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Preventi ve Medi ci ne 29, 8791 (1999)

Arti cl e I D pmed.1999.0529, avai l abl e onl i ne at http://www.i deal i brary.com on

Toward Improved Management of NIDDM: A Randomized, Controlled,
Pilot Intervention Using a Lowfat, Vegetarian Diet
Andrew S. Ni chol son, M.D.,* Mark Skl ar, M.D., Neal D. Barnard, M.D.,*
Saroji ni Gore, R.D., C.D.E.,
Ri ck Sul l i van, M.S., and Shaunagh Browni ng, R.N., C.D.E.
*Physicians Committeefor ResponsibleMedicine; Department of Endocrinology, Georgetown University Medical Center,
Washington, DC; and Montgomery County Department of Mental Health Services, Rockville, Maryland
reductionsof serumcholesterol and24-hmicroalbumi-
Obj ecti ve. Toinvestigatewhether glycemic and lipid
nuria did not reach statistical significance; however,
control in patients with non-insulin-dependent diabe-
high-density lipoprotein concentration fell more
sharply (0.20mmol/L) in the experimental group than
fat, vegetarian (vegan) diet in the absence of recom-
in the control group (0.02 mmol/L) (P 0.05).
mendations regarding exercise or other lifestyle
Concl usi on. The use of a lowfat, vegetarian diet in
patients with NIDDM was associated with significant
Methods. Eleven subjects with NIDDM recruited
fromtheGeorgetownUniversityMedical Center or the
body weight in the absence of recommendations for
local community were randomly assigned to a lowfat exercise. A larger study is needed for confirmation.
vegan diet (seven subjects) or a conventional lowfat 1999 American Health Foundation and Academic Press
diet (four subjects). Two additional subjects assigned Key Words: diet; diet therapy; NIDDM; vegetarian
to the control group failed to complete the study. The diet; vegetarianism.
dietswerenot designedtobeisocaloric. Fastingserum
glucose, body weight, medication use, and blood pres-
surewereassessedat baselineandbiweeklythereafter
Approxi matel y 8 mi l l i on Ameri cans have di abetes
for 12 weeks. Serum lipids, glycosylated hemoglobin,
mel l i tus, the vast majori ty of whom have NI DDM [1].
urinary albumin, anddietary macronutrientswereas-
Long-standi ng di abetes i s often accompani ed by severe
sessed at baseline and 12 weeks.
and l i fe-threateni ng compl i cati ons, parti cul arl y cardi o-
Resul ts. Althoughthesamplewasintentionallysmall
vascul ar di sease, reti nopathy, nephropathy, and neu-
in accordance with the pilot study design, the 28%
ropathy [25].
mean reduction in fastingserumglucoseof theexperi-
I n epi demi ol ogi c studi es, l owfat pl ant-based di ets are
mental group, from 10.7 to 7.75 mmol/L (195 to 141
associ ated wi th a markedl y reduced preval ence of
mg/dl),wassignificantlygreater thanthe12%decrease,
NI DDM and i ts compl i cati ons, compared to unmodi fi ed from 9.86 to 8.64 mmol/L (179 to 157 mg/dl), for the
di ets, suggesti ng an i mportant rol e for such di ets i n control group (P 0.05). Themean weight losswas 7.2
cl i ni cal practi ce [611]. Accordi ngl y, studi es usi ng l ow- kg in the experimental group, compared to 3.8 kg for
thecontrol group(P 0.005).Ofsixexperimental group fat vegetari an and near-vegetari an di ets have yi el ded
subjects on oral hypoglycemic agents, medication use excel l ent gl ycemi c control , reduced need for hypogl yce-
was discontinued in oneand reduced in three. Insulin
mi c medi cati ons, and reduced neuropathi c symptoms,
was reduced in both experimental group patients on
but the i nterpretati on of al l such studi es to date has
insulin. Nopatient in thecontrol group reduced medi-
been compl i cated by thei r i ncl usi on of exerci se recom-
cation use. Differences between thediet groups in the
mendati ons [1214]. The current study was desi gned
as a pi l ot i nvesti gati on of the effect of a di etary i nterven-
ti on al one usi ng a randomi zed, control l ed desi gn.
Thi s research was supported by a grant from the Di abetes Acti on
Research and Educati on Foundati on, wi th addi ti onal fundi ng from
the Physi ci ans Commi ttee for Responsi bl e Medi ci ne.
Thi rteen outpati ent subjects (si x men, seven women)
To whom correspondence and repri nt requests shoul d be ad-
wi th NI DDM were recrui ted from the Georgetown Uni -
dressed at 5100 Wi sconsi n Avenue, Sui te 404, Washi ngton, DC 20016.
