diabetic retinopathy in patients in the second, third, and fourth quartiles of sodium intake compared with the first quartile were 0.87 (95% CI, 0.31–2.41), 2.61 (1.00–6.83), and 3.70 (1.37–10.02), respectively. Findings indicate that high sodium intake under conditions of low vegetable intake is associated with an elevated incidence of diabetic retinopathy in elderly patients with type 2 diabetes.

Fruit Intake to Prevent and Control Hypertension and Diabetes

Fruits are considered healthy because of their high antioxidant, vitamin, mineral, fiber, and phytochemical contents. However, their high sugar content is a concern for glucose, lipid, and uric acid metabolism. We reviewed related articles published in the last 10 years and summarized evidence that relates fruit intake to the prevention and control of hypertension and diabetes mellitus. Clinicians should familiarize themselves with appropriate fruit intake to counsel at-risk patients on hypertension and diabetes.

The colorful world of carotenoids: a profound insight on therapeutics and recent trends in nano delivery systems

The therapeutic effects of carotenoids as dietary supplements to control or even treat some specific diseases including diabetic retinopathy, cardiovascular diseases, bacterial infections, as well as breast, prostate, and skin cancer are discussed in this review and also thoughts on future research for their widespread use are emphasized. From the stability standpoint, carotenoids have low bioavailability and bioaccessibility owing to their poor water solubility, deterioration in the presence of environmental stresses such as oxygen, light, and high heat as well as rapid degradation during digestion. Nanoencapsulation technologies as wall or encapsulation materials have been increasingly used for improving food product functionality. Nanoencapsulation is a versatile process employed for the protection, entrapment, and the delivery of food bioactive products including carotenoids from diverse environmental conditions for extended shelf lives and for providing controlled release. Therefore, we present here, recent (mostly during the last five years) nanoencapsulation methods of carotenoids with various nanocarriers. To us, this review can be considered as the first highlighting not only the potential therapeutic effects of carotenoids on various diseases but also their most effective nanodelivery systems.HighlightsBioactive compounds are of deep interest to improve food properties.Carotenoids (such as β-carotene and xanthophylls) play indispensable roles in maintaining human health and well-being.A substantial research effort has been carried out on developing beneficial nanodelivery systems for various carotenoids.Nanoencapsulation of carotenoids can enhance their functional properties.Stable nanoencapsulated carotenoids could be utilized in food products.

Diet and risk of visual impairment: a review of dietary factors and risk of common causes of visual impairment

Age-related macular degeneration, diabetic retinopathy, cataract, and glaucoma remain the leading causes of visual impairment in developed nations, resulting in a substantial treatment burden on sufferers and health care systems. Despite significant advances in diagnostic testing and therapeutics, population-based strategies to reduce the burden of these diseases remain limited. However, there is some evidence that these diseases may share overlapping risk factors, particularly in regard to dietary intake and antioxidant status, and it is thus possible that dietary modification may reduce both the prevalence and severity of these conditions. In particular, dietary intake of green leafy vegetables, hyperglycemia/glycemia index, and omega-3 fatty acid intake, as well as overall dietary patterns, may affect risk of one or more of these conditions. In this review, we analyse the evidence for dietary intake and the association with these conditions, and provide insights into possible modifications that may thus simultaneously reduce the risk of visual impairment from multiple causes, including improving dietary intake of green leafy vegetables and reducing dietary glycemic index, both of which have been associated with a decreased risk of multiple causes of visual impairment.

Association between dietary antioxidants and risk for diabetic retinopathy in a Chinese population

BACKGROUND

Diabetic retinopathy (DR) is related to oxidative stress and insufficient intake of dietary antioxidants may be associated with the onset and progression of DR. This study aimed to detect the association between main dietary antioxidants intake and the risk for DR.

METHODS

This is a cross-sectional study of a Chinese urban population. Four hundred and fifty-five subjects with type 2 diabetes were recruited and divided into diabetic patients without retinopathy (DWR) group and DR group based on their retinal status. CSMO (clinically significant macular oedema) was diagnosed by stereoscopic photography. Demographic and lifestyle characteristics were ascertained by questionnaire. General physical and ophthalmic examinations were completed for all subjects. Dietary antioxidants were assessed by 3-day food records. Subjects who have taken any type of vitamin supplements were excluded from the study. The association of dietary antioxidants with the risk for DR was analysed by logistic regression with adjustment of other factors. The dietary antioxidants levels of the CSMO subjects and non-CSMO subjects were compared using the Wilcoxon rank sum test.

