Improving the scientific rigour of nutritional recommendations for adults with type 2 diabetes: A comprehensive review of the American Diabetes Association guideline-recommended eating patterns

Psychometrics properties of type 2 diabetes treatment adherence questionnaire (DTAQ): a study based on Pender's health promotion model

BACKGROUND

Management of type 2 diabetes (T2D) as a chronic disease requires treatment adherence such as controlling the blood glucose level and adopting a healthy lifestyle. The present study aimed to develop and psychometrically evaluate a questionnaire based on the Pender's Health Promotion Model (HPM) to measure treatment adherence and the associated factors among T2D patients.

METHODS

The present study was conducted in qualitative and the quantitative phases between March 2022 and March 2023. The participants were T2D patients visiting Shahid Mohammadi hospital Diabetes Clinic in Bandar Abbas in the south of Iran. The first draft of items was extracted from the qualitative phase. The present study used interviews with T2D patients, item construction, validity and reliability evaluation of the instrument, and the relevant statistical analyses. It emphasized the significance of content, face, and construct validity, along with reliability testing using Cronbach's alpha and test-retest method. Data were analyzed using SPSS software, V16 and AMOS, V23.

RESULTS

A 97-item questionnaire was developed through the qualitative phase and, after content validity, it was reduced to 86 items. Five items were removed in face validation, and after the test-retest method, 79 items were retained. The confirmatory factors analysis confirmed a 65-item model with appropriate fitness of data. Cronbach's alpha coefficient showed an acceptable reliability of the diabetes treatment adherence questionnaire (α = 0.92).

CONCLUSION

The questionnaire developed based on the HPM model provides a standard and comprehensive measurement of the degree of adherence to treatment and the associated factors among Iranian T2D patients. This is especially valuable in the Iranian healthcare context, where effective management of chronic diseases such as diabetes is of a top priority. Questionnaires can help identify barriers and facilitators of treatment adherence to inform systematic and goal-oriented interventions. The proposed questionnaire had good psychometric properties, and can be used as a valid and practical instrument to measure the factors related to treatment adherence behaviors.

Determinants of Adherence to Treatment in Type 2 Diabetic Patients: A Directed Qualitative Content Analysis Based on Pender's Health Promotion Model

Adherence to the treatment of type 2 diabetes (T2D), which includes the use of prescribed drugs, following a healthy diet, and adopting a physically active lifestyle, is important to control the disease and improve the patients' quality of life. The present study aimed to explain the determinants of adherence to treatment in patients with T2D based on Pender's Health Promotion Model (HPM). The present research used a qualitative content analysis and was based on Pender's HPM. The data were collected through in-depth semi-structured interviews with 20 T2D patients using a purposive sampling in Bandar Abbas, southern Iran. Maximum variation was considered in terms of gender, age, history of diabetes, type of drug used, education, and occupation. The data collection continued until data saturation. At the same time, the collected data were analyzed using the directed content analysis. MAXQDA 10 was used to manage codes and facilitate data analysis. The data analysis led to the extraction of 10 categories and 19 subcategories as the determinants of adherence to the treatment of T2D patients. The participants shared their experiences about personal characteristics and their ecological environment, specific cognition and emotions, and the behavioral results and experience as the determinants of adherence to T2D treatment. The categories extracted from this study in the form of HPM constructs provided a framework to explain treatment adherence. This information can help policy makers and planners in designing future programs.

Effects of a low carbohydrate diet on heart failure symptoms and quality of life in patients with diabetic cardiomyopathy: A randomised controlled trial pilot study

BACKGROUND AND AIMS

Heart failure, insulin resistance and/or type 2 diabetes mellitus coexist in the syndrome that is diabetic cardiomyopathy. Patients with diabetic cardiomyopathy experience high symptom burden and poor quality of life. We tested the hypothesis that a low carbohydrate diet improves heart failure symptoms and quality of life in patients with diabetic cardiomyopathy.

