Reducing the global burden of type 2 diabetes by improving the quality of staple foods: The Global Nutrition and Epidemiologic Transition Initiative

Non-use of diabetes medication and its associated factors: a comparative analysis of female and male patients in four Sub-Saharan African countries

BACKGROUND

Globally, the burden of disease is shifting towards non-communicable diseases (NCDs), including diabetes. Sub-Saharan Africa (SSA) faces an increasing prevalence of diabetes, hindering the achievement of global health goals. This study investigates the determinants of non-use of diabetes medication, specifically exploring potential sex differences in four SSA countries.

METHODS

This cross-sectional study analyzed recent Demographic and Health Survey (DHS) data (2017-2021) from four SSA countries (Benin, Cameroon, Madagascar, and Mauritania). Samples included 23,695 women and 25,339 men, focusing on individuals with diabetes not using medication (248 women, 162 men). Descriptive and inferential analyses, including chi-square tests and binary logistic regression models, were conducted using Stata version 14. Odds ratios were calculated with a 95% confidence interval to determine the associations.

RESULTS

This study found that a larger proportion of female patients with diabetes (64.1%) were not using diabetes medication compared to their male counterparts (59.4%). Age influenced medication non-use in males, with older individuals exhibiting lower odds of non-usage. Higher wealth status was associated with lower odds of non-use of diabetes medications. The presence of heart disease was associated with a lower likelihood of medication non-use among females.

CONCLUSIONS

This study demonstrates sex disparities, age differences, wealth status, heart disease, and country-specific variations in medication non-use. Tailored interventions for different age groups, as well as socioeconomic support, are critical, as is integrated cardiovascular and diabetes care. These actions can improve medication use and adherence, quality of life, and long-term diabetes management outcomes.

Trend and spatial clustering of medical education in Brazil: an ecological study of time series from 2010 to 2021

CONTEXT

Studies that analyze the temporal trend and spatial clustering of medical education indicators are scarce, especially in developing countries such as Brazil. This analysis is essential to subsidize more equitable policies for the medical workforce in the states and regions of Brazil. Thus, this study aimed to analyze the temporal trend and identify spatial clusters of medical education indicators in Brazil disaggregated by public and private education, states, and regions.

METHODS

A time-series ecological study was conducted using data from the Higher Education Census of the Ministry of Education from 2010 to 2021. The study analyzed vacancy density indicators of active and former students/100,000 population, disaggregated by public and private education, 27 states, and 5 regions in Brazil. Prais-Winsten regression was used for trend analyses of indicators. Hot Spot Analysis (Getis-Ord Gi*) was used to identify spatial clusters of indicators.

RESULTS

The number of medical schools increased by 102.2% between 2010 and 2021. A total of 366 medical schools offered 54,870 vacancies at the end of 2021. Vacancy density and active and former students increased significantly in the period, but this increase was greater in private institutions. Most states and regions showed an increasing trend in the indicators, with higher increase percentages in private than in public schools. Hot spot spaces changed over time, concentrated in the southeast, center-west, and north at the end of 2021. Medical education remains uneven in Brazil, with a low provision in regions with low socioeconomic development, academic structure, and health services, represented by regions in the north and northeast.

CONCLUSIONS

There is a growing trend in medical education indicators in Brazil, especially in the private sector. Spatial clusters were found predominantly in the southeast, center-west, and north. These results indicate the need for more equitable medical education planning between the regions.

Estimating the Health Care Expenditure to Manage and Care for Type 2 Diabetes in Nepal: A Patient Perspective

Background. This study aimed to estimate the health care expenditure for managing type 2 diabetes (T2D) in the community setting of Nepal. Methods. This is a baseline cross-sectional study of a heath behavior intervention that was conducted between September 2021 and February 2022 among patients with T2D (N = 481) in the Kavrepalanchok and Nuwakot districts of Nepal. Bottom-up and micro-costing approaches were used to estimate the health care costs and were stratified according to residential status and the presence of comorbid conditions. A generalized linear model with a log-link and gamma distribution was applied for modeling the continuous right-skewed costs, and 95% confidence intervals were obtained from 10,000 bootstrapping resampling techniques. Results. Over 6 months the mean health care resource cost to manage T2D was US $22.87 per patient: 61% included the direct medical cost (US $14.01), 15% included the direct nonmedical cost (US $3.43), and 24% was associated with productivity losses (US $5.44). The mean health care resource cost per patient living in an urban community (US $24.65) was about US $4.95 higher than patients living in the rural community (US $19.69). The health care costs per patient with comorbid conditions was US $22.93 and was US $22.81 for those without comorbidities. Patients living in rural areas had 16% lower health care expenses compared with their urban counterparts. Conclusion. T2D imposes a substantial financial burden on both the health care system and individuals. There is a need to establish high-value care treatment strategies for the management of T2D to reduce the high health care expenses.

Highlights

More than 60% of health care expenses comprise the direct medical cost, 15% direct nonmedical cost, and 24% patient productivity losses. The costs of diagnosis, hospitalization, and recommended foods were the main drivers of health care costs for managing type 2 diabetes.Health care expenses among patients living in urban communities and patients with comorbid conditions was higher compared with those in rural communities and those with without comorbidities.The results of this study are expected to help integrate diabetes care within the existing primary health care systems, thereby reducing health care expenses and improving the quality of diabetes care in Nepal.

Design and Implementation of a Culturally-Tailored Randomized Pilot Trial: Puerto Rican Optimized Mediterranean-Like Diet

Background

Adhering to a Mediterranean Diet (MedDiet) is associated with a healthier cardiometabolic profile. However, there are limited studies on the MedDiet benefits for non-Mediterranean racial/ethnic minorities, for whom this diet may be unfamiliar and inaccessible and who have a high risk of chronic diseases.

Objectives

To describe the study design of a pilot trial testing the efficacy of a MedDiet-like tailored to adults in Puerto Rico (PR).

Methods

The Puerto Rican Optimized Mediterranean-like Diet (PROMED) was a single-site 4-mo parallel two-arm randomized pilot trial among a projected 50 free-living adults (25-65 y) living in PR with at least two cardiometabolic risk factors (clinicaltrials.gov registration #NCT03975556). The intervention group received 1 individual nutritional counseling session on a portion-control culturally-tailored MedDiet. Daily text messages reinforced the counseling content for 2 mo, and we supplied legumes and vegetable oils. Participants in the control group received cooking utensils and one standard portion-control nutritional counseling session that was reinforced with daily texts for 2 mo. Text messages for each group were repeated for two more months. Outcome measures were assessed at baseline, 2 and 4 m. The primary outcome was a composite cardiometabolic improvement score; secondary outcomes included individual cardiometabolic factors; dietary intake, behaviors, and satisfaction; psychosocial factors; and the gut microbiome.

Results

PROMED was designed to be culturally appropriate, acceptable, accessible, and feasible for adults in PR. Strengths of the study include applying deep-structure cultural components, easing structural barriers, and representing a real-life setting. Limitations include difficulty with blinding and with monitoring adherence, and reduced timing and sample size. The COVID-19 pandemic influenced implementation, warranting replication.

Conclusions

If PROMED is proven efficacious in improving cardiometabolic health and diet quality, the findings would strengthen the evidence on the healthfulness of a culturally-appropriate MedDiet and support its wider implementation in clinical and population-wide disease-prevention programs.