RESULTS

One hundred and nineteen subjects in DR group and 336 subjects in DWR group participated in the study. Only ten DR subjects had CSMO. The results showed that higher vitamin E (OR (95% CI):0.97 (0.95, 1.00), P = 0.036) and selenium (OR (95% CI):0.98 (0.96, 1.00), P = 0.017) intake appear to be the protective factors of DR. The dietary antioxidants levels of CSMO and non-CSMO subjects had no statistical differences (P > 0.05).

CONCLUSIONS

Dietary antioxidants intake, particularly vitamin E and selenium, were observed to have protective effects on DR.

Adjuvant Therapies in Diabetic Retinopathy as an Early Approach to Delay Its Progression: The Importance of Oxidative Stress and Inflammation

Diabetes mellitus (DM) is a progressive disease induced by a sustained state of chronic hyperglycemia that can lead to several complications targeting highly metabolic cells. Diabetic retinopathy (DR) is a multifactorial microvascular complication of DM, with high prevalence, which can ultimately lead to visual impairment. The genesis of DR involves a complex variety of pathways such as oxidative stress, inflammation, apoptosis, neurodegeneration, angiogenesis, lipid peroxidation, and endoplasmic reticulum (ER) stress, each possessing potential therapeutic biomarkers. A specific treatment has yet to be developed for early stages of DR since no management is given other than glycemic control until the proliferative stage develops, offering a poor visual prognosis to the patient. In this narrative review article, we evaluate different dietary regimens, such as the Mediterranean diet, Dietary Pattern to Stop Hypertension (DASH) and their functional foods, and low-calorie diets (LCDs). Nutraceuticals have also been assessed in DR on account of their antioxidant, anti-inflammatory, and antiangiogenic properties, which may have an important impact on the physiopathology of DR. These nutraceuticals have shown to lower reactive oxygen species (ROS), important inflammatory factors, cytokines, and endothelial damage biomarkers either as monotherapies or combined therapies or concomitantly with established diabetes management or nonconventional adjuvant drugs like topical nonsteroidal anti-inflammatory drugs (NSAIDs).

Glycemic Control Among People Living with Diabetes and Human Immunodeficiency Virus in Ethiopia: Leveraging Clinical Care for the Looming Co-Epidemics

BACKGROUND

Antiretroviral therapy has decreased human immunodeficiency virus related mortality. However, the incidence of diabetes mellitus is increasing among people living with human immunodeficiency virus and adds complexity to the standards of care.

OBJECTIVE

The study was aimed to determine the glycemic control and delivery of clinical care among people living with diabetes and human immunodeficincy virus in Ethiopia.

METHODS

A comparative prospective cohort study was conducted among patients living with diabetes at follow-up clinics of Jimma Medical Center in two study arms. The first arm was people living with diabetes and human immunodeficiency virus. The second arm was human immunodeficiency virus negative patients living with diabetes. The expanded English version of the summary of diabetes self-care activities scale was used to measure self-care behaviors. In order to identify the predictors of glycemic control, multivariable Cox regression analysis was used. Statistical significance at p-value ≤0.05 was considered.

RESULTS

A total of 297 eligible participants were followed for one year, with a mean age of 44.35±12.55 years. Males accounted for 55.9%. After one year of follow-up, 61.9% of diabetes people living with human immunodeficiency virus, and 49% of human immunodeficiency virus-negative patients with diabetes poorly met blood glucose target (p=0.037). Female gender [AHR: 2.72; 95% CI (1.21-5.72)], age >31 years [AHR: 2.48; 95% CI (1.34-11.01)], increased waist circumference [AHR: 3.64; 95% CI (2.57-16.12)], overweight [AHR: 3.63; 95% CI (1.65-22.42)], chronic disease comorbidity [AHR: 2.02; 95% CI (1.44-2.84)], human immunodeficiency virus infection [AHR: 3.47; 95% CI (2.03-23.75)], living longer with diabetes (>5 years) [AHR: 3.67; 95% CI (3.26-4.14)] showed a higher risk of blood sugar control failure and were independent predictors of uncontrolled glycemia. Tuberculosis infection increased the risk of uncontrolled blood sugar among people living with diabetes and human immunodeficency virus[AHR:3.82;95% CI(2.86-5.84].