Fax: (202) 686-2216. versi ty medi cal and endocri ne cl i ni cs and through a
87 0091-7435/99 $30.00
Copyri ght 1999 by Ameri can Heal th Foundati on and Academi c Press
Al l ri ghts of reproducti on i n any form reserved.
newspaper adverti sement. I ncl usi on cri teri a were non- weeks. The 3-day di etary record i s consi dered to be a
qual i tati ve representati on of nutri ent i ntake [15]. Re- i nsul i n-dependent di abetes mel l i tus, age greater than
25 years, wi l l i ngness to attend al l components of the cords were anal yzed i n the Department of Nutri ti on
and Food Sci ence at the Uni versi ty of Maryl and, usi ng study, and resi dence wi thi n commuti ng di stance of
Georgetown Uni versi ty. Excl usi onary cri teri a i ncl uded Nutri ti oni st I V for Wi ndows. I n addi ti on, di etary com-
pl i ance was assessed weekl y through sel f-report ques- smoki ng, regul ar al cohol use, current or past drug
abuse, pregnancy, psychi atri c i l l ness, and medi cal i n- ti onnai res handed out at the group meal s.
The groups attended separate hal f-day ori entati on stabi l i ty. Each subject compl eted a medi cal hi story and
physi cal exami nati on, and l aboratory speci mens were sessi ons expl ai ni ng the general rol e of nutri ti on i n di a-
betes, the overal l study structure, and the di et to whi ch col l ected for fasti ng serum gl ucose, hemogl obi n A1C,
serum l i pi ds, and uri nary mi croal bumi n. they were assi gned. Thereafter, subjects attended
twi ce-weekl y support groups, strati fi ed by treatment Subjects were randoml y assi gned to ei ther an experi -
mental l owfat vegan di et (seven subjects) or a control assi gnment, whi ch i ncl uded cooki ng and nutri ti on
cl asses and a shared meal , for the remai nder of the di et (si x subjects) for a peri od of 12 weeks. Two control
group subjects, both femal e, dropped out of the study study. Subjects were encouraged to i nvi te a spouse, si b-
l i ng, parent, or fri end to joi n them i n thei r assi gned due to an unrel ated medi cal probl em i n one case and a
fami l y emergency i n the other. Data from these subjects di ets and i n group sessi ons.
Subjects met wi th the medi cal di rector or nurse-proj- were not i ncl uded i n the anal ysi s.
The vegan di et consi sted of whol e grai ns, vegetabl es, ect coordi nator every 2 weeks. Medi cati on needs were
assessed at these vi si ts and as needed between vi si ts, l egumes, and frui ts. Ani mal products, added oi l s, sug-
ars, and refi ned carbohydrates, such as whi te bread or accordi ng to an establ i shed protocol . Bl ood pressure
was measured bi weekl y usi ng a standard cuff of a si ze refi ned pasta, were proscri bed. A typi cal menu con-
si sted of l enti l soup, cucumber sal ad, and ri ce crackers appropri ate to the subjects arm, wi th subjects i n a
seated posi ti on after resti ng at l east 5 mi n, averagi ng for l unch and garbanzo stew, bul gur, and l eafy greens
for di nner. The di et deri ved 1015% of cal ori es from the resul ts of two to three measurements. Wei ght was
measured bi weekl y to the nearest 0.1 kg, wi th i ndoor protei n and l ess than 10% of cal ori es from fat, wi th
the remai ni ng cal ori es comi ng from unrefi ned compl ex cl othi ng but wi thout shoes, usi ng a di gi tal scal e. Dura-
ti on of exerci se per week was ascertai ned for each par- carbohydrates. Chol esterol content was zero. The di et
was adequate i n al l nutri ents except vi tami n B
. ti ci pant at basel i ne and 12 weeks, but no exerci se rec-
ommendati ons were made. Vi tami n B
suppl ementati on was recommended for
those pl anni ng to conti nue the di et after the studys Fasti ng serum gl ucose was measured at basel i ne and
bi weekl y thereafter usi ng an Abbott Spectrum anal yzer concl usi on.
The control di et emphasi zed the use of fi sh and poul - (Abbott Park, I L) wi th a gl ucose oxi dase method [16].