White rice, brown rice and the risk of type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

Intake of white rice has been associated with elevated risk for type 2 diabetes (T2D), while studies on brown rice are conflicting. To inform dietary guidance, we synthesised the evidence on white rice and brown rice with T2D risk.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE and Cochrane databases were searched through November 2021.

ELIGIBILITY CRITERIA

Prospective cohort studies of white and brown rice intake on T2D risk (≥1 year), and randomised controlled trials (RCTs) comparing brown rice with white rice on cardiometabolic risk factors (≥2 weeks).

DATA EXTRACTION AND SYNTHESIS

Data were extracted by the primary reviewer and two additional reviewers. Meta-analyses were conducted using random-effects models and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using the Newcastle Ottawa Scale for prospective cohort studies and the Cochrane Risk of Bias Tool for RCTs. Strength of the meta-evidence was assessed using NutriGrade.

RESULTS

Nineteen articles were included: 8 cohort studies providing 18 estimates (white rice: 15 estimates, 25 956 cases, n=5 77 426; brown rice: 3 estimates, 10 507 cases, n=1 97 228) and 11 RCTs (n=1034). In cohort studies, white rice was associated with higher risk of T2D (pooled RR, 1.16; 95% CI: 1.02 to 1.32) comparing extreme categories. At intakes above ~300 g/day, a dose-response was observed (each 158 g/day serving was associated with 13% (11%-15%) higher risk of T2D). Intake of brown rice was associated with lower risk of T2D (pooled RR, 0.89; 95% CI: 0.81 to 0.97) comparing extreme categories. Each 50 g/day serving of brown rice was associated with 13% (6%-20%) lower risk of T2D. Cohort studies were considered to be of good or fair quality. RCTs showed an increase in high-density lipoprotein-cholesterol (0.06 mmol/L; 0.00 to 0.11 mmol/L) in the brown compared with white rice group. No other significant differences in risk factors were observed. The majority of RCTs were found to have some concern for risk of bias. Overall strength of the meta-evidence was moderate for cohort studies and moderate and low for RCTs.

CONCLUSION

Intake of white rice was associated with higher risk of T2D, while intake of brown rice was associated with lower risk. Findings from substitution trials on cardiometabolic risk factors were inconsistent.

PROSPERO REGISTRATION NUMBER

CRD42020158466.

Economic Evaluation of Health Behavior Interventions to Prevent and Manage Type 2 Diabetes Mellitus in Asia: A Systematic Review of Randomized Controlled Trials

Health behavior interventions implemented in Asian countries often lack economic evaluations that effectively address the problems of type 2 diabetes mellitus. This review systematically assessed the existing literature on economic evaluation of health behavior interventions to prevent and manage type 2 diabetes mellitus for people living in Asian countries. Eligible studies were identified through a search of six bibliographic databases, namely, PubMed, Scopus, Public Health Database by ProQuest, Cumulative Index to Nursing and Allied Health Literature Complete, Web of Science, and Google Scholar. Randomized controlled trials of health behavior interventions and studies published in the English language from January 2000 to May 2022 were included in the review. The search yielded 3867 records, of which 11 studies were included in the review. All included studies concluded that health behavior interventions were cost-effective. Eight of these studies undertook an evaluation from a health system perspective, two studies used both societal and health system perspectives, and one study utilized a societal and multi-payer perspective. This review identified the time horizon, direct and indirect medical costs, and discount rates as the most important considerations in determining cost effectiveness. These findings have implications in extending health behavior interventions to prevent and manage type 2 diabetes mellitus in low-resource settings, and are likely to yield the most promising outcomes for people with type 2 diabetes mellitus.

A diet rich in fruit and whole grains is associated with a low risk of type 2 diabetes mellitus: findings from a case-control study in South China

OBJECTIVE

Various foods are associated with or protect against type 2 diabetes mellitus (T2DM). This study was to examine the associations of foods and food patterns with the risk of T2DM in South China.

DESIGN

Case-control study.

SETTING

The dietary patterns were identified by a principal components factor analysis. Univariable and multivariable conditional logistic regression analyses were used to analyse the associations between food groups and dietary patterns and the risk of T2DM.

PARTICIPANTS

A total of 384 patients with T2DM and 768 controls.

RESULTS

After adjustment for total energy intake, the standard intake of grains (228·3 ± 71·9 v. 238·8 ± 73·1 g/d, P = 0·025) and fruits (109 ± 90 v. 145 ± 108 g/d, P < 0·001) were lower in T2DM than in controls. Four dietary patterns were identified: (1) high light-coloured vegetables and low grains, (2) high fruits, (3) high red meat and low grains and (4) high dark-coloured vegetable. After adjustment for covariables, multivariable conditional logistic regression analyses showed significant dose-dependent inverse associations between total fruit intake, whole grains intake and the score of the high-fruit dietary pattern (all Pfor trend < 0·001) and the risk of T2DM. The adjusted OR (95 % CI) for T2DM comparing the extreme quartiles were 0·46 (0·29, 0·76) for total fruits, 0·48(0·31, 0·77) for whole grains and 0·42 (0·26, 0·68) for the high-fruit dietary pattern, respectively. Similar associations were observed for all subgroups of fruits (dark-colour and light-colour).

CONCLUSION

In South China, a diet rich in fruit and whole grains is associated with lower risk of T2DM.

Short-term effectiveness of nutrition therapy to treat type 2 diabetes in low-income and middle-income countries: systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

This review examined the evidence arising from randomised controlled trials regarding the impact of nutrition therapy on glycaemic control in people living with type 2 diabetes mellitus (T2DM) in low/middle-income countries (LMICs).

DESIGN

Systematic review and meta-analysis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Approach.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, OpenGrey and the International Clinical Trials Registry were searched (up to July 3 2020).

ELIGIBILITY CRITERIA

Trials were included if they evaluated nutrition therapy in adults diagnosed with T2DM, were conducted in LMICs, measured glycaemic control and the trial included a 3-month post-intervention assessment. Nutrition therapy was defined according to American Diabetes Association recommendations.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened the database. Study characteristics and outcome data were extracted using a data collection form. Meta-analyses were conducted for glycated haemoglobin (HbA1c) and fasting blood glucose. Trials were assessed for risk of bias (Cochrane Risk-of-Bias, Version 2.0) and overall certainty of evidence (GRADE).

RESULTS

Four trials met inclusion criteria (total n=463), conducted in Malaysia, Iran and South Africa. All trials focused on nutrition education with no direct prescription or manipulation of diet. Mean differences between intervention and standard care were -0.63% (95% CI -1.47% to 0.21%) for HbA1c and -13.63 mg/dL (95% CI -37.61 to 10.34) for fasting blood glucose in favour of the intervention. Given the small number of eligible trials, moderate to high risk of publication bias and serious concerns regarding consistency and precision of the evidence, certainty of evidence was deemed to be very low.

CONCLUSIONS

There is a lack of well-conducted randomised controlled trials that examine the long-term impact of nutrition therapy in LMICs, preventing firm conclusions to be made on their effectiveness. Further research is essential to discover realistic, evidence-based solutions.

PROSPERO REGISTRATION NUMBER

CRD42020188435.