CONCLUSION

Significant gaps were observed in achieving the recommended glycemic target and involvement of patients on self-care care behavior in the study area. The co-occurrence of tuberculosis, human immunodeficiency virus, and diabetes is triple trouble needing special attention in their management. It is high time to leverage the clinical care of the looming co-epidemics through chronic comprehensive care clinic.

The Therapeutic Role of Carotenoids in Diabetic Retinopathy: A Systematic Review

BACKGROUND

Carotenoids are a large group of natural pigments that occur in many foods, fruits, and vegetables. Several studies have shown a number of biological properties of carotenoids, particularly beneficial impacts on cancer, metabolic, neurodegenerative, and cardiovascular diseases. However, recent evidence has shown that these compounds could prevent, delay, and ameliorate diabetic retinopathy (DR). The aim of current study was to review the therapeutic effects of carotenoids in the treatment of DR and discuss the molecular mechanisms that are behind these pharmacological activities.

METHODS

Six online databases (Medline/PubMed, Scopus, Web of Knowledge, Embase, ScienceDirect, and ProQuest) were searched until September 2019. The systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

RESULTS

A total of 25 studies were included after the final retrieval. A relationship was observed between carotenoids and management of DR. Findings also demonstrated that the underlying mechanism of beneficial effects of these compounds was antioxidant, anti-inflammatory, anti-angiogenic, and neuroprotective properties.

CONCLUSION

Carotenoids potentially delay the initiation and prevent the progression of DR; however, ample preclinical studies are required to confirm their effect, and adequate clinical trials are needed to really understand how well these compounds influence DR among humans.

Oxidative Stress as the Main Target in Diabetic Retinopathy Pathophysiology

Diabetic retinopathy (DR) is one of the most common complications of diabetes mellitus (DM) causing vision impairment even at young ages. There are numerous mechanisms involved in its development such as inflammation and cellular degeneration leading to endothelial and neural damage. These mechanisms are interlinked thus worsening the diabetic retinopathy outcome. In this review, we propose oxidative stress as the focus point of this complication onset.

Dietary factors and diabetes-related health outcomes in patients with type 2 diabetes: protocol for a systematic review and meta-analysis of prospective observational studies

INTRODUCTION

Type 2 diabetes (T2D) is a major health concern associated with several comorbidities such as diabetic chronic kidney disease, neuropathy and cardiovascular diseases. Many of these complications may be preventable by an adequate lifestyle, including a favourable dietary behaviour, additionally to pharmacological management. In general, dietary guidelines for patients with diabetes recommend a hypocaloric diet to achieve a normal weight, but there is a lack of detailed instructions on specific nutrients and foods to prevent diabetes-related outcomes. Therefore, the aim of this systematic review and meta-analysis is to summarise the available evidence on the association between dietary factors and health-related outcomes in patients with T2D.

METHODS AND ANALYSIS

A systematic literature search will be conducted in PubMed and Web of Science in May 2019 to identify prospective observational studies investigating dietary factors in association with major complications in patients with T2D. We will include studies investigating dietary patterns, food groups, foods, macronutrients and micronutrients as well as secondary plant compounds. As diabetes-related outcomes, we will include macrovascular (cardiovascular and cerebrovascular diseases) and microvascular outcomes (nephropathy, neuropathy and retinopathy), as well as cancer, quality of life, depression, cognitive disorders and mortality. We will conduct dose-response meta-analyses using random effects models. We will investigate heterogeneity across studies and publication bias. To assess the risk of bias and quality of the included studies, we will use the Cochrane risk of bias tool ROBINS-I and the quality of evidence will be assessed using Grades of Recommendation, Assessment, Development, and Evaluation.