METHODS AND RESULTS

We conducted a 16-week randomised controlled pilot trial comparing the effects of a low carbohydrate diet (LC) to usual care (UC) in 17 adult patients with diabetic cardiomyopathy. New York Heart Association classification, weight, thirst distress and quality of life scores as well as blood pressure and biochemical data were assessed at baseline and at 16 weeks. Thirteen (n = 8 LC; n = 5 UC) patients completed the trial. The low carbohydrate diet induced significant weight loss in completers (p = 0.004). There was a large between-group difference in systolic blood pressure at the end of the study (Hedges's g 0.99[-014,2.08]). There were no significant differences in thirst or quality of life between groups.

CONCLUSION

This is the first clinical trial utilising the low carbohydrate dietary approach in patients with diabetic cardiomyopathy in an outpatient setting. A low carbohydrate diet can lead to significant weight loss in patients with diabetic cardiomyopathy. Future clinical trials with larger samples and that focus on fluid and sodium requirements of patients with diabetic cardiomyopathy who engage in a low carbohydrate diet are warranted.

CLINICAL TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry (ANZCTR): ACTRN12620001278921.

DATE OF REGISTRATION

26th November 2020.

Sex-biased gene expression in nutrient-sensing pathways

Differences in lifespan between males and females are found across many taxa and may be determined, at least in part, by differential responses to diet. Here we tested the hypothesis that the higher dietary sensitivity of female lifespan is mediated by higher and more dynamic expression in nutrient-sensing pathways in females. We first reanalysed existing RNA-seq data, focusing on 17 nutrient-sensing genes with reported lifespan effects. This revealed, consistent with the hypothesis, a dominant pattern of female-biased gene expression, and among sex-biased genes there tended to be a loss of female-bias after mating. We then tested directly the expression of these 17 nutrient-sensing genes in wild-type third instar larvae, once-mated 5- and 16-day-old adults. This confirmed sex-biased gene expression and showed that it was generally absent in larvae, but frequent and stable in adults. Overall, the findings suggest a proximate explanation for the sensitivity of female lifespan to dietary manipulations. We suggest that the contrasting selective pressures to which males and females are subject create differing nutritional demands and requirements, resulting in sex differences in lifespan. This underscores the potential importance of the health impacts of sex-specific dietary responses.

Clinical Evidence of Low-Carbohydrate Diets against Obesity and Diabetes Mellitus

The popularity of low-carbohydrate diets (LCDs) in the last few decades has motivated several research studies on their role in a variety of metabolic and non-morbid conditions. The available data of the results of these studies are put under the research perspective of the present literature review of clinical studies in search of the effects of LCDs on Obesity and Diabetes Mellitus. The electronic literature search was performed in the databases PubMed, Cochrane, and Embase. The literature search found seven studies that met the review's inclusion and exclusion criteria out of a total of 2637 studies. The included studies involved randomized controlled trials of at least 12 weeks' duration, in subjects with BMI ≥ 25 kg/m², with dietary interventions. The results of the study on the effects of LCDs on obesity showed their effectiveness in reducing Body Mass Index and total body fat mass. In addition, LCDs appear to cause drops in blood pressure, low-density lipoprotein (LDL), and triglycerides, and seem to improve high-density lipoprotein (HDL) values. Regarding the effectiveness of LCDs in Diabetes Mellitus, their effect on reducing insulin resistance and fasting blood glucose and HbA1c values are supported. In conclusion, the results suggest the critical role of LCDs to improve the health of people affected by obesity or diabetes.

The potential role of plantains, moringa, plantain-moringa combined diets, and other plant-based dietary patterns in controlling glycaemia among T2DM persons, a hospital based cross sectional survey in Ghana

BACKGROUND

Diabetes mellitus (DM) is an independent risk-factor for cardiovascular diseases. Plant-based dietary-patterns have been shown to reverse the effects of these cardiovascular risk-factors. Our study therefore aimed to investigate the potential roles moringa, moringa-plantain combined, and other plant based dietary-patterns could play in controlling glycaemia among persons with type-2-diabetes Mellitus (T2DM).

METHODS

Facility-based cross-sectional-study was conducted among 530 T2DM patients from August 2018 to September 2019 in Ghana. Structured-questionnaires were used to collect demographic, anthropometric, and clinical variables. Adherence to plant-based dietary-patterns were assessed using 3-day food record. SPSS version-20 was used to analyse the data.