Burden of Diabetes Mellitus in Nepal: An Analysis of Global Burden of Disease Study 2019

Globally, the number of people living with diabetes mellitus (DM) increased by 62% between 1990 and 2019, affecting 463 million people in 2019, and is projected to increase further by 51% by 2045. The increasing burden of DM that requires chronic care could have a considerable cost implication in the health system, particularly in resource constraint settings like Nepal. In this context, this study attempts to present the burden of DM in terms of prevalence, mortality, and disability adjusted life years (DALYs). The study is based on the Global Burden of Disease Study 2019, a multinational collaborative research, led by the Institute for Health Metrics and Evaluations. In the study, the overall prevalence of DM was estimated using DisMod MR-2.1, a Bayesian metaregression model. DALYs were estimated summing years of life lost due to premature death and years lived with disability. There were a total of 1,412,180 prevalent cases of DM, 3,474 deaths and 189,727 DALYs, due to DM in 2019. All-age prevalence rate and the age-standardized prevalence rate of DM stood at 4,642.83 (95% uncertainty interval (UI): 4,178.58-5,137.74) and 5,735.58 (95% UI: 5,168.74-6327.73) cases per 100,000 population, respectively, in 2019. In 2019, 1.8% (95% UI: 1.54, 2.07) of total deaths were from DM, which is a more than three-fold increase from the proportion of deaths attributed in 1990 (0.43%, 95% UI: 0.36, 0.5) with most of these deaths being from DM type 2. In 2019, a total of 189,727 disability adjusted life years (DALYs) were attributable to DM of which 105,950 DALYs were among males, and the remaining 83,777 DALYs were among females. Overall, between 1990 and 2019, the DALYs, attributable to Type 1 and 2 DM combined and for Type 2 DM only, have increased gradually across both sexes. However, the DALYs per 100,000 attributable to DM have slightly reduced across both sexes in that time. There is a high burden of DM in Nepal in 2019 with a steep increase in the proportion of deaths attributable to DM in Nepal which could pose a serious challenge to the health system. Primary prevention of DM requires collaborative efforts from multiple sectors. Meanwhile, the current federal structure could be an opportunity for integrated, locally tailored public health and clinical interventions for the prevention of the disease and its consequences.

Artificial Intelligence in Functional Food Ingredient Discovery and Characterisation: A Focus on Bioactive Plant and Food Peptides

Scientific research consistently demonstrates that diseases may be delayed, treated, or even prevented and, thereby, health may be maintained with health-promoting functional food ingredients (FFIs). Consumers are increasingly demanding sound information about food, nutrition, nutrients, and their associated health benefits. Consequently, a nutrition industry is being formed around natural foods and FFIs, the economic growth of which is increasingly driven by consumer decisions. Information technology, in particular artificial intelligence (AI), is primed to vastly expand the pool of characterised and annotated FFIs available to consumers, by systematically discovering and characterising natural, efficacious, and safe bioactive ingredients (bioactives) that address specific health needs. However, FFI-producing companies are lagging in adopting AI technology for their ingredient development pipelines for several reasons, resulting in a lack of efficient means for large-scale and high-throughput molecular and functional ingredient characterisation. The arrival of the AI-led technological revolution allows for the comprehensive characterisation and understanding of the universe of FFI molecules, enabling the mining of the food and natural product space in an unprecedented manner. In turn, this expansion of bioactives dramatically increases the repertoire of FFIs available to the consumer, ultimately resulting in bioactives being specifically developed to target unmet health needs.

Some pearl millet-based foods promote satiety or reduce glycaemic response in a crossover trial

In a previous trial in Mali, we showed that traditional pearl millet couscous and thick porridge delayed gastric emptying (about 5 h half-emptying times) in a normal-weight population compared with non-traditional carbohydrate-based foods (pasta, potatoes, white rice; about 3 h half-emptying times), and in a gastric simulator we showed millet couscous had slower digestion than wheat couscous. In light of these findings, we tested the hypothesis in a normal-weight US population (n 14) that millet foods would reduce glycaemic response (continuous glucose monitor), improve appetitive sensations (visual analogue scale ratings), as well as reduce gastric emptying rate (13C-octanoic acid breath test). Five carbohydrate-based foods (millet couscous - commercial and self-made, millet thick porridge, wheat couscous, white rice) were fed in a crossover trial matched on available carbohydrate basis. Significantly lower overall glycaemic response was observed for all millet-based foods and wheat couscous compared with white rice (P ≤ 0·05). Millet couscous (self-made) had significantly higher glycaemic response than millet couscous (commercial) and wheat couscous (P < 0·0001), but as there were no differences in peak glucose values an extended glycaemic response was indicated for self-made couscous. Millet couscous (self-made) had significantly lower hunger ratings and higher fullness ratings (P < 0·05) than white rice, millet thick porridge and millet couscous (commercial). A normal gastric emptying rate (<3 h half-emptying times) was observed for all foods, with no significant differences among them. In conclusion, some traditionally prepared pearl millet foods show the potential to reduce glycaemic response and promote satiety.

Labor migration is associated with lower rates of underweight and higher rates of obesity among left-behind wives in rural Bangladesh: a cross-sectional study

BACKGROUND

Among Bangladeshi men, international labor migration has increased ten-fold since 1990 and rural to urban labor migration rates have steadily increased. Labor migration of husbands has increased household wealth and redefined women's roles, which have both positively and negatively impacted the health of wives "left behind". We examined the direct and indirect effects of husband labor migration on chronic disease indicators and outcomes among wives of labor migrants.

METHODS

We collected survey, anthropometric, and biomarker data from a random sample of women in Matlab, Bangladesh, in 2018. We assessed associations between husband's migration and indicators of adiposity and chronic disease. We used structural equation modeling to assess the direct effect of labor migration on chronic disease, undernutrition, and adiposity, and the mediating roles of income, food security, and proportion of food purchased from the bazaar. Qualitative interviews and participant observation were used to help provide context for the associations we found in our quantitative results.

FINDINGS

Among study participants, 9.0% were underweight, 50.9% were iron deficient, 48.3% were anemic, 39.6% were obese, 27.3% had a waist circumference over 35 in., 33.1% had a high whole-body fat percentage, 32.8% were diabetic, and 32.9% had hypertension. Slightly more women in the sample (55.3%) had a husband who never migrated than had a husband who had ever migrated (44.9%). Of those whose husband had ever migrated, 25.8% had a husband who was a current international migrant. Wives of migrants were less likely to be underweight, and more likely to have indicators of excess adiposity, than wives of non-migrants. Protection against undernutrition was attributable primarily to increased food security among wives of migrants, while increased adiposity was attributable primarily to purchasing a higher proportion of food from the bazaar; however, there was a separate path through income, which qualitative findings suggest may be related to reduced physical activity.

CONCLUSIONS

Labor migration, and particularly international labor migration, intensifies the nutrition transition in Bangladesh through increasing wealth, changing how foods are purchased, and reducing physical activity, which both decreases risk for undernutrition and increases risk for excess adiposity.

Healthful grain foods consumption by São Paulo residents: a 12-year analysis and future trends

OBJECTIVE

Understanding trends in grain consumption is essential to tackle the low consumption of healthful grain foods. This study aimed to evaluate trends and determinants of grain foods meeting the ≤10:1 carbohydrate:fibre ratio (≤10:1 ratio) in Brazil and to estimate this intake for the next years.

DESIGN

Three editions of the cross-sectional, population-based study Health Survey of São Paulo (2003, 2008 and 2015).

SETTING

Urban area of São Paulo, Brazil.

PARTICIPANTS

The sample included 5801 participants aged 12 years or more.