ETHICS AND DISSEMINATION

As the systematic review is based on published studies, ethical considerations are not required. The systematic review and meta-analysis will be published in a peer-reviewed Journal.

PROSPERO REGISTRATION NUMBER

CRD42018110669.

Association of vitreous vitamin C depletion with diabetic macular ischemia in proliferative diabetic retinopathy

Purpose

Vitreous vitamin C, as an anti-oxidant, is responsible for regulating oxygen tension and oxidative stress in the eye. Oxidative stress and retinal ischemia are implicated in the development of proliferative diabetic retinopathy (PDR). In this study, we aimed to determine whether vitreous level of vitamin C is compromised in patients with PDR and to investigate the association of diabetic macular ischemia and vitamin C.

Methods

This prospective study enrolled forty patients who underwent pars plana vitrectomy for the treatment of PDR (PDR group, n = 20) and idiopathic epiretinal membrane (control group, n = 20). Serum, aqueous humor, and the vitreous were collected for the analysis of vitamin C level by HPLC. Diabetic macular ischemia (DMI) in PDR group was evaluated with fluorescein angiography (FA).

Results

PDR patients (60.4 ± 2.1 y) were younger than non-diabetic control patients (67.4 ± 1.2 y). Serum, aqueous, and vitreous levels of vitamin C in PDR were 38.7%, 22.5%, and 11.1% of non-diabetic control group, respectively. All PDR patients had DMI (grade 1: 25%, grade 2: 30%, grade 3: 30%, grade 4: 15%). DMI grade was inversely correlated with the level of vitreous vitamin C (r = -0.546, P = 0.019), not with HbA1C, serum, or aqueous vitamin C level. In addition, the level of vitreous vitamin C (4.5 ± 2.6 μg/ml) in high DMI group (Gr 3 &4) was lower than that (31.0 ± 9.1 μg/ml) in low DMI group (Gr 1&2) (P = 0.015).

Conclusions

Vitreous level of vitamin C in PDR patients showed a tenfold decrease, which was associated with the degree of macular ischemia. This suggests that vitreous vitamin C depletion may cause macula ischemia in PDR patients.

Does daily dietary intake affect diabetic retinopathy progression? 10-year results from the 45 and Up Study

Background/aims

To evaluate the associations of dietary consumption with the 10-year incidence of diabetic retinopathy (DR) progression in working-aged Australians with diabetes.

Methods

We obtained longitudinal data of all diabetic subjects aged 45–65 years from the baseline of the 45 and Up Study and linked this data with Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme claims until 2016. Retinal photocoagulation (RPC), as determined based on the MBS data, was used as a proxy measure of DR progression. Dietary measurements were assessed via self-reported consumption of meat, dairy products, whole-meal bread, breakfast cereal, vegetables, fruit and fruit juice using a self-administered questionnaire at baseline. Cox regression was used to assess the association between dietary consumption and incident RPC during the follow-up period.

Results

A total of 8122 participants were included in the current analysis with a mean age of 57.2±5.2 years. During a mean follow-up of 8.6 years, 314 participants (3.8% of baseline) received RPC. Higher consumption of cheese and whole-meal bread was associated with a lower risk of incident RPC, with the HRs of the highest quartiles versus the lowest being 0.58 (95% CI 0.41 to 0.83; test for trend, p=0.007) and 0.64 (0.46 to 0.89; p=0.04), respectively. Body mass index, insulin treatment and gender were significant modifiers for the association between cheese/whole-meal bread and RPC.

Conclusion

Consumption of cheese and whole-meal bread could reduce the risk of DR progression among the working-aged Australian population with diabetes.

Whole Fruits and Fruit Fiber Emerging Health Effects

Less than 10% of most Western populations consume adequate levels of whole fruits and dietary fiber with typical intake being about half of the recommended levels. Evidence of the beneficial health effects of consuming adequate levels of whole fruits has been steadily growing, especially regarding their bioactive fiber prebiotic effects and role in improved weight control, wellness and healthy aging. The primary aim of this narrative review article is to examine the increasing number of health benefits which are associated with the adequate intake of whole fruits, especially fruit fiber, throughout the human lifecycle. These potential health benefits include: protecting colonic gastrointestinal health (e.g., constipation, irritable bowel syndrome, inflammatory bowel diseases, and diverticular disease); promoting long-term weight management; reducing risk of cardiovascular disease, type 2 diabetes and metabolic syndrome; defending against colorectal and lung cancers; improving odds of successful aging; reducing the severity of asthma and chronic obstructive pulmonary disease; enhancing psychological well-being and lowering the risk of depression; contributing to higher bone mineral density in children and adults; reducing risk of seborrheic dermatitis; and helping to attenuate autism spectrum disorder severity. Low whole fruit intake represents a potentially more serious global population health threat than previously recognized, especially in light of the emerging research on whole fruit and fruit fiber health benefits.