RESULTS

BMI, HbA1c%, HDL-cholesterol and LDL-cholesterol were significantly correlated with adherence to plant-based dietary-patterns (p-value < 0.05). After adjusting for physical activity, adherence to plantain diets Standardized regression coefficient β (95%CI): -0.098 (-0.321, -0.022), yam β (95%CI): 0.148 (0.066, 0.496), moringa diets β (95%CI): -0.095 (-0.325,-0.011) and bean-diets β (95%CI): -0.112 (-0.577, -0.007) were significantly associated with glycemic control. Adherence to plantain-moriga combined diets β (95%CI): -0.406 (-0.413, -0.049) and plantain-beans combined diets β (95%CI): -0.128 (-0.188, -0.038) were also significantly associated with glycemic control.

CONCLUSION

Adherence to plantain, yam, beans, plantain-moriga combined diets, and plantain-beans combined diets could be associated with glycemic-control. Health care workers should prioritize these plant-based dietary-patterns for disease prevention and health promotion.

Periodontitis and diabetes mellitus co-morbidity: A molecular dialogue

BACKGROUND

Type 2 diabetes mellitus (T2DM) and periodontitis are two biologically linked diseases that often coexist in complex interaction. While periodontitis may lead to insulin receptor desensitization, diabetes may increase the expression of inflammatory cytokines, such as Tumor Necrosis Factor-α (TNF-α) and Interleukin 6 (IL-6), in the gingival crevicular fluid and activate osteoclasts via Receptor activator of nuclear factor kappa-Β ligand (RANK-L) production, leading to bone resorption. However, the association between the two diseases processes, where one may exacerbate the progression of the other, is unclear. In addition, both diseases have similar mechanistic themes, such as chronic inflammation and oxidative stress. This review aimed to investigate the pathophysiological and molecular mechanisms underlying T2DM and periodontitis.

HIGHLIGHT

Uncontrolled diabetes is often associated with severe periodontitis, measured by clinical attachment loss. Alteration in the oral microbiome composition, which may activate the host inflammatory response and lead to irreversible oxidative stress, is a common finding in both diseases. An understanding of the molecular crosstalk between the two disease processes is crucial for developing therapeutic targets that inhibit bone resorption and halt the progression of periodontitis in patients with diabetes.

CONCLUSION

The Oral microbiome composition in T2DM and periodontitis shifts toward dysbiosis, favoring bacterial pathogens, such as Fusobacteria and Porphyromonas species. Both conditions are marked by pro-inflammatory immune activity via the activation of Interleukin 17 (IL-17), Interleukin 1 (IL-1), TNF-α, and Nuclear Factor Kappa Beta (NF-κB). Common molecular crosstalk signaling appears to involve advanced glycation end products (AGEs) and oxidative stress. Thus, future drug targets are multifactorial, ranging from modulatory of host inflammatory response to preventing the accumulation of AGEs and oxidative free radicals.

Executive summary: Updates to the dietary treatment of prediabetes and type 2 diabetes mellitus

Adequate lifestyle changes significantly reduce the cardiovascular risk factors associated with prediabetes and type 2 diabetes mellitus. Therefore, healthy eating habits, regular physical activity, abstaining from using tobacco, and good sleep hygiene are recommended for managing these conditions. There is solid evidence that diets that are plant-based; low in saturated fatty acids, cholesterol, and sodium; and high in fiber, potassium, and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects. In view of the foregoing, the Mediterranean diet, the DASH diet, a low-carbohydrate diet, and a vegan-vegetarian diet are of note. Additionally, the relationship between nutrition and these metabolic pathologies is fundamental in targeting efforts to prevent weight gain, reducing excess weight in the case of individuals with overweight or obesity, and personalizing treatment to promote patient empowerment. This document is the executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in people with prediabetes or type 2 diabetes mellitus. The full review is available on the webpages of the Spanish Society of Arteriosclerosis, the Spanish Diabetes Society, and the Spanish Society of Internal Medicine.

Effect of a Free-Living Ketogenic Diet on Feasibility, Satiety, Body Composition, and Metabolic Health in Women: The Grading Level of Optimal Carbohydrate for Women (GLOW) Study

OBJECTIVE

The study's purpose was to examine a free-living, ketogenic diet (WFKD) on feasibility, satiety, body composition, and metabolic health in women.