RESULTS

A growing trend in the intake of these foods (0·9 percentage of energy (%E) in 2003 to 1·5 %E in 2015) was observed. Also, the proportion of the population consuming at least one grain food meeting the ≤10:1 ratio increased from 8·7 % in 2003 to 15·8 % in 2015, and 20·3 % of the population would be consuming some kind of healthful grain food by 2030. Sociodemographic factors associated with the consumption of grain foods meeting the ≤10:1 ratio changed according to study edition, but overall, older individuals (+79 %), females (+28 %), those with higher education (+138 %) and higher family income (+135 %) were more likely to consume grain foods meeting the ratio, whereas participants who self-reported black, brown or indigenous ethnicity were less likely to consume these foods (-30 %).

CONCLUSIONS

There was a growing trend to consume grain foods meeting the ≤10:1 ratio from 2003 to 2015, but this consumption continues to be far from recommended levels. Intersectoral changes are urgently needed in order to increase the intake of healthful grain foods.

Prevalence of Diabetes, Prediabetes, and Associated Risk Factors Among Agricultural Village Residents in the Dominican Republic

This study examined the prevalence and risk factors of prediabetes and type 2 diabetes among residents of agricultural settlement villages (bateyes) in the Dominican Republic. From March to April 2016, a cross-sectional, multi-stage cluster survey was conducted across the country's three agricultural regions (southwest, east, and north). At selected households, an adult completed a questionnaire to assess demographics, diabetes knowledge, and care, and two household residents of any age provided finger-prick blood samples that were analyzed for hemoglobin A1c (HbA1c). HbA1c was categorized as normal (< 5.7%), prediabetic (5.7-6.4%), or diabetic (≥ 6.5%). The prevalence rates of diabetes and prediabetes were 8.6% (95% confidence interval [CI], 6.2-11.8%) and 20.4% (95% CI, 17.9-23.2%), respectively, among all participants (N = 1293; median age, 35 years; range, 2-96 years), and 10.0% (95% CI, 7.2-13.8%) and 20.0% (95% CI, 17.4-23.0%), respectively, among adults 18 years or older (N = 730). The average age of participants with diabetes was 47.2 years. The average age of participants with prediabetes was 40.7 years. Among adult questionnaire respondents, 64.8% of all participants and 39.4% of patients with diabetes had not been tested for diabetes previously. Among patients with diabetes, 28.4% were previously diagnosed; 1.2% of prediabetes patients were previously diagnosed. Half (50.7%) of the respondents had heard of diabetes. The majority (94.1%) of patients previously diagnosed with diabetes reported using diabetes medication. Among both undiagnosed and previously diagnosed patients with diabetes, diabetes knowledge, previous diabetes testing, and diabetes care-seeking were lowest among Haitian-born participants. A high burden of undiagnosed diabetes and deficiencies in diabetes knowledge, access to care, and diagnosis exist among all batey inhabitants, but most acutely among Haitians. Improvements will require a multi-sectoral approach.

Glycemic index values of traditional Kenyan foods: the missing link in the effectiveness of dietary approach in the prevention and management of diabetes mellitus in Kenya

BACKGROUND

Glycemic index (GI) measures postprandial blood sugar after consumption of carbohydrate-rich foodstuff. Kenya is yet to fully embrace this concept in prevention and management of diabetes mellitus.

OBJECTIVE

To review and tabulate GIs of locally consumed foods in order to improve dietary management of diabetes mellitus.

METHODOLOGY

A literature search was conducted using Google scholar and PubMed databases which identified 7 articles on glycemic index values of Kenyan foods published between 2002 and 2020. Two articles failed to meet the inclusion criteria and five proceeded for review. Key search words used included GI, glycemic load and glycemic response combined with Kenya. The data was reported depending on whether the testing involved healthy individuals or patients suffering from diabetes mellitus.

RESULTS

Nine individual foods and 7 mixed meals were identified. Low GI foods included beans and whole maize ugali consumed alongside cowpea leaves. High GI foods included whole maize ugali eaten with beef, boiled rice, boiled cassava and cassava-sorghum ugali eaten with silver fish.

CONCLUSION

Proper meal mixing is important in diabetes management. Cowpea leaves and beans possess GI lowering potential. This information can be used to improve guidance on food choices for diabetes patients.

Opportunities for diet quality improvement: the potential role of staple grain foods

OBJECTIVE

Given the high disease burden associated with the low intake of whole grains, modelling studies that estimate the impact of dietary strategies to increase more healthful grain foods consumption are essential to inform evidence-based and culturally specific policies. The current study investigated the potential nutritional impact of replacing staple grain foods with more healthful options.

DESIGN

Based on the 2015 Health Survey of São Paulo, a cross-sectional, population-based study, we modelled the substitution of white rice and white bread with brown rice and whole-wheat bread. Outcomes included changes in more healthful grain foods, energy and nutrient intakes.

SETTING

Urban area of São Paulo, Brazil.

PARTICIPANTS

Participants aged over 12 years who completed a semi-structured questionnaire and one 24-h recall (n 1741).

RESULTS

The substitution of all white rice and white bread with brown rice and whole-wheat bread, respectively, would result in more than 5 % increases in Zn (+9·1 %), Ca (+9·3 %), vitamin E (+18·8 %), dietary fibre (+27·0 %) and Mg (+52·9 %) intake, while more than a 5 % decrease would be seen for total carbohydrate (-6·1 %), folate (-6·6 %), available carbohydrate (-8·5 %), Fe (-8·6 %), vitamin B6 (-12·5 %), vitamin B2 (-17·4 %), and vitamin B1 (-20·7 %). A substantial increase in the amount of more healthful grain foods consumed would be seen (10 g/d to 220 g/d, or from 4 % to 69 % of total grain intake).

CONCLUSIONS

Replacing white rice and white bread with their whole-grain versions has the potential to improve diet quality, suggesting they are prime targets for policy actions aiming at increasing intake of more healthful grain foods.

Viewpoint: Agri-nutrition research: Revisiting the contribution of maize and wheat to human nutrition and health

Research linking agriculture and nutrition has evolved since the mid-20th century. The current focus is on child-stunting, dietary diversity and 'nutrient-rich' foods in recognition of the growing burdens of malnutrition and non-communicable diseases. This article concerns the global dietary and health contribution of major cereals, specifically maize and wheat, which are often considered not to be 'nutrient-rich' foods. Nevertheless, these cereals are major sources of dietary energy, of essential proteins and micronutrients, and diverse non-nutrient bioactive food components. Research on bioactives, and dietary fibre in particular, is somewhat 'siloed', with little attention paid by the agri-nutrition research community to the role of cereal bioactives in healthy diets, and the adverse health effects often arising through processing and manufacturing of cereals-based food products. We argue that the research agenda should embrace the whole nutritional contribution of the multiple dietary components of cereals towards addressing the triple burden of undernutrition, micronutrient malnutrition, overweight/obesity and non-communicable diseases. Agri-nutrition and development communities need to adopt a multidisciplinary and food systems research approach from farm to metabolism. Agriculture researchers should collaborate with other food systems stakeholders on nutrition-related challenges in cereal production, processing and manufacturing, and food waste and losses. Cereal and food scientists should also collaborate with social scientists to better understand the impacts on diets of the political economy of the food industry, and the diverse factors which influence local and global dietary transitions, consumer behavioural choices, dietary change, and the assessment and acceptance of novel and nutritious cereal-based products.