Fasti ng serum l i pi ds were measured at basel i ne and 12 try, rather than red meat. I t was desi gned to deri ve
5560% of cal ori es from carbohydrate and l ess than weeks. Chol esterol and tri acyl gl ycerol concentrati ons
were measured usi ng an Abbott Spectrum anal yzer by 30% of cal ori es from fat, wi th approxi matel y 200 mg of
chol esterol per day. enzymati c methods [17,18]. Hi gh-densi ty l i poprotei n
(HDL) chol esterol concentrati on was measured after For al l l unches and di nners duri ng the 12-week study,
subjects i n both groups were offered prepared meal s doubl e preci pi tati on wi th dextran and MgCl
[19]. Low-
densi ty l i poprotei n (LDL)chol esterol concentrati on was conformi ng to thei r respecti ve di et gui del i nes and re-
qui ri ng onl y reheati ng at home. Menus were anal yzed esti mated usi ng the Fri edewal d equati on [20].
Gl ycosyl ated hemogl obi n was assayed at basel i ne usi ng Nutri ti oni st I V for Wi ndows (Fi rst Databank Di -
vi si on, Hearst Corporati on, San Bruno, CA, Apri l 1995). and 12 weeks usi ng affi ni ty chromatography on an Ab-
bott I Mx anal yzer [21]. Uri nary mi croal bumi n was as- Because the vegan di et was much l ower i n fat, the di ets
were not desi gned to be i socal ori c. The mean energy sayed at basel i ne and 12 weeks usi ng a doubl e anti body
radi oi mmunoassay ki t provi ded by Di agnosti c Products content of a prepared vegan l unch and di nner was 1,050
kcal (4,390 kJ) and 1,200 kcal (5,030 kJ) for the control Corporati on (Los Angel es, CA). Laboratory tests were
performed at Georgetown Uni versi ty. di et. Parti ci pants were responsi bl e for prepari ng thei r
own breakfast and were free to add any desi red quanti - Anal ysi s of covari ance was used to test the effect of
di et on gl ycosyl ated hemogl obi n, 24-h uri nary mi croal - ti es of foods to thei r di ets at any ti me of day wi thout
cal ori c restri cti on, provi ded that they adhered to the bumi nuri a, serum total chol esterol , LDL, HDL, and tri -
acyl gl ycerol concentrati ons. The 12-week measure was prescri bed gui del i nes. Subjects were permi tted to pre-
pare thei r own meal s i f they so chose, al though most the outcome vari abl e, and the basel i ne measure was
the covari ate. Thus, the anal ysi s exami ned the effect used the catered meal s.
Subjects compl eted a 3-day di etary record, i ncl udi ng of di et on the 12-week val ues, adjusti ng for the base-
l i ne val ues. 2 weekdays and 1 weekend day, at basel i ne and 12
unchanged, fi ber i ntake i ncreased, and chol esterol i n- TABLE 1
take decreased. Al though verbal reports from al l sub-
Basel i ne Demographi c and Cl i ni cal Characteri sti cs
jects duri ng group meeti ngs i ndi cated good adherence
Experi mental Control
to thei r di ets, two experi mental group subjects l ater
(n 7) (n 4)
i ndi cated to the project coordi nator several l apses i n
Mean age (years) 51 60 compl i ance.
Age range 3462 5174
The vegan group parti ci pants exerci sed somewhat
Women 3 2
more at basel i ne than di d those i n the control group (a
On oral hypogl ycemi c agents 6 4
mean of 3.4 and 2.2 h per week, respecti vel y), and these
On i nsul i n 2 0
fi gures remai ned essenti al l y unchanged at 12 weeks
Hi story of hypertensi on 5 4
Recei vi ng anti hypertensi ves 5 4
(3.4 and 2.0 h per week, respecti vel y).
Hi story of coronary artery bypass
I n order to test the effect of di et group on body wei ght,
graft surgery 1 1
a mul ti vari ate anal ysi s of covari ance was done wi th
basel i ne wei ght as the covari ate and si x bi weekl y
wei ght measures as the dependent vari abl es. Di et ex-
Al l other vari abl es were tested usi ng mul ti vari ate
erted a si gni fi cant effect on the si x bi weekl y wei ght
anal ysi s of covari ance due to the use of mul ti pl e mea-
measures duri ng the i nterventi on (F(1,5) 20.9,
surements duri ng the i nterventi on. I n these anal yses,
p .005). The experi mental group l ost an average of
the basel i ne measure was a covari ate, di et group was
7.2 kg over 12 weeks, compared to a mean wei ght l oss
the i ndependent vari abl e, and the repeated measure-
of onl y 3.8 kg i n the control group (Tabl e 3).
ments over the i nterventi on were the dependent vari -
A si mi l ar anal ysi s of fasti ng serum gl ucose reveal ed
abl es. A two-tai l ed p of .05 was used as the cri teri on
a si gni fi cant di fference between groups on si x bi weekl y
for stati sti cal si gni fi cance. Anal yses were performed
measures (F(1,5) 13.97, p .05). Because much of
usi ng SAS 6.10 for Mi crosoft Wi ndows (Cary, NC, 1995).