Type 1 Diabetic Subjects with Diabetic Retinopathy Show an Unfavorable Pattern of Fat Intake

Medical nutrition therapy is an important part of the management of type 1 diabetes mellitus (T1DM). Proper adherence to a healthy diet may have a favorable impact on diabetes management and its diabetic complications. Our aim was to assess differences in food and nutrient intake of type 1 diabetic patients with and without diabetic retinopathy (DR). This was a two-center, cross-sectional study in patients with T1DM, with and without DR. Subjects were recruited from the outpatient clinic of the two participating centers. A validated food frequency questionnaire was administered. A total of 103 T1DM patients with DR and 140 T1DM patient without DR were recruited. Subjects with DR showed a lower intake of total fat (p = 0.036) than that of their non-DR counterparts. DR was associated with increasing age (p = 0.004), hypertension (p < 0.001), and diabetes duration (p < 0.001), however there was a negative association with high educational level (p = 0.018). The multivariate-adjusted analysis showed that the intake of complex carbohydrates was positively related to the presence of DR (p = 0.031). In contrast, the intakes of total fat (p = 0.009), monounsaturated fatty acids (MUFAs) (p = 0.012), oleic acid (p = 0.012), and vitamin E (p = 0.006) were associated with the absence of DR. As conclusions, the intake of total MUFAs, oleic acid, and vitamin E is associated with a lower frequency of DR in patients with T1DM. These results suggest a potential protective effect of these lipid components for DR.

Association of dietary patterns with diabetes complications among type 2 diabetes patients in Gaza Strip, Palestine: a cross sectional study

BACKGROUND

The prevalence of diabetes mellitus is rising worldwide. When diabetes is uncontrolled, it has dire consequences for health and well-being. However, the role of diet in the origin of diabetes complications is not understood well. This study identifies major dietary patterns among type 2 diabetes patients and its association with diabetes complications in Gaza Strip, Palestine.

METHODS

This cross sectional study was conducted among 1200 previously diagnosed type 2 diabetes mellitus (both genders, aged 20-64 years), patients receiving care in primary healthcare centers in Gaza Strip, Palestine. Dietary patterns were evaluated using a validated semi-quantitative food frequency questionnaire. Additional information regarding demographic and medical history variables was obtained with an interview-based questionnaire. Statistical analysis was performed using SPSS version 20.

RESULTS

Two major dietary patterns were identified by factor analysis: Asian-like pattern and sweet-soft drinks-snacks pattern. After adjustment for confounding variables, patients in the lowest tertile of the Asian-like pattern characterized by a high intake of whole grains, potatoes, beans, legumes, vegetables, tomatoes and fruit had a lower odds for (High BP, kidney problems, heart problems, extremities problems and neurological problems), (OR 0.710 CI 95% (.506-.997)), (OR 0.834 CI 95% (.700-.994)), (OR 0.730 CI 95% (.596-.895)), (OR 0.763 CI 95% (.667-.871)) and (OR 0.773 CI 95% (.602-.991)) respectively, (P value <0.05 for all). No significant association was found between the sweet-soft drinks snacks pattern with diabetes complications.

CONCLUSION

The Asian-like pattern may be associated with a lower prevalence of diabetes complications among type 2 diabetes patients.

Fresh fruit consumption in relation to incident diabetes and diabetic vascular complications: A 7-y prospective study of 0.5 million Chinese adults

BACKGROUND

Despite the well-recognised health benefits of fresh fruit consumption, substantial uncertainties remain about its potential effects on incident diabetes and, among those with diabetes, on risks of death and major vascular complications.