The Healthy Gluten-Free Diet: Practical Tips to Prevent Metabolic Disorders and Nutritional Deficiencies in Celiac Patients

The gluten-free diet (GFD) is the cornerstone treatment for coeliac disease (CD). However, a healthy GFD is more complex than the only exclusion of gluten-containing foods. Most celiac patients do not receive nutritional advice and tend to consume industrial gluten-free products (GFPs), which often lack fiber, vitamins, and other micronutrients while being rich in saturated fats and refined sugars. This review focuses on the main potential metabolic disorders and nutritional deficiencies in CD patients at diagnosis and dissects the main nutritional and metabolic issues due to a non-balanced GFD. Nutritional tips to achieve an adequate dietary approach in CD are provided. We also compared the main nutritional components of naturally gluten-free cereals (including pseudocereals) to give an exhaustive overview of the possible healthy alternatives to processed GFPs. Clinicians and dietitians should be systematically involved in the diagnosis of CD to monitor the appropriateness of GFD and the patient’s nutritional status over time.

Carotenoid absorption in rats fed with vacuum-fried papaya chips depends on processed food microstructure associated with saturated and unsaturated oils

Many studies indicate that food matrix microstructure and type of dietary oil or fat play a key role in carotenoid absorption. Therefore, this work was designed to highlight the relationship between processed food microstructure and carotenoid absorption. This study aimed to evaluate the consumption of a carotenoid-rich fruit snack on lipid profile, glycemia and especially on carotenoid absorption/bioconversion in Wistar rats. Animals were fed with mixtures based on vacuum-fried papaya chips with either soy oil (PC-S) or palm oil (PC-P) during 7 days, receiving 0.29 mg lycopene/kg/day and 0.35 mg total carotenoids/kg/day. Lycopene and retinoids were analyzed in plasma and liver of rats by HPLC-DAD. Results showed that the consumption of mixtures based on papaya chips did not affect the lipid profile or glycemia in rat plasma, regardless the type of oil. Wide-field and confocal microscopy analyses of food matrix helped to understand why lycopene accumulation in the liver was higher (p < 0.05) in rats fed with PC-P (0.442 µg/g liver) than in those fed with PC-S (0.291 µg/g liver). A better dissolution of crystalloid lycopene was found in PC-P. Conversely, a higher bioconversion of provitamin A carotenoids was observed for soy products. The effect of type of oil was underlined by epifluorescence microscopy of papaya mixtures showing homogeneous and small lipid droplets for soy products. These results showed that PC-S could be recommanded as a healthy snack, being a source of provitamin A carotenoids and bioavailable lycopene in a diversified diet.

Making novel staple foods the norm: perspectives from adult consumers with and without diabetes

Novel staple foods are staple foods that are modified with the purpose of improving their nutritional properties. However, consumers' acceptance towards novel staple foods remains to be evaluated, especially in Asian populations where staple foods like white rice are a major source of energy. The objective of this study was to explore consumers' attitudes and perceptions towards novel staple foods in a multi-ethnic Asian population. We conducted 11 focus group discussions, with 37 healthy participants and 22 participants with diabetes recruited through newspaper, email and poster advertisement and in-person recruitment at a clinic. Thematic analysis using the general inductive approach was performed. We found that participants' conceptual understanding of the modification process affected their acceptance towards novel staple foods. Plant-based modifications were considered natural and acceptable while genetic modification and use of chemicals were unnatural and undesirable. Participants expected novel staple foods to be more expensive and less tasty and this was largely due to their perceptions and experiences with healthy eating. Participants with diabetes or family history of diabetes were generally more willing to compromise taste and cost for healthier staple foods, and this appeared to be driven by concerns about diabetes and its related co-morbidities. The appearance of food was an important influence on participants' initial impression of the food, which appeared to be mediated by taste expectations. Participants' trust of novel staple foods was largely influenced by their trust in food industry, governmental authorities and nutrition science that was mediated through pathways of information and food safety.

Remission of new-onset type 2 diabetes mellitus in an adolescent using an integrative medicine approach: A case report

Among adolescents, the incidence of type 2 diabetes mellitus (T2DM) has recently increased. A 12-year-old Chinese boy with a one-year history of hyperphagia presented to our clinic. The patient was diagnosed with T2DM one month prior to visiting the clinic and reported undergoing no pharmacologic treatment. Using an integrative medicine approach, including Chinese herbal decoction, berberine hydrochloride tablets, physical exercise and diet control, the patient's fasting blood glucose (FBG) decreased from 8.3 mmol/L to 5.5 mmol/L. Additionally, his glycated haemoglobin decreased from 12.9% to 6.1%, indicating that without any Western medicine intervention his diabetes has been reversed after six months of treatment. His FBG remained normal, and nine months after completion of treatment it was 4.9 mmol/L. A potential mechanism in this response may be related to improved insulin resistance and β-cell function, as indicated by observed changes in homeostasis model assessment of insulin resistance and β-cell function. Further, weight loss may also have contributed to the effectiveness of the treatment. This case study is the first to present the innovative approach of integrative medicine to achieve remission of new-onset adolescent T2DM.

The association between purchasing locally produced food and diet quality among adults in Puerto Rico

OBJECTIVE

Diminished diet quality in the Caribbean and other island settings may be related to a dietary transition from local foods towards imported products. The current study aimed to characterise the association between intentionally purchasing local foods (IPLF) and diet quality in Puerto Rico (PR).

DESIGN

Cross-sectional study.

SETTING

Primary care clinics in the PR metropolitan area.

PARTICIPANTS

Data were obtained from adult participants (30-75 years; n 243) of the Puerto Rico Assessment of Diet, Lifestyle, and Diseases. IPLF was probed by asking: 'How often do you purposely purchase foods from PR (like fruits, vegetables, meat and other products that are produced on the island rather than being imported)?' Dietary intake was measured using a FFQ, and diet quality was assessed by the Alternate Healthy Eating Index (range 0-110; higher scores indicating higher diet quality). Multivariate-adjusted generalised linear models tested the association between IPLF and Alternate Healthy Eating Index 2010 (AHEI) and its component scores.

RESULTS

A third (33·9 %) of participants reported seldom, 33·5 % reported often and 30·6 % reported always IPLF. Compared with seldom IPLF, fully adjusted mean AHEI scores were 3·6 (P = 0·038) points higher among those often IPLF and 9·3 (P < 0·0001) points higher among those always IPLF. Compared with seldom IPLF, those who always IPLF had significantly higher fully adjusted mean component scores for vegetables, fruits, whole grains, nuts and legumes, trans fat and n-3 fats.

CONCLUSIONS

Adults in PR who intentionally purchase local foods had higher diet quality, especially for intake of plant-based foods and healthy fats, highlighting potential dietary benefits associated with improved local food availability in PR.

Strategies to improve wheat for human health

Despite their economic importance and growing demand, concerns are emerging around wheat-based foods and human health. Most wheat-based foods are made from refined white flour rather than wholemeal flour, and the overconsumption of these products may contribute to the increasing global prevalence of chronic diseases, particularly type 2 diabetes and obesity. Here, we review how the amount, composition and interactions of starch and cell wall polysaccharides, the major carbohydrate components in refined wheat products, impact human health. We discuss strategies and challenges to manipulate these components for improved diet and health using newly developed wheat genomics tools and resources. Commercial foods developed from these novel approaches must be produced without adverse effects on cost, consumer acceptability and processing properties.