METHODS

Twenty-two women (age (yr.) 42.2 ± 8.1, Ht. (cm) 164.2 ± 5.9, BMI 27.3 ± 6.0) participated in a 21-day, free-living dietary intervention. Daily ketone measurements and satiety/craving surveys, weekly diet records, and PRE and POST assessments of anthropometrics, body composition, blood pressure, and fasted capillary-blood glucose (BG) and cholesterol panels were collected.

RESULTS

Women maintained calories (PRE: 1938 kcal vs POST: 1836 kcal) and protein (PRE: 17% vs POST: 20%) but decreased carbohydrate (PRE: 36% vs POST: 13%) and increased fat (PRE: 45% vs POST: 65%) PRE to POST (p ≤ 0.05). Daily self-reports suggested no changes in satiety or food cravings between PRE, WK 1, WK 2, and WK 3. Ketones increased (PRE 0.3 ± 0.2 mmol vs POST 0.8 ± 0.6 mmol) PRE to POST with significant differences between PRE and all other time points (p ≤ 0.05). Bodyweight (PRE: 73.9 kg vs POST: 72.3 kg) and body fat (PRE: 28.9 ± 13.4 kg vs POST 27. 4 ± 13.5 kg) decreased but there were no differences in fat-free mass PRE to POST (p ≤ 0.05). Systolic blood pressure decreased (PRE: 119.2 ± 8.9 mmHg vs POST: 109.5 ± 10.9 mmHg), diastolic blood pressure increased (PRE: 74.1 ± 7.5 mmHg vs POST: 78.8 ± 7.4 mmHg), and BG improved (94.0 ± 8.3 mg/dL vs POST 89.9 ± 9.0 mg/dL) PRE to POST (p ≤ 0.05). No differences were observed in total cholesterol (TC), high-density lipoprotein (HDL), and triglycerides (TG) but TC/HDL decreased and low-density lipoprotein increased PRE to POST (p ≤ 0.05).

CONCLUSION

Women were able to maintain calories, improve body composition, blood pressure, and BG, increase ketones, and improve some but not all cholesterol markers after 21 days on a free-living WFKD.

Executive summary: Updates to the dietary treatment of prediabetes and type 2 diabetes mellitus

Adequate lifestyle changes significantly reduce the cardiovascular risk factors associated with prediabetes and type 2 diabetes mellitus. Therefore, healthy eating habits, regular physical activity, abstaining from using tobacco, and good sleep hygiene are recommended for managing these conditions. There is solid evidence that diets that are plant-based; low in saturated fatty acids, cholesterol, and sodium; and high in fiber, potassium, and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects. In view of the foregoing, the Mediterranean diet, the DASH diet, a low-carbohydrate diet, and a vegan-vegetarian diet are of note. Additionally, the relationship between nutrition and these metabolic pathologies is fundamental in targeting efforts to prevent weight gain, reducing excess weight in the case of individuals with overweight or obesity, and personalizing treatment to promote patient empowerment. This document is the executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in people with prediabetes or type 2 diabetes mellitus. The full review is available on the webpages of the Spanish Society of Arteriosclerosis, the Spanish Diabetes Society, and the Spanish Society of Internal Medicine.

Executive summary: Updates to the dietary treatment of prediabetes and type 2 diabetes mellitus

Adequate lifestyle changes significantly reduce the cardiovascular risk factors associated with prediabetes and type 2 diabetes mellitus. Therefore, healthy eating habits, regular physical activity, abstaining from using tobacco, and good sleep hygiene are recommended for managing these conditions. There is solid evidence that diets that are plant-based; low in saturated fatty acids, cholesterol, and sodium; and high in fiber, potassium, and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects. In view of the foregoing, the Mediterranean diet, the DASH diet, a low-carbohydrate diet, and a vegan-vegetarian diet are of note. Additionally, the relationship between nutrition and these metabolic pathologies is fundamental in targeting efforts to prevent weight gain, reducing excess weight in the case of individuals with overweight or obesity, and personalizing treatment to promote patient empowerment. This document is the executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in people with prediabetes or type 2 diabetes mellitus. The full review is available on the webpages of the Spanish Society of Arteriosclerosis, the Spanish Diabetes Society, and the Spanish Society of Internal Medicine.