METHODS AND FINDINGS

Between June 2004 and July 2008, the nationwide China Kadoorie Biobank study recruited 0.5 million adults aged 30-79 (mean 51) y from ten diverse localities across China. During ~7 y of follow-up, 9,504 new diabetes cases were recorded among 482,591 participants without prevalent (previously diagnosed or screen-detected) diabetes at baseline, with an overall incidence rate of 2.8 per 1,000 person-years. Among 30,300 (5.9%) participants who had diabetes at baseline, 3,389 deaths occurred (overall mortality rate 16.5 per 1,000), along with 9,746 cases of macrovascular disease and 1,345 cases of microvascular disease. Cox regression yielded adjusted hazard ratios (HRs) associating each disease outcome with self-reported fresh fruit consumption, adjusting for potential confounders such as age, sex, region, socio-economic status, other lifestyle factors, body mass index, and family history of diabetes. Overall, 18.8% of participants reported consuming fresh fruit daily, and 6.4% never/rarely (non-consumers), with the proportion of non-consumers about three times higher in individuals with previously diagnosed diabetes (18.9%) than in those with screen-detected diabetes (6.7%) or no diabetes (6.0%). Among those without diabetes at baseline, higher fruit consumption was associated with significantly lower risk of developing diabetes (adjusted HR = 0.88 [95% CI 0.83-0.93] for daily versus non-consumers, p < 0.001, corresponding to a 0.2% difference in 5-y absolute risk), with a clear dose-response relationship. Among those with baseline diabetes, higher fruit consumption was associated with lower risks of all-cause mortality (adjusted HR = 0.83 [95% CI 0.74-0.93] per 100 g/d) and microvascular (0.72 [0.61-0.87]) and macrovascular (0.87 [0.82-0.93]) complications (p < 0.001), with similar HRs in individuals with previously diagnosed and screen-detected diabetes; estimated differences in 5-y absolute risk between daily and non-consumers were 1.9%, 1.1%, and 5.4%, respectively. The main limitation of this study was that, owing to its observational nature, we could not fully exclude the effects of residual confounding.

CONCLUSION

In this large epidemiological study in Chinese adults, higher fresh fruit consumption was associated with significantly lower risk of diabetes and, among diabetic individuals, lower risks of death and development of major vascular complications.

Nutrition for diabetic retinopathy: plummeting the inevitable threat of diabetic vision loss

Diabetic retinopathy (DR) is among the leading causes of preventable blindness. Hyperglycemia, hypertension, hyperlipidemia and anemia majorly predispose its pathogenesis. The current treatment modalities of DR include laser photocoagulation therapy, intravitreal corticosteroids, intravitreal anti-vascular endothelial growth factor (VEGF) agents and vitreo-retinal surgery which are costly, highly invasive, unproven for prolonged use and opted in advanced stages of DR. By then retina already encounters a vast damage. Nutrients by their natural physiological, biochemical and molecular action can preserve retinal structure and functions by interfering with the various pathological steps prompting DR incidence, thereby altering the risk of developing this ocular morbidity. Nutrients can also play a central role in DR patients resistant towards the conventional medical treatments. However due to the byzantine interplay existing between nutrients and DR, the worth of nutrition in curbing this vision-threatening ocular morbidity remains silent. This review highlights how nutrients can halt DR development. A nutritional therapy, if adopted in the initial stages, can provide superior-efficacy over the current treatment modalities and can be a complementary, inexpensive, readily available, anodyne option to the clinically unmet requirement for preventing DR. Assessment of nutritional status is presently considered relevant in various clinical conditions except DR. Body Mass Index (BMI) conferred inconclusive results in DR subjects. Subjective Global Assessment (SGA) of nutritional status has recently furnished relevant association with DR status. By integrating nutritional strategies, the risk of developing DR can be reduced substantially. This review summarizes the subsisting knowledge on nutrition, potentially beneficial for preventing DR and sustaining good vision among diabetic subjects.

Nutrition in Type 2 Diabetes and the Metabolic Syndrome

For individuals at risk for type 2 diabetes mellitus or the metabolic syndrome, adherence to an idealized dietary pattern can drastically alter the risk and course of these chronic conditions. Target levels of carbohydrate intake should approximate 30% of consumed calories. Healthy food choices should include copious fruits, vegetables, and nuts while minimizing foods with high glycemic indices, especially processed foods.