Dietary patterns of patients with psoriasis at a public healthcare institution in Brazil

BACKGROUND

Psoriasis is a chronic inflammatory disease with systemic repercussions and an association with comorbidities such as metabolic syndrome, cardiovascular diseases, and obesity. Psoriasis patients have a higher prevalence of obesity compared to the general population. Diet is a relevant environmental factor, since malnutrition, inadequate body weight, and metabolic diseases, in addition to the direct health risk, impair the treatment of psoriasis.

OBJECTIVES

To evaluate food intake patterns, anthropometric, and metabolic syndrome-related aspects in psoriasis patients.

METHODS

Cross-sectional study through anthropometric assessment and food frequency questionnaire. Food frequency questionnaire items were evaluated by exploratory factor analysis and identified dietary patterns were analyzed by multivariate methods.

RESULTS

This study evaluated 94 patients, 57% female, with a mean age of 54.9 years; the prevalence of obesity was 48% and of metabolic syndrome, 50%. Factor analysis of the food frequency questionnaire identified two dietary patterns: Pattern 1 - predominance of processed foods; Pattern 2 - predominance of fresh foods. Multivariate analysis revealed that Patterns 1 and 2 showed inverse behaviors, and greater adherence to Pattern 2 was associated with females, eutrophic individuals, absence of lipid and blood pressure alterations, and lower waist-to-hip ratio and skin disease activity.

STUDY LIMITATIONS

Monocentric study conducted at a public institution, dependent on dietary memory.

CONCLUSION

Two dietary patterns were identified in a Brazilian sample of psoriasis patients. The prevalence of obesity and metabolic syndrome were greater than in the adult Brazilian population. The fresh diet was associated with lower indicators of metabolic syndrome in this sample.

Glycemic Index (GI) Values for Major Sources of Dietary Carbohydrates in Iran

BACKGROUND

The glycemic index (GI) values of staple foods are not available in a standardized method in Iran.

OBJECTIVES

The aim of this study was to measure the GI values of the major carbohydrate sources in a typical Iranian diet.

METHODS

Using the international standard method, the GI values were determined for four wheat flatbreads, barley and rye bread, white and brown rice, as well as white and brown rice mixed with lentils. Twelve healthy adults were given 50 g anhydrous glucose three times (as the reference carbohydrate) and the test foods once each throughout the study. Using finger-prick blood samples, capillary blood glucose was measured using a reliable glucometer. The GI was calculated using the trapezoidal method.

RESULTS

The GI values of the following types of bread were: Barley 66, Lavash 72, Taftoon 79, Sangak 82, rye 84, and Barbari 99. The GI values for brown and white rice were 65 and 71, respectively. The mixture of brown rice with lentils had a GI value of 55, and the mixture of white rice with lentils had a GI of 79.

CONCLUSIONS

The most common types of bread and white rice consumed in Iran have high GI values. There is potential to reduce the overall GI values in the Iranian diet by encouraging the consumption of barley bread and brown rice.

Effect of cooking, 24 h cold storage, microwave reheating, and particle size on in vitro starch digestibility of dry and fresh pasta

The aim of this study was to investigate the effect of preparation method and particle size on digestion of starch in fresh and dry pasta types. Pasta samples were boiled, refrigerated and re-heated, with samples collected after each stage, and then prepared as small (2 mm) and large (5 mm) particles for subsequent starch digestibility testing and logarithm of slope analyses. There were significant main effects of particle size (F_1,24 = 568.895, p < 0.001, η_p² = 0.960) and processing treatment (F_2,24 = 19.897, p < 0.001 η_p² = 0.624) on starch digestibility overall, however the main effect of pasta type was not significant at the p < 0.05 level (F_1,24 = 2.978, p = 0.097, η_p² = 0.110). Particle size had the largest effect on digestibility, and the extent of starch digestion was at least 50% lower in samples prepared as large particles compared with small particles. The most digestible sample was the boiled fresh-type pasta prepared as small particles (C_∞ = 57.9%) and cold storage alone and/or with subsequent re-heating significantly reduced the extent of digestion in this sample to ∼40.6%. In the dry pasta type, processing treatment had no significant effects on starch digestibility. The rate constant, k, was not significantly altered by processing treatment or pasta type (k = 0.0275 min^-1, mean of all samples). These findings suggest that cold-storage and re-heating treatments have limited potential to impact on glycaemic responses and highlight the importance of masticated particle size as a potential rate-limiting factor in digestibility studies.

Improving nutritional quality of rice for human health

This review surveys rice nutritional value, mainly focusing on breeding achievements via adoption of both genetic engineering and non-transgenic strategies to improve key nutrients associated with human health. Rice (Oryza sativa) is an essential component of the diets and livelihoods of over 3.5 billion people. Polished rice is mostly consumed as staple food, fulfilling daily energy demands and part of the protein requirement. Brown rice is comparatively more nutritious, containing more lipids, minerals, vitamins, dietary fiber, micronutrients, and bioactive compounds. In this article, we review the nutritional facts about rice including the level of γ-aminobutyric acid, resistant starch, lysine, iron, zinc, β-carotene, folate, anthocyanin, various carotenoids, and flavonoids, focusing on their synthesis and metabolism and the advances in their biofortification via adoption of both conventional and genetic engineering strategies. We conclude that besides representing a staple food, rice has the potential to become a source of various essential nutrients or bioactive compounds through appropriate genetic improvements to benefit human health and prevent certain chronic diseases. Finally, we discuss the available, non-genetically engineering strategies for the nutritional improvement of rice, including their main strengths and constraints.

Food Behaviors, Health, and Bean Nutrition Awareness among Low-Income Men: A Pilot Study

Bean consumption is known to lower blood cholesterol and postprandial blood glucose. With higher chronic disease risk, low-income men could theoretically benefit from increased bean intakes. The study objective was to explore low-income men’s food behaviors, bean health benefit awareness, and bean consumption practices and preferences. Seventy-one low-income men aged 18–65 years (µ 41 ± 12.7; 53% white, 16% black, 31% Hispanic) completed a survey on health risks, food behaviors, bean health knowledge, attitudes toward dry and canned beans, and bean preferences. Eighty-seven percent had one or more health risk factors of physical inactivity, smoking, or obesity. Most men compared food prices, and thought about healthy food choices for their families, but few planned meals or read nutrition facts labels. White men had significantly higher bean health benefit knowledge than black or Hispanic men (p < 0.01). Most men liked the taste of beans, disagreed dry beans took too long to prepare, and 79% ate them at least 2–3 times per month. Forty-nine percent agreed beans caused intestinal gas. Improving men’s awareness of the health benefits of beans as well as leveraging existing positive attitudes may be useful approaches to increase bean consumption among low-income and minority male populations.