Executive summary: Updates to the dietary treatment of prediabetes and type 2 diabetes mellitus

Adequate lifestyle changes significantly reduce the cardiovascular risk factors associated with prediabetes and type 2 diabetes mellitus. Therefore, healthy eating habits, regular physical activity, abstaining from using tobacco, and good sleep hygiene are recommended for managing these conditions. There is solid evidence that diets that are plant-based; low in saturated fatty acids, cholesterol, and sodium; and high in fiber, potassium, and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects. In view of the foregoing, the Mediterranean diet, the DASH diet, a low-carbohydrate diet, and a vegan-vegetarian diet are of note. Additionally, the relationship between nutrition and these metabolic pathologies is fundamental in targeting efforts to prevent weight gain, reducing excess weight in the case of individuals with overweight or obesity, and personalizing treatment to promote patient empowerment. This document is the executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in people with prediabetes or type 2 diabetes mellitus. The full review is available on the webpages of the Spanish Society of Arteriosclerosis, the Spanish Diabetes Society, and the Spanish Society of Internal Medicine.

Executive summary: Updates to the dietary treatment of prediabetes and type 2 diabetes mellitus

Adequate lifestyle changes significantly reduce the cardiovascular risk factors associated with prediabetes and type 2 diabetes mellitus. Therefore, healthy eating habits, regular physical activity, abstaining from using tobacco, and good sleep hygiene are recommended for managing these conditions. There is solid evidence that diets that are plant-based; low in saturated fatty acids, cholesterol, and sodium; and high in fiber, potassium, and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects. In view of the foregoing, the Mediterranean diet, the DASH diet, a low-carbohydrate diet, and a vegan-vegetarian diet are of note. Additionally, the relationship between nutrition and these metabolic pathologies is fundamental in targeting efforts to prevent weight gain, reducing excess weight in the case of individuals with overweight or obesity; and personalizing treatment to promote patient empowerment. This document is the executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in people with prediabetes or type 2 diabetes mellitus. The full review is available on the webpages of the Spanish Society of Arteriosclerosis (SEA, for its initials in Spanish), the Spanish Diabetes Society (SED, for its initials in Spanish), and the Spanish Society of Internal Medicine (SEMI, for its initials in Spanish).

Current Evidence Regarding Low-carb Diets for The Metabolic Control of Type-2 Diabetes

The management of diabetes requires a medical nutrition therapy as an essential part of this treatment. There should be no "one-size-fits-all" eating pattern for different patient´s profiles with diabetes. It is clinically complex to suggest an ideal percentage of calories from carbohydrates, protein and lipids recommended for all patients with diabetes. Among the eating patterns that have shown beneficial effects on metabolic control of patients with type 2 diabetes is the lowcarb diet, since the carbohydrate ingestion is viewed as the most important determinant of postprandial glucose and insulin response. In this context, theoretically, it could make sense to reduce the daily amount of carbohydrates ingested, to achieve lower levels of HbA1c. There could be risks associated to this approach. The adherence to a low-carb diet is here also discussed. This narrative review shows on the current evidence for answering these questions regarding low-carb diet as a possible alternative eating pattern for type 2 diabetes.

Scutellarin Reduce the Homocysteine Level and Alleviate Liver Injury in Type 2 Diabetes Model

Scutellarin (SCU) is an active ingredient extracted from Erigeron breviscapus (Vaniot) Hand.-Mazz. Its main physiological functions are anti-inflammatory and antioxidant. In this study, we established a STZ-induced model of type 2 diabetes (T2DM) and a homocysteine (Hcy)-induced apoptosis model of LO2 to investigate whether SCU can alleviate liver damage by regulating Hcy in type 2 diabetes. Biochemical analysis indicated that SCU could improve the lipid metabolism disorder and liver function in diabetic rats by downregulating the levels of triglycerides (TG), cholesterol (CHO), low-density lipoprotein (LDL), alanine transaminase (ALT) and aspartate transaminase (AST), and by upregulating the level of high-density lipoprotein (HDL). Interestingly, SCU also could down-regulate the levels of Hcy and insulin and enhance the ability of type 2 diabetic rats to regulate blood glucose. Mechanistically, our results indicated that SCU may control the level of Hcy through regulating the levels of β-Cystathionase (CBS), γ-Cystathionase (CSE) and 5,10-methylenetetrahydrofolate (MTHFR) in liver tissue, and up-regulate folic acid, VitB₆ and VitB₁₂ levels in serum. Furthermore, SCU inhibits apoptosis in the liver of T2DM rats and in cultured LO2 cells treated with Hcy. Together, our findings suggest that SCU may alleviate the liver injury thorough downregulating the level of Hcy in T2DM rats.

