EditorialKeywords: Calorie Restriction (CR); low carbohydrate diet (LCD); Look AHEAD (Action for Health in Diabetes); American Diabetes Association (ADA); Mediterranean Diet
Abbreviations: CR: Calorie Restriction; LCD: Low Carbohydrate Diet; ADA: American Diabetes Association; G-I-N: Guidelines International Network; AHEAD: Action for Health in Diabetes; MACE: Major Cardiovascular Events; MNT: Medical Nutrition Therapy
Editorial
As for nutritional therapy, the discussion concerning Calorie
Restriction (CR) and Low Carbohydrate Diet (LCD) has been
continued. Among them, LCD has shown predominance of efficacy
for glucose variability in the diabetes. Author and colleagues have
continued clinical research of CR and LCD for years, in which the
effect of LCD has been shown [1]. Recent study also indicated the
clinical efficacy of LCD by systematic review [2].
On the other hand, the development of standards for guideline
would give medical organizations to ensure that recommendations
come from various evidence and help medical staffs recognize highquality
guidelines [3]. For this process, the Guidelines International
Network (G-I-N) becomes a network of guideline developers across
the world. Consequently, clinical practice guidelines have been
developed for years, and increasingly prominent for broad areas.
Among them, those become most beneficial tools for standard
decision making in various specialties [4]. A variety of guidelines
were categorized by organizations as consensus-based or evidencebased
background.
There is a significant report of the Look AHEAD (Action
for Health in Diabetes) trial for 4901 participants [5]. They
studied the prediction effect of intensive lifestyle intervention
for Major Cardiovascular Events (MACE) risk, which include all
possible treatment-by-covariate interaction terms. As a result,
hazard ratio from quartile 1-4 was 0.64, 0.81, 1.13 and 1.37,
respectively. It proved to be a significant treatment benefit of
intensive lifestyle intervention. Consequently, Look AHEAD
study showed the efficacy of reducing cardiovascular events by
lifestyle intervention, associated with medical history, physical
examination, and laboratory values [5]. There was a significant
Consensus report by American Diabetes Association (ADA) in 2019
[6]. It was intended to give clinical professionals basal evidencebased
guidance concerning individualizing nutrition therapy for
diabetes or prediabetes. Several important strategies for improving
and maintaining glycemic targets would include weight control,
improving cardiovascular risk factors (blood pressure, lipids, etc.)
within individualized targets.
There is not an ideal eating plan or eating type for the management
and prevention of diabetes. Because diabetic people show a
broad spectrum of diabetes and prediabetes, associated a variety of
co-occurring conditions, personal preferences, cultural situations
and socioeconomic backgrounds. According to various research
for diabetes, there are several choices of eating patterns, which can
lead people to healthier goals and quality of life. As one of the standard
guidelines, Medical Nutrition Therapy (MNT) was shown as
the fundamental diabetes management plan by the ADA. Further- more, MNT will be reassessed by several health care providers in
frequent times for changing life stages and health situations in the
future [7,8]. Current consensus report includes guidelines on prediabetes,
which was not informed in last edition in 2014 [9]. The
characteristic point of this edition would describe prediabetes, type
1 and 2 diabetes mellitus. Nutrition treatment for gestational diabetes
and children is shown in other ADA publications, which is
Standards of Medical care in Diabetes in 2019 [8].
The present consensus report has revealed the fundamental comment as follows [6]. They are
a. Reducing overall carbohydrate intake for diabetic
individuals has demonstrated the most evidence for improving
glycemia and may be applied in a variety of eating patterns that
meet individual needs and preferences, and
b. For select T2DM adults not meeting glycemic targets or
where reducing ant glycemic medications is a priority, reducing
overall carbohydrate intake with low- or very low-carbohydrate
eating plans is a viable approach. There are some consensus
recommendations for eating patterns [6]. They include
a. A variety of eating patterns are acceptable for the
management of diabetes,
b. Health care providers should focus on the key factors
that are common among the patterns, until the evidence
surrounding comparative benefits of different eating patterns
in specific individuals strengthens. Some examples are shown,
including
c. Emphasize non-starchy vegetables.
d. Minimize added sugars and refined grains, and
e. Choose whole foods over highly processed foods to the
extent possible.
The report includes 9 types of nutritional therapy, which are described in the following.
a. U.S. Department of Agriculture (USDA): Dietary guidelines
for Americans: it emphasizes various vegetables including
fruits, grains lower fat dairy and protein foods [10].
b. Mediterranean Diet: It emphasizes plant-based food, fish,
seafood, olive oil, dairy products in low to moderate amounts,
typically fewer than 4 eggs/week, red meat and wine in low
frequency and amounts and rarely concentrated sugars or
honey. It reduces risk of diabetes, A1c value, triglycerides and
risk of major cardiovascular events. There are several evidences
concerning clinical efficacy [11,12].
c. Vegetarian or Vegan: It emphasizes plant-based vegetarian
eating, and devoid all flesh foods without egg or dairy products.
It can reduce risk of diabetes, A1c value, body weight, and lower
LDL-C and non-HDL-C [13,14].
d. Low-Fat: It emphasizes vegetables, fruits, starches, lean
protein sources, and low-fat dairy products. It has some effects
for reducing risk of diabetes and body weight [15,16].
e. Very Low-Fat: It emphasizes fiber-rich vegetables, beans,
fruits, whole intact grains, nonfat dairy, fish, and egg whites and
comprises 70–77% carbohydrate (including 30–60 g fiber),
10% fat and 13–20% protein. It would lower blood pressure
and body weight [17].
f. Low-Carbohydrate Diet (LCD): It avoids starchy and
sugary foods such as rice, pasta, bread, potatoes, and sweets.
There is no consistent definition of LCD. In this review, LCD is
defined as reducing carbohydrates to 26–45% of total calories.
Its effects include A1C reduction, weight loss, lowered blood
pressure, increased HDL-C and lowered triglycerides [18-20].
g. Very Low-Carbohydrate Diet (VLCD): It often has a goal
of 20–50 g of nonfiber carbohydrate a day to induce nutritional
ketosis. In this review, a VLCD eating pattern is defined as
reducing carbohydrate to less than 26% of total calories [18-
20].
h. Dietary Approaches to Stop Hypertension (DASH): It
emphasizes vegetables, fruits, and low-fat dairy products and
includes whole intact grains, poultry, fish, and nuts. In contrast,
it reduces in saturated fat, red meat, sweets, and sugarcontaining
beverages. It can reduce risk of diabetes, body
weight and blood pressure level [21,22].
i. Paleo: It emphasizes foods theoretically eaten regularly
during early human evolution. It includes lean meat, fish,
vegetables, shellfish, eggs, nuts and berries, and avoids grains,
dairy, salt, refined fats, and sugar. It probably has mixed results
and inconclusive evidence [23,24].
Conclusion
In conclusion, further recommendations for individualization
of goals can be observed in the ADA Standards of Medical Care in
Diabetes 2019 [8]. Important focus of management for diabetes
would be
a. Achieving and maintaining body weight goals and
b. Making delay or prevention of complications of diabetes.
This article would be expected to become a reference of
nutritional therapy for diabetes in the future.
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