Association of low oleic acid intake with diabetic retinopathy in type 2 diabetic patients: a case-control study

BACKGROUND

The objective of this study was to describe the intake of macronutrient, especially fatty acids, and explore their possible effect on diabetic retinopathy (DR) in patients with type 2 diabetes mellitus.

METHODS

In this case-control study, we included a total of 146 patients with DR and 148 without DR. The intake of macronutrient was evaluated using a validated food frequency questionnaire. We used logistic regression adjusted for sex, age, diabetes duration, energy intake, educational level, physical activity, waist circumference, systolic blood pressure, high-density lipoprotein cholesterol and diabetes treatment, to estimate odds ratio (ORs) of DR.

RESULTS

Patients with DR had significantly lower intake of fibre, monounsaturated fatty acids (MUFA), and palmitic and oleic acid. Inverse associations were observed between MUFA and oleic acid intake in DR. Subjects with intermediate and high MUFA intake were less likely to have DR than those with lower MUFA intake, with ORs of 0.46 (95 % CI: 0.22-0.93) and 0.42 (95 % CI: 0.18-0.97), respectively. Similarly, intermediate and high oleic acid intake were associated with reduced DR frequency compared with low oleic acid intake, with OR values of 0.48 (95 % CI: 0.23-0.97) and 0.37 (95 % CI: 0.16-0.85), respectively. These associations were stronger in patients with a longer diabetes duration.

CONCLUSION

In type 2 diabetes mellitus, MUFA and oleic acid intake were inversely associated with DR.

Fiber in Diet Is Associated with Improvement of Glycated Hemoglobin and Lipid Profile in Mexican Patients with Type 2 Diabetes

Objective. To assess the association of dietary fiber on current everyday diet and other dietary components with glycated hemoglobin levels (HbA1c), glucose, lipids profile, and body weight body weight, in patients with type 2 diabetes. Methods. A cross-sectional survey of 395 patients with type 2 diabetes was performed. HbA1c, fasting glucose, triglycerides, and lipids profile were measured. Weight, waist circumference, blood pressure, and body composition were measured. Everyday diet with a semiquantitative food frequency questionnaire was evaluated. ANOVA, Kruskal-Wallis, chi-square tests and multivariate logistic regression were used in statistical analysis. Results. Higher fiber intake was associated with a low HbA1c, high HDL-c levels, low weight, and waist circumference. The highest tertile of calories consumption was associated with a higher fasting glucose level and weight. The highest tertile of carbohydrate consumption was associated with a lower weight. The lowest tertile of total fat and saturated fat was associated with the highest tertile of HDL-c levels, and lower saturated fat intake was associated with lower weight (p < 0.05). Conclusions. A higher content of fiber in the diet reduces HbA1c and triglycerides, while improving HDL-c levels. Increasing fiber consumption while lowering calorie consumption seems to be an appropriate strategy to reduce body weight and promote blood glucose control.

Mediterranean Diet, Retinopathy, Nephropathy, and Microvascular Diabetes Complications: A Post Hoc Analysis of a Randomized Trial

OBJECTIVE

To date no clinical trials have evaluated the role of dietary patterns on the incidence of microvascular diabetes complications. We hypothesized that a nutritional intervention based on the Mediterranean diet (MedDiet) would have greater protective effect on diabetic retinopathy and nephropathy than a low-fat control diet.

RESEARCH DESIGN AND METHODS

This was a post hoc analysis of a cohort of patients with type 2 diabetes participating in the PREvención con DIeta MEDiterránea (PREDIMED) study, a multicenter randomized nutritional intervention trial conducted in a population at high cardiovascular risk. Individuals with type 2 diabetes who were free of microvascular complications at enrollment (n = 3,614, aged 55-80 years) were randomly assigned to one of three dietary interventions: MedDiet supplemented with extravirgin olive oil (MedDiet+EVOO), MedDiet supplemented with mixed nuts (MedDiet+Nuts), or a low-fat control diet. Two independent outcomes were considered: new onset of diabetic retinopathy and nephropathy. Hazard ratios (HRs) were calculated using multivariable-adjusted Cox regression.

