During the last few years well-conducted, randomized studies have unequivocally shown that type-2 diabetes mellitus can be effectively prevented or delayed by lifestyle modification programs in people at risk of developing it [2-4]. The ADA, the DNSG of the EASD and Diabetes UK have incorporated diabetes prevention guidelines in their nutritional recommendations. The ADA gives emphasis to the fact that structured programs that focus on lifestyle changes, including education, reduced fat and energy intake, regular physical activity and regular participant contact, can reduce the risk of developing diabetes. The DNSG of the EASD state that weight reduction and maintenance of weight loss in overweight individuals is a critical component of the lifestyle modification program, which may be expected to reduce the risk of developing type-2 diabetes. The appropriate macronutrient composition of the diet is a total fat <30% of energy intake, saturated fat <10% and fiber intake >15g/1,000kcal. Diabetes UK state that structured programs of lifestyle change which emphasize weight loss by reduced energy and fat intake and increased physical activity can reduce the risk of overweight people with impaired glucose tolerance to develop type-2 diabetes.
In both studies of diabetes prevention mentioned above [3, 4] frequent ingestion of wholegrain products, vegetables, fruits, low-fat milk and meat products, soft margarines and vegetable oils rich in MUFAs was the means of facilitating the appropriate macronutrient composition of the diet for achieving a weight loss of 5-7% of the initial body weight. Thus, for people who are overweight/obese, especially if there is a strong family history of diabetes or if they have impaired glucose metabolism, weight loss with diet and exercise should be strongly advised.
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2 Pan XR, Li GW, Hu YH, et al: Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20: 537-544.
3 Tuomilehto J, Lindstrom J, Ericsson JG, et al, Finnish Diabetes Prevention Study Group: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343-1350.
4 Knowler WC, Barrett-Connor E, Fowler S, et al, Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.
5 American Diabetes Association: Position Statement: Standards of medical care in diabetes. Diabetes Care 2005;28(suppl 1):S4-S36.
6 Mann JI, De Leeuw I, Hermansen K, et al, Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD): Evidence-based nutritional approaches to the treatment and prevention of diabetes mellitus. Nutr Metab Cardiovasc Dis 2004;14:373-394.
7 Wolever T, Gougeon R, Freeze C, et al: Nutrition therapy. Canadian Diabetes Association. Clinical Practice Guidelines Expert Committee, 2003 (accessed online at www.diabetes.ca).
8 Joslin Diabetes Center and Joslin Clinic: Clinical nutrition guidelines for overweight and obese adults with type 2 diabetes, prediabetes or at high risk of developing type 2 diabetes, 2005, pp 1-5 (accessed online at www.joslin.org).
9 The American Association of Clinical Endocrinologists Medical Guidelines for the Management of Diabetes Mellitus: The AACE system of intensive diabetes self-management -2002 update. Endocr Pract 2002;8(suppl 1):45-48.
10 Connor H, Annan F, Bunn E, et al, Nutrition Subcommittee of the Diabetes Care Advisory Committee of Diabetes UK: The implementation of nutritional advice for people with diabetes. Diabet Med 2003;20:786-807.
11 Scottish Intercollegiate Guidelines Network. SIGN Guidelines: An introduction to SIGN methodology for the development of evidence-based clinical guidelines, 1999 (www.show. scot.nhs.uk/sign/home.htm).
12 The Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD), 1999: Recommendations for the nutritional management of patients with diabetes mellitus. Eur J Clin Nutr 2000;54:353-355.
13 American Diabetes Association: Clinical Practice Recommendations 2004: Nutrition principles and recommendations in diabetes. Diabetes Care 2004;27(suppl 1):S36-S46.
14 Franz MJ, Bantle JP, Beebe CA, et al: Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002;25:148-198.
15 Mann J, Hermansen K, Vessby B, Toeller M, Diabetes Nutrition Study Group of the European Association for the Study of Diabetes: Evidence-based nutritional recommendations for the treatment and prevention of diabetes and related complications. A European perspective (letter). Diabetes Care 2002;25:1256-1258.
16 Franz MJ, Bantle JP: Response to the Diabetes Nutrition Study Group of the European Association for the Study of Diabetes. Diabetes Care 2002;25:1258-1259.
17 Irwin T: New dietary guidelines from the American Diabetes Association (letter). Diabetes Care 2002;25:1262.
18 Franz MJ, Bantle JP: Response to Irwin. Diabetes Care 2002;25:1262-1263.
19 Wolever T: American Diabetes Association evidence-based nutrition principles and recommendations are not based on evidence (letter). Diabetes Care 2002;25:1263-1264.
20 Franz MJ, Bantle JP: Response to Wolever. Diabetes Care 2002;25:1264-1265.
21 ADA Statement: Dietary carbohydrate (amount and type) in the prevention and management of diabetes. A statement by the American Diabetes Association. Diabetes Care 2004;27:2266-2271.
22 Bornet FR, Costagliola D, Rizkalla et al: Insulinemic and glycemic indexes of six starch-rich foods taken alone and in a mixed meal by type 2 diabetics. Am J Clin Nutr 1987;45:588-595.
23 Katsilambros N, Philippides P, Davoulos G, et al: Sesame-derived candies and glycaemic response in type II diabetic subjects. Diabetes Nutr Metab 1991;4:325-327.
24 Brinkworth GD, Noakes M, Parker B, et al: Long-term effects of advice to consume a highprotein, low-fat diet, rather than a conventional weight-loss diet, in obese adults with type 2 diabetes: one-year follow-up of a randomized trial. Diabetologia 2004;47:1677-1686.
25 Trichopoulou A, Costacou T, Bamia C, Trichopoulos D: Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 2003;348:2599-2608.
26 Katsilambros N, Kostalas G, Michalakis N, et al: Metabolic effects of long-term diets enriched in olive oil or sunflower oil in non-insulin-dependent diabetes. Nutr Metab Cardiovasc Dis 1996;6:164-167.
27 Thanopoulou A, Karamanos B, Angelico F, et al, Multi-Centre Study of the Mediterranean Group for the Study of Diabetes (MGSD): Nutritional habits of subjects with type 2 diabetes mellitus in the Mediterranean basin: comparison with the non-diabetic population and the dietary recommendations. Multi-Centre Study of the Mediterranean Group for the Study of Diabetes (MGSD). Diabetologia 2004;47:367-376.
28 Pitsavos C, Makrilakis K, Panagiotakos DB, Chrysohoou C, et al: The J-shape effect of alcohol intake on the risk of developing acute coronary syndromes in diabetic subjects: the CAR-DI02000 II Study. Diabet Med 2005;22:243-248.
Ms. Franz: It is essential that nutrition recommendations be evidence-based, but it is also important to have evidence that recommendations can be implemented in the 'real world' and that outcomes from free-living subjects are similar to the findings from subjects in controlled research settings. For example, a number of small, short-term studies have reported benefits from a diet with 30% of energy intake from protein . However, in a study comparing long-term compliance to diets low in fat and high in either protein or carbohydrate, at the 52-week follow-up protein intake was similar in each group suggesting that long-term it is difficult to change protein intake .
Dr. Katsilambros: Thank you very much for your comments.
1 Gannon MC, Nuttall FQ, Saeed A, et al: An increase in dietary protein improves the blood glucose response in persons with type 2 diabetes. Am J Clin Nutr 2003;78:734-741.
2 Brinkworth GD, Noakes M, Keogh JB, et al: Long-term effects of a high-protein, low-carbohydrate diet on weight control and cardiovascular risk markers in obese hyperinsulinemic subjects. Int J Obes Relat Metab Disord 2004;28:661-670.
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