the i mprovement i n fasti ng gl ucose occurs i n the i ni ti al
The study was approved by the Georgetown Uni ver-
days fol l owi ng di etary change and because there i s nor-
si ty I nsti tuti onal Revi ew Board.
mal l y substanti al vari abi l i ty i n fasti ng val ues, an i nter-
venti on mean was created for descri pti ve purposes by
averagi ng the si x bi weekl y i nterventi on val ues. Fasti ng
serum gl ucose val ues dropped 28%from basel i ne to the Basel i ne demographi c data are presented i n Tabl e 1.
i nterventi on mean for the experi mental group, com- None of the subjects had major mi crovascul ar di abeti c
pared to a 12% decrease i n the control group (Tabl e compl i cati ons. Three vegan group parti ci pants and one
3). The effect of di et on gl ycosyl ated hemogl obi n was control group parti ci pant were on l i pi d-l oweri ng agents.
not si gni fi cant. None had had congesti ve heart fai l ure or unstabl e
Whi l e there were substanti al changes i n serum l i pi d angi na i n the 3 months pri or to the study or any hi story
val ues, no si gni fi cant effect was found for di et group of myocardi al i nfarcti on, l i ver di sease, or thyroi d
on total chol esterol , LDL, or tri acyl gl ycerol concentra- abnormal i ti es.
ti ons. However, there was an effect of di et group on Basel i ne di ets were si mi l ar for the two groups (Tabl e
HDL, wi th a greater decrease i n the experi mental group 2). Duri ng the course of the study, fat, chol esterol , and
(F(1,8) 7.13, p.05, Tabl e 3). There were no changes protei n i ntakes decreased substanti al l y for the experi -
i n the use of l i pi d-l oweri ng medi cati ons. mental group, whi l e carbohydrate and fi ber i ntake i n-
creased. I n the control group, total fat i ntake remai ned Most i ndi vi dual s i n the experi mental group showed
Di etary Characteri sti cs
Experi mental Control
(n 7) (n 4)
Basel i ne 12 weeks Basel i ne 12 weeks
Total energy (kcal /day) 1683 (435) 1409 (549) 1430 (403) 1526 (314)
Protei n (% of energy) 20 (5.9) 14 (1.6) 23 (9.7) 18 (1.4)
Carbohydrate (% of energy) 46 (7.0) 75 (4.4) 46 (10.1) 51 (3.5)
Fi ber (g) 14 (4.3) 26 (8.2) 12 (2.4) 20 (2.7)
Total fat (% of energy) 34 (5.3) 11 (4.7) 31 (8.5) 31 (2.4)
Saturated fat (% of energy) 10 (2.4) 3 (2.0) 11 (2.2) 8 (1.8)
Chol esterol (mg) 289 (86) 4.4 (7.4) 310 (185) 122 (31)
Note. Standard devi ati ons are i ndi cated i n parentheses.
Cl i ni cal Changes from Basel i ne to 12 Weeks
Experi mental Control
(n 7) (n 4)
Basel i ne 12 weeks Basel i ne 12 weeks
Wei ght (kg)* 96.7 (13.3) 89.5 (14.4) 97.0 (22.9) 93.2 (22.2)
FSG (mmol /L)** 10.74 (2.85) 7.75 (2.07) 9.86 (1.63) 8.64 (0.20)
HbA1C (%) 8.3 (1.7) 6.9 (1.1) 8.0 (1.1) 7.0 (0.6)
Chol (mmol /L) 5.26 (1.09) 4.63 (1.32) 5.56 (0.61) 4.93 (0.46)
HDL (mmol /L)** 1.15 (0.32) 0.95 (0.28) 1.12 (0.17) 1.10 (0.17)
TG (mmol /L) 2.12 (0.78) 1.87 (0.63) 2.29 (1.92) 1.85 (1.14)
Syst BP (mm Hg) 136.6 (10.0) 126.2 (14.9) 149.5 (21.6) 130.6 (11.9)
Di ast BP (mm Hg) 84.0 (4.5) 78.2 (9.7) 86.0 (15.8) 75.4 (11.6)
Mi croal bumi n (mg/24 h) 434.8 (565.5) 155.2 (182.6) 82.9 (114.6) 169.2 (298.0)
Note. Standard devi ati ons are i ndi cated i n parentheses.
The tabl e presents basel i ne and 12-week data onl y. The fasti ng gl ucose and bl ood pressure 12-week val ues are means of bi weekl y
i nterventi on measures.