RESULTS

During a median follow-up of 6.0 years, we identified 74 new cases of retinopathy and 168 of nephropathy. Compared with the control diet, multivariable-adjusted HRs for diabetic retinopathy were 0.56 (95% CI 0.32-0.97) for the MedDiet+EVOO and 0.63 (0.35-1.11) for the MedDiet+Nuts. No between-group differences were found for nephropathy. When the yearly updated information on adherence to the MedDiet was considered, the HR for retinopathy in the highest versus the lowest quintile was 0.34 (0.13-0.89; P = 0.001 for trend). No significant associations were found for nephropathy.

CONCLUSIONS

A MedDiet enriched with EVOO may protect against diabetic retinopathy but not diabetic nephropathy.

Relationship between dietary pattern and cognitive function in elderly patients with type 2 diabetes mellitus

OBJECTIVE

To analyse the relationships between dietary patterns and cognitive function in elderly patients with type 2 diabetes mellitus (T2DM).

METHODS

Patients with T2DM completed a 3-day dietary record and Mini-mental State Examination (MMSE). Dietary patterns were identified by factor analysis.

RESULTS

The study included 73 patients and identified five dietary patterns, one of which was characterized by high loading for vegetables and fish. A higher consumption of vegetables and fish was significantly associated with improved MMSE score (unadjusted model, model adjusted for age and sex, and model adjusted for age, sex, education, diabetic nephropathy and alcohol consumption), and decreased prevalence of suspected mild dementia (unadjusted model, model adjusted for age and sex).

CONCLUSIONS

A high score in the vegetables and fish dietary pattern was associated with high MMSE score and low prevalence of suspected mild dementia in elderly patients with T2DM.

Current concepts in diabetic retinopathy

For the past several decades, tremendous efforts have been made to decrease the complications of diabetes, including diabetic retinopathy. New diagnostic modalities like ultrawide field fundus fluorescein angiography and spectral domain optical coherence tomography has allowed more accurate diagnosis of early diabetic retinopathy and diabetic macular edema. Antivascular endothelial growth factors are now extensively used to treat diabetic retinopathy and macular edema with promising results. There remains uncertainty over the long term effects and the socioeconomic costs of these agents.

Dietary stimulators of GLUT4 expression and translocation in skeletal muscle: a mini-review

Chronic insulin resistance can lead to type II diabetes mellitus, which is also directly influenced by an individual's genetics as well as their lifestyle. Under normal circumstances, insulin facilitates glucose uptake in skeletal muscle and adipose tissue by stimulating glucose transporter 4 (GLUT4) translocation and activity. GLUT4 activity is directly correlated with the ability to clear elevated blood glucose and insulin sensitivity. In diabetes, energy excess and prolonged hyperinsulinemia suppress muscle and adipose response to insulin, in part through reduced GLUT4 membrane levels. This work uniquely describes much of the experimental data demonstrating the effects of various dietary components on GLUT4 expression and translocation in skeletal muscle. These observations implicate several individual dietary chemicals as potential adjuvant therapies in the maintenance of diabetes and insulin resistance.

Functional foods-based diet as a novel dietary approach for management of type 2 diabetes and its complications: A review

Type 2 diabetes is a complicated metabolic disorder with both short- and long-term undesirable complications. In recent years, there has been growing evidence that functional foods and their bioactive compounds, due to their biological properties, may be used as complementary treatment for type 2 diabetes mellitus. In this review, we have highlighted various functional foods as missing part of medical nutrition therapy in diabetic patients. Several in vitro, animal models and some human studies, have demonstrated that functional foods and nutraceuticals may improve postprandial hyperglycemia and adipose tissue metabolism modulate carbohydrate and lipid metabolism. Functional foods may also improve dyslipidemia and insulin resistance, and attenuate oxidative stress and inflammatory processes and subsequently could prevent the development of long-term diabetes complications including cardiovascular disease, neuropathy, nephropathy and retinopathy. In conclusion available data indicate that a functional foods-based diet may be a novel and comprehensive dietary approach for management of type 2 diabetes.