Impact of a 2-year trial of nutritional ketosis on indices of cardiovascular disease risk in patients with type 2 diabetes

BACKGROUND

We have previously reported that in patients with type 2 diabetes (T2D) consumption of a very low carbohydrate diet capable of inducing nutritional ketosis over 2 years (continuous care intervention, CCI) resulted in improved body weight, glycemic control, and multiple risk factors for cardiovascular disease (CVD) with the exception of an increase in low density lipoprotein cholesterol (LDL-C). In the present study, we report the impact of this intervention on markers of risk for atherosclerotic cardiovascular disease (CVD), with a focus on lipoprotein subfraction particle concentrations as well as carotid-artery intima-media thickness (CIMT).

METHODS

Analyses were performed in patients with T2D who completed 2 years of this study (CCI; n = 194; usual care (UC): n = 68). Lipoprotein subfraction particle concentrations were measured by ion mobility at baseline, 1, and 2 years and CIMT was measured at baseline and 2 years. Principal component analysis (PCA) was used to assess changes in independent clusters of lipoprotein particles.

RESULTS

At 2 years, CCI resulted in a 23% decrease of small LDL IIIb and a 29% increase of large LDL I with no change in total LDL particle concentration or ApoB. The change in proportion of smaller and larger LDL was reflected by reversal of the small LDL subclass phenotype B in a high proportion of CCI participants (48.1%) and a shift in the principal component (PC) representing the atherogenic lipoprotein phenotype characteristic of T2D from a major to a secondary component of the total variance. The increase in LDL-C in the CCI group was mainly attributed to larger cholesterol-enriched LDL particles. CIMT showed no change in either the CCI or UC group.

CONCLUSION

Consumption of a very low carbohydrate diet with nutritional ketosis for 2 years in patients with type 2 diabetes lowered levels of small LDL particles that are commonly increased in diabetic dyslipidemia and are a marker for heightened CVD risk. A corresponding increase in concentrations of larger LDL particles was responsible for higher levels of plasma LDL-C. The lack of increase in total LDL particles, ApoB, and in progression of CIMT, provide supporting evidence that this dietary intervention did not adversely affect risk of CVD.

The Efficacy of an Energy-Restricted Anti-Inflammatory Diet for the Management of Obesity in Younger Adults

There is growing evidence of the dietary impact on obesity-induced low-grade chronic inflammation and the associated chronic non-communicable diseases modification. We determined changes in body composition and cardiometabolic and inflammatory status of participants with obesity after 24 weeks of a dietary intervention based on an energy-reduced anti-inflammatory diet and examined the relationship of these changes with changes in the inflammatory potential of the diet. The anthropometric and body composition parameters of 81 participants (average age of 43 years, 74 women) were assessed. Metabolic status was determined using the glycemic and lipid statuses, and the cardiometabolic index and inflammatory status were determined using the concentration of high-sensitivity C-reactive protein (hs-CRP), interleukin 6 (IL-6), and tumor necrosis factor α (TNF-α). The inflammatory potential of the diet was assessed using the Dietary Inflammatory Index (DII^®). Intervention with an anti-inflammatory diet resulted in a significant reduction in body weight and visceral adipose tissue and caused improvements in the participants’ cardiometabolic and inflammatory statuses. The anti-inflammatory diet was shown to be effective regarding obesity management. The study data could advance current scientific knowledge in the field of inflammation and diet, provide guidelines for obesity management, and find its application in routine clinical practice.