* p .005 for the effect of di et, control l i ng for basel i ne, on si x bi weekl y measures.
** p .05 for the effect of di et, control l i ng for basel i ne, on si x bi weekl y measures (fasti ng serum gl ucose) or at 12 weeks (HDL).
substanti al decreases i n 24-h mi croal bumi nuri a, i n con- Previ ous studi es usi ng vegetari an or near-vegetari an
trast wi th the mi l d to marked i ncreases seen i n most di ets have yi el ded substanti al i mprovements i n gl y-
of the control subjects (Tabl e 3). However, due to the cemi c control and symptoms of neuropathy, al though al l
wi de range of basel i ne mi croal bumi nuri a val ues wi thi n such studi es have used mi xed i nterventi ons i ncl udi ng
each group, no si gni fi cant effect of di et group was found exerci se [1214,22]. Al though such a di et often causes
on changes i n thi s measurement over the 12 weeks.
wei ght l oss [23], wei ght control i s not the onl y mecha-
Di et group di d not exert a si gni fi cant effect on systol i c
ni sm by whi ch i t may i mprove gl ycemi c management
and di astol i c bl ood pressure.
[24]. Anderson used a hi gh-carbohydrate, hi gh-fi ber
Of si x experi mental group subjects on oral hypogl yce-
di et to achi eve decreases i n fasti ng serum gl ucose i n
mi c agents, medi cati on use was di sconti nued i n one
15 of 20 subjects wi th NI DDM on i nsul i n, despi te the
and decreased i n three. I nsul i n doses decreased i n both
use of meal porti ons that prevented decreases i n body
pati ents on i nsul i n i n the experi mental group. Gl ycemi c
wei ght. Ni ne subjects di sconti nued the use of i nsul i n,
changes i n the control group were i nsuffi ci ent to permi t
yet average fasti ng gl ucose decreased from 9.02 to 8.36
dosage reducti ons i n any of the four control group sub-
mmol /L over the 16-day tri al [25].
jects, al l of whom were treated wi th oral hypogl ycemi c
The i nterpretati on of the present study i s l i mi ted by
agents. No control subjects were taki ng i nsul i n.
i ts smal l sampl e si ze and by the fact that parti ci pants,
Anti hypertensi ve medi cati ons were di sconti nued i n
al l of whom were wi l l i ng to accept assi gnment to a
two of fi ve experi mental group subjects on these medi -
vegetari an di et, may have been more moti vated than
ci nes. Al l four control group subjects were on anti hyper-
other persons wi th di abetes. Al so, our randomi zati on
tensi ve medi ci nes, and one subject stopped one of four
procedures produced two groups that were di ssi mi l ar i n
types he was on i n the course of the study.
uri nary al bumi n concentrati on. Total reported energy
i ntakes for both groups were l ow, suggesti ng underre-
porti ng of food consumpti on, whi ch i s common among
i ndi vi dual s who are not extensi vel y practi ced i n 3-day
Despi te the smal l sampl e si ze, the di fferences be-
di etary records. Our study di d not assess the sus-
tween the treatment groups i n the reducti ons of fasti ng
tai nabi l i ty of our di etary i nterventi on over the l onger
serum gl ucose and body wei ght reached stati sti cal si g-
term, nor di d i t control for the effect of soci oeconomi c
ni fi cance. The 28% reducti on i n fasti ng serum gl ucose
status or wai st-to-hi p rati o.
i n the experi mental group, compared to onl y 12%i n the
Di fferences i n energy i ntake cannot ful l y account for
control group, occurred even though most experi mental
di fferences between the two groups i n wei ght l oss, group subjects reduced thei r use of hypogl ycemi c medi -
whi ch may al so be affected by exerci se, the thermi c cati ons. The 7.2-kg wei ght l oss experi enced by the ex-
effect of food, and resti ng metabol i c rate (whi ch may peri mental group was achi eved wi th no attempt to l i mi t
energy i ntake. be i nfl uenced by a vegetari an di et) [26].
a prospecti ve study of 4,400 pati ents observed between 1947 and
The reducti on i n HDL whi ch occurred i n the experi -
1973. Di abetes Care 1978;1:16880.
mental group i s a common fi ndi ng wi th l owfat and vege-
11. Di abetes Drafti ng Group. Preval ence of smal l vessel and l arge
tari an di ets and appears not to be associ ated wi th el e-
vessel di sease i n di abeti c pati ents from 14 centres: the Worl d
vated atheroscl eroti c ri sk i n the context of a l ow total
Heal th Organi zati on Mul ti nati onal Study of Vascul ar Di sease i n
serum chol esterol concentrati on [23,27,28].
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