Identification of a major QTL and associated molecular marker for high arabinoxylan fibre in white wheat flour

Dietary fibre (DF) has multiple health benefits and wheat grains are major sources of DF for human health. However, DF is depleted in white wheat flour which is more widely consumed than wholegrain. The major DF component in white flour is the cell wall polysaccharide arabinoxylan (AX). We have identified the Chinese wheat cultivar Yumai 34 as having unusually high contents of AX in both water-soluble and insoluble forms. We have therefore used populations generated from crosses between Yumai 34 and four other wheat cultivars, three with average contents of AX (Ukrainka, Altigo and Claire) and one also having unusually high AX (Valoris), in order to map QTLs for soluble AX (determined as relative viscosity of aqueous extracts of wholemeal flours) and total AX (determined by enzyme fingerprinting of white flour). A number of QTL were mapped, but most were only detected in one or two crosses. However, all four crosses showed strong QTLs for high RV/total AX on chromosome 1B, with Yumai 34 being the increasing parent, and a KASP marker for the Yumai 34 high AX allele was validated by analysis of high AX lines derived from Yumai 34 but selected by biochemical analysis. A QTL for RV was also mapped on chromosome 6B in Yumai 34 x Valoris, with Valoris being the increasing allele, which is consistent with the observation of transgressive segregation for this population. Association studies in an independent germplasm panel identified marker trait associations for relative viscosity in these same locations while direct selection for fibre content in breeding resulted in high levels of enrichment for the Yumai 34 1B allele. The data therefore indicate that marker-assisted breeding can be used to develop wheat with high AX fibre in white flour.

The Impact of New Biomarkers and Drug Targets on Age-Related Disorders

The increase in the human lifespan has not been paralleled by an increase in healthy life. With the increase in the proportion of the aged population, there has been a natural increase in the prevalence of age-related disorders, such as Alzheimer's disease, type 2 diabetes mellitus, frailty, and various other disorders. A continuous rise in these conditions could lead to a widespread medical and social burden. There are now considerable efforts underway to address these deficits in preclinical and clinical studies, which include the use of better study cohorts, longitudinal designs, improved translation of data from preclinical models, multi-omics profiling, identification of new biomarker candidates and refinement of computational tools and databases containing relevant information. Such efforts will support future interdisciplinary studies and help to identify potential new targets that are amenable to therapeutic approaches such as pharmacological interventions to increase the human healthspan in parallel with the lifespan.

Effects of Undaria pinnatifida (Wakame) on Postprandial Glycemia and Insulin Levels in Humans: a Randomized Crossover Trial

Postprandial hyperglycemia is a known risk factor for the development of several health disorders, including type 2 diabetes, obesity and cardiovascular disease. This study aimed to investigate the acute effect of Undaria pinnatifida (Wakame), a discriminative constituent of the Japanese diet, on postprandial blood glucose and insulin levels. The study was conducted using a crossover method among 26 subjects. Blood was sampled for glucose and insulin measurements at 0, 30, 60, 90 and 120 min after a subject consumed either 200 g of rice or 200 g rice with 4 g of dried wakame. Blood glucose and insulin levels were significantly lower at 30 min after consuming rice with wakame than after consuming rice alone. Moreover, the incremental areas under the curves for glucose and insulin were lower when wakame was included. Wakame intake can improve postprandial glucose homeostasis. Wakame intake may offer a simple behavioural strategy that can reduce glycemic excursions in prediabetes. This study was registered with the UMIN Clinical Trial Registry (UMIN000031050).

Glycemic Index and Microstructure Evaluation of Four Cereal Grain Foods

To determine the glycemic index (GI) of selected cereals and association with their microstructure. The GI of whole grain pilaf (WGP), instant brown rice (IBR), whole maize ugali (MWU), and refined maize ugali (RMU) was assessed in a randomized trial. Fourteen healthy participants with mean age of 25 years were administered 50 g portions of available carbohydrates from glucose and various test foods after an overnight fast on separate occasions. Capillary blood samples of participants were used to measure blood glucose over 2 hr. The GI was calculated as per standard protocol. The microstructure of test foods, determined by scanning electron microscopy was evaluated to understand the measured GI values. The GI (mean ± standard error) of IBR was the highest (87.8 ± 6.8) followed by RMU (74.7 ± 6.5) and WMU (71.4 ± 5.1). WGP had medium GI (58.9 ± 5.1; P < 0.01 vs. IBR). Microstructure examination of IBR revealed disruption of bran layer and presence of fissures indicating loss of intactness of bran. Stereozoom images for WGP revealed intact bran and germ. For RMU and WMU, the grain was milled leading to loss of integrity. IBR, RMU, and WMU have high GI values, which is likely due to disruption of bran layer, endosperm modification (IBR), and loss of grain matrix (WMU, RMU). WGP has medium GI probably due to fairly intact bran and germ. PRACTICAL APPLICATION: Wholegrain or whole meal flour may not necessarily be low in glycemic index (GI; low GI < 55; medium 55 to 69 and high GI ≥70). "Ugali" a commonly consumed cereal staple food in Tanzania made from either refined or whole meal maize flour was found to be a high GI food. Intact whole grain foods, such as whole grain pilaf (mixed intact whole grains) is a healthier alternative to milled whole grains such as whole meal maize flour. Instant quick cooking brown rice exhibited a high GI, due to the processing method, suggesting that regular brown rice may be a healthier option.

The effects of passive stretching on the blood glucose levels of patients with type 2 diabetes

BACKGROUND

Type 2 diabetes is characterized by poor glycemic control due to decreased insulin sensitivity. Physical activity plays an important role in the management of diabetes and reduces blood glucose level. The aim of this study was to evaluate the effectiveness of passive stretching (PS) on the blood glucose level (BGL) of diabetic patients.

MATERIALS AND METHODS

In this randomized clinical trial, fifty patients with type 2 diabetes and mean age of 50.7 ± 4.8 years were randomly and equally allocated into control and intervention groups. Patients in the intervention and control groups underwent 20 min of passive stretching (PS) and passive movement (PM), respectively. BGL was measured before and immediately after, 20 min after and 1 h after PS/PM in the two study groups. BGL at the mentioned times was compared between and within the groups.

RESULTS

The findings showed that when compared with before the PS (195.7 ± 30.1), BGL significantly reduced (p < 0.001) immediately after (178.9 ± 29.7), 20 min after (183.2 ± 29.1), and 1 h after (187.8 ± 29.6) the PS. However, BGL after PM (immediately, 20 min and 1 h after PM) did not significantly change (p > 0.05).

CONCLUSION

The findings of this study indicated that PS has a significant effect on the reduction of the immediate BGL in type 2 diabetic patients. The trend reduced even though the effect remained for 1 h after PS. It is therefore suggested that the effectiveness of these types of activities should be evaluated over a longer duration of study.

Substituting brown rice for white rice on diabetes risk factors in India: a randomised controlled trial

India has the second largest number of people with type 2 diabetes (T2D) globally. Epidemiological evidence indicates that consumption of white rice is positively associated with T2D risk, while intake of brown rice is inversely associated. Thus, we explored the effect of substituting brown rice for white rice on T2D risk factors among adults in urban South India. A total of 166 overweight (BMI ≥ 23 kg/m2) adults aged 25-65 years were enrolled in a randomised cross-over trial in Chennai, India. Interventions were a parboiled brown rice or white rice regimen providing two ad libitum meals/d, 6 d/week for 3 months with a 2-week washout period. Primary outcomes were blood glucose, insulin, glycosylated Hb (HbA1c), insulin resistance (homeostasis model assessment of insulin resistance) and lipids. High-sensitivity C-reactive protein (hs-CRP) was a secondary outcome. We did not observe significant between-group differences for primary outcomes among all participants. However, a significant reduction in HbA1c was observed in the brown rice group among participants with the metabolic syndrome (-0·18 (se 0·08) %) relative to those without the metabolic syndrome (0·05 (se 0·05) %) (P-for-heterogeneity = 0·02). Improvements in HbA1c, total and LDL-cholesterol were observed in the brown rice group among participants with a BMI ≥ 25 kg/m2 compared with those with a BMI &lt; 25 kg/m2 (P-for-heterogeneity &lt; 0·05). We observed a smaller increase in hs-CRP in the brown (0·03 (sd 2·12) mg/l) compared with white rice group (0·63 (sd 2·35) mg/l) (P = 0·04). In conclusion, substituting brown rice for white rice showed a potential benefit on HbA1c among participants with the metabolic syndrome and an elevated BMI. A small benefit on inflammation was also observed.