A novel risk assessment model of contrast-induced nephropathy after percutaneous coronary intervention in patients with diabetes

The purpose of our study was to develop a simple clinical pre-procedure risk model based on clinical characteristics for the prediction of contrast-induced nephropathy (CIN) and major adverse cardiac events (MACEs) after percutaneous coronary intervention (PCI) in patients with diabetes. A total of 1113 patients with diabetes who underwent PCI with contrast exposure were randomized into a development group (n = 742) and a validation group (n = 371) in a 2:1 ratio. CIN was defined as an increase of either 25% or 0.5 mg/dL (44.2 μmol/L) in serum creatinine within 72 hours after contrast infusion. A simple CIN risk score based on independent predictors was established. Four variables were identified for our risk score model: LVEF < 40%, acute coronary syndrome (ACS), eGFR < 60, and contrast volume > 300 mL. Based on this new CIN risk score, the incidence of CIN had a significant trend with increased predicting score values of 5.9%, 32.9% and 60.0%, corresponding to low-, moderate- and high-risk groups, respectively. The novel risk assessment exhibited moderate discrimination ability for predicting CIN, with an AUC of 0.759 [95% CI 0.668-0.852, P = .001] in the validation cohort. It also had similar prognostic values for one-year follow-up MACE (C-statistic: 0.705 and 0.606 for new risk score and Mehran score, respectively). This novel risk prediction model could be effective for preventing nephropathy in diabetic patients receiving contrast media during surgical procedures.

The biochemistry of low-carbohydrate and ketogenic diets

PURPOSE OF REVIEW

To summarize the underlying biochemical basis for low-carbohydrate and ketogenic diets (LC/KD) and provide mechanisms to account for demonstrated effectiveness.

RECENT FINDINGS

LC/KD continue to have success, to outperform other diets as well as most drugs for weight loss and diabetes treatment. In many cases, LC/KD can effect remission (absence of drugs) or reversal (only metformin or nondiabetes drugs) of type 2 diabetes and can provide a significant adjunct to pharmacology in type 1. Medication is reduced or eliminated in most cases. The results are consistent with the biochemical rationale which stresses the global effects of the glucose-insulin axis.

SUMMARY

Evidence for the superior effectiveness of LC/KD for metabolic disease is now overwhelming. At the same time, the approach has received only limited support, and in many cases, persistence of the traditional opposition. Clinical practice or research must confront this crisis in order to bring practice in line with current science and to avoid continued harm to medicine and ultimately, the patient.

Low-Carbohydrate Diets in the Management of Obesity and Type 2 Diabetes: A Review from Clinicians Using the Approach in Practice

Low-carbohydrate diets are increasingly used to help patients with obesity and type 2 diabetes. We sought to provide an overview of the evidence for this treatment approach, considering the epidemiology and pathophysiology of obesity and diabetes in terms of carbohydrate excess. We describe the mechanistic basis for the clinical benefits associated with nutritional ketosis and identify areas of practice where the evidence base could be improved. We summarize the key principles which inform our approach to treating patients with low-carbohydrate diets. The scientific controversy relating to these diets is real but is consistent with the known challenges of any dietary interventions and also the limitations of nutritional epidemiology. Secondly, notwithstanding any controversy, international guidelines now recognize the validity and endorse the use of these diets as a therapeutic nutritional approach, in appropriate patients. Thirdly, we have found that early de-prescription of diabetes medications is essential, in particular insulin, sulphonylureas, and sodium-glucose cotransporter (SGLT2) inhibitors. Fourthly, we encourage patients to eat ad libitum to satiety, rather than calorie counting per se. Furthermore, we monitor cardiovascular risk factors frequently, as with all patients with obesity or diabetes, but we do not necessarily consider an increase in low-density lipoprotein (LDL)-cholesterol as an absolute indication to stop these diets, as this is usually related to large LDL particles, which are not associated with increased cardiovascular risk. In the absence of large randomized controlled trials with cardiovascular and other hard endpoints, adopting a low-carbohydrate diet is a legitimate and potentially effective treatment option for patients with diabetes or obesity.

Optimal Dietary Strategies for Prevention of Atherosclerotic Cardiovascular Disease in Diabetes: Evidence and Recommendations

PURPOSE OF REVIEW

This review presents the current available evidence of the effects of several dietary patterns on atherosclerotic cardiovascular disease (ASCVD) risk in patients with type 2 diabetes (T2D).

