Alana Todd

NUTR 417