Association of health literacy with type 2 diabetes mellitus self-management and clinical outcomes within the primary care setting of Iran

This study explores the potential association of health literacy with type 2 diabetes mellitus (T2DM) self-management and clinical outcomes in the primary care setting of Iran. A total of 347 T2DM patients, mostly female (52.4%), 50 years old or younger (63.1%), unemployed (53.6%) and rural residents (55.6%) participated in this study. Most of the respondents had type 2 diabetes mellitus (T2DM) for 2-5 years (63.1%) and did not receive any T2DM education (52.2%). Approximately 19.0% were hospitalised due to uncontrolled T2DM. Participants mainly found managing T2DM self-management behaviours difficult. Approximately half of the participants had poor fasting blood sugar (FBS) (47.0%) and haemoglobin A1c (HbA1c) (59.4%) control and were overweight or obese (77.6%). The level of health literacy was poor and most of the participants had difficulties reading hospital materials (66.0%), understanding medical materials (62.5%) and engaging in medical conversations (63.7%). Health literacy could predict 22.5% variance in difficulty of T2DM self-management and 3.8-23.3% variance in T2DM clinical outcomes after controlling for sociodemographic factors. Participants with higher health literacy were more likely to find managing T2DM less challenging and their clinical outcomes were within the normal range. This implies that interventions targeting patient's health literacy can be a promising tool for addressing the burden of T2DM.

Does intake of bread supplemented with wheat germ have a preventive role on cardiovascular disease risk markers in healthy volunteers? A randomised, controlled, crossover trial

OBJECTIVE

Intake of whole grains is associated with a reduced risk of cardiovascular disease (CVD). This evidence is also strong for bran alone, but findings about germ are conflicting. Our aim was to elucidate the role of germ in primary prevention of cardiovascular events, and therefore, a staple food was selected for 6 g of germ supplementation. This corresponds to sixfold increase in the global mean consumption of germ, while preserving the sensory proprieties of refined bread which is crucial for consumer's acceptance.

DESIGN

Randomised, double-blinded, crossover, controlled clinical trial with 15-week follow-up comprising a 2-week run-in, two intervention periods of 4 weeks each and a 5-week washout period.

SETTING

A single centre in the north of Portugal.

PARTICIPANTS

55 eligible healthy adults (mean age of 34 years and body mass index between 19 and 38 kg/m²) were randomly assigned.

INTERVENTIONS

The study consisted of two intervention periods including daily intake of refined wheat bread enriched with 6 g of wheat germ and control (non-enriched bread).

OUTCOMES

Changes in fasting cholesterol and triglycerides, fasting and postprandial glucose, insulin sensitivity and C reactive protein.

RESULTS

We observed no significant effect of daily intake of wheat germ on cholesterol and triglycerides levels, on postprandial glucose response and on insulin sensitivity. Incremental area under curve glucose and homeostasis model assessment for insulin resistance did not change, suggesting that 6 g of wheat germ have no effect on glucose metabolism. No effect was also observed in the subgroup of participants who complied with the protocol (n=47).

CONCLUSIONS

The absence of alterations on lipid and glucose profiles suggests that germ up to 6 g/day may have no preventive effect on CVD risk. However, it is important to investigate other food vehicles that can accommodate higher doses of wheat germ in future studies.

TRIAL REGISTRATION NUMBER

NCT02405507.

Dietary Acculturation among Puerto Rican Adults Varies by Acculturation Construct and Dietary Measure

Background

The role of acculturation in dietary behaviors among Hispanics/Latinos in the United States remains unclear. Discrepancies may be explained by variations in acculturation constructs or ethnicity-specific dynamics.

Objective

We aimed to compare relations between 3 different acculturation constructs with dietary quality and patterns among Puerto Ricans in the mainland United States.

Methods

We analyzed cross-sectional data with 1194-1380 Puerto Ricans, aged 45-75 y. Acculturation was measured with the use of a language-based scale (0-100; higher score denotes more English use), a psychological-based scale (0-50; higher score denotes stronger US orientation), and years living in the mainland United States. Diet quality scores (higher scores denote healthier diet) were defined with the use of the Alternate Healthy Eating Index-2010 (AHEI) and the Mediterranean Diet Score (MeDS). Three dietary patterns were previously derived with the use of principal components analysis. Adjusted multivariable regression models tested the association of each acculturation construct with diet quality score or pattern. Interaction terms were included for income or education status.

Results

Psychological-based acculturation, but not the other constructs, was positively associated with AHEI (β ± SE: 0.013 ± 0.004; P = 0.002) and MeDS (0.009 ± 0.005; P = 0.041). Income, but not education, moderated this association (P = 0.03), with higher diet quality observed with higher income (>$25,000) and stronger US orientation. All constructs were inversely associated with a traditional dietary pattern, with the language-based scale being stronger (z score β ± SE: -0.160 ± 0.032; P < 0.0001) than the psychological-based scale (-0.097 ± 0.028; P = 0.001) or years living in the mainland United States (-0.058 ± 0.028; P = 0.041). No associations were observed for the Western or sweets/desserts patterns.

Conclusions

In Puerto Rican adults, stronger psychological US orientation was associated with higher diet quality, particularly with higher income. More Spanish use, stronger psychological Puerto Rican orientation, and shorter length of mainland-US residency were associated with traditional dietary patterns. Appropriate diet-related acculturation constructs should be carefully considered among Hispanics/Latinos. This trial was registered at clinicaltrials.gov as NCT01231958.

Remodeling of Retinal Architecture in Diabetic Retinopathy: Disruption of Ocular Physiology and Visual Functions by Inflammatory Gene Products and Pyroptosis

Diabetic patients suffer from a host of physiological abnormalities beyond just those of glucose metabolism. These abnormalities often lead to systemic inflammation via modulation of several inflammation-related genes, their respective gene products, homocysteine metabolism, and pyroptosis. The very nature of this homeostatic disruption re-sets the overall physiology of diabetics via upregulation of immune responses, enhanced retinal neovascularization, upregulation of epigenetic events, and disturbances in cells' redox regulatory system. This altered pathophysiological milieu can lead to the development of diabetic retinopathy (DR), a debilitating vision-threatening eye condition with microvascular complications. DR is the most prevalent cause of irreversible blindness in the working-age adults throughout the world as it can lead to severe structural and functional remodeling of the retina, decreasing vision and thus diminishing the quality of life. In this manuscript, we attempt to summarize recent developments and new insights to explore the very nature of this intertwined crosstalk between components of the immune system and their metabolic orchestrations to elucidate the pathophysiology of DR. Understanding the multifaceted nature of the cellular and molecular factors that are involved in DR could reveal new targets for effective diagnostics, therapeutics, prognostics, preventive tools, and finally strategies to combat the development and progression of DR in susceptible subjects.