RECENT FINDINGS

Evidence demonstrates improvements in cardiovascular risk factors with some dietary patterns in the general population. However, evidence is limited for glycemic control and cardiovascular benefit in patients with T2D for Dietary Approaches to Stop Hypertension and plant-based dietary patterns. Evidence suggests that carbohydrate-restricted dietary patterns improve glycemic control and decrease the use of anti-hyperglycemic medications. The Mediterranean dietary pattern has the most evidence for glycemic control and decreased ASCVD risk in patients with T2D. There is no evidence on ASCVD outcomes in patients with T2D for any other dietary pattern. The Mediterranean dietary pattern has the most evidence for cardiovascular benefit in patients with T2D. Future research should examine the effect of dietary patterns on ASCVD outcomes.

Improving the scientific rigour of nutritional recommendations for adults with type 2 diabetes: A comprehensive review of the American Diabetes Association guideline-recommended eating patterns

AIMS

The global rate of type 2 diabetes (T2D) continues to rise. Guidelines that influence the worldwide treatment of this disease are central to changing this trajectory. We sought in this review to evaluate the appropriateness of sources cited in the American Diabetes Association's (ADA) guidelines on eating patterns for T2D management, identify additional relevant sources, and evaluate the evidence.

MATERIALS AND METHODS

We reviewed the evidence behind the ADA's recommendations on eating patterns in the 2018 and 2019 ADA Standards of Care and the 2014 ADA Nutrition Therapy Recommendations for Adults with Diabetes. Additionally, we conducted a comprehensive search to identify any additional studies not included in the cited evidence. To determine appropriateness of inclusion in the guidelines, the following criteria were applied: 1) it was a clinical trial or systematic review/meta-analysis of clinical trials; 2) it involved persons with T2D; 3) one of the study arms followed one of the eating patterns currently recommended; 4) its reported outcomes included glycaemic control; 5) outcomes were reported separately for persons with T2D.

RESULTS

We found a wide variation in the evidence for each eating pattern. Issues that have hampered the guideline process include: lack of a rigorous literature review, resulting in the omission of pertinent studies; an overreliance on prospective cohort studies; inconsistent standards for evidence; inclusion of studies not on persons with T2D; and bias.

CONCLUSIONS

The ADA Guidelines recommended eating patterns fall short of rigorous standards of scientific review according to state-of-the-art systematic review and guideline creation practices.

Diet, Diabetes Status, and Personal Experiences of Individuals with Type 2 diabetes Who Self-Selected and Followed a Low Carbohydrate High Fat diet

BACKGROUND

Low carbohydrate high fat (LCHF) diets are increasing in popularity amongst patients with type 2 diabetes (T2D), however it is unclear what constitutes a sustainable LCHF diet in a real-world setting.

METHODS

This descriptive multi-method study characterized the diets, T2D status, and personal experiences of individuals with T2D who claimed to have followed an LCHF diet for at least 6 months. Participants completed a medications history, mixed-method dietary assessment, provided a blood sample, and were interviewed in-depth about their experiences with the diet (First-Assessment). Past medical records were obtained corresponding to T2D diagnosis and prior to starting their LCHF diets. Additionally, participants were followed up 15 months later to assess T2D remission (Follow-Up).

RESULTS

Twenty-eight participants completed First-Assessment and 24 completed Follow-Up. Habitual carbohydrate intake was 20 to 50 g/d for 10 participants and 50 to 115 g/d for 17 participants. Commonly reported foods were full-fat dairy, non-starchy vegetables, coconut oil, eggs, nuts, olives and avocados, olive oil, and red meat and poultry with fat. Median (interquartile range) for HbA1c was 7.5 (6.5-9.5) % prior to starting their diets, 5.8 (5.4-6.2) % at First-Assessment and 5.9 (5.3-6.6) % at Follow-Up. Reported body weight and glucose-lowering medication requirements were considerably lower at both assessments than when starting the diet. At Follow-Up, 24 participants had been following their LCHF diets for 35 (26-53) months, the majority of which were in full or partial T2D remission. Participants perceived reduced hunger and cravings as one of the most important aspects of their diets. Of concern, many participants felt unsupported by their doctors.

CONCLUSION

This study described the foods and characteristics of an LCHF "lifestyle" that was sustainable and effective for certain T2D patients in a real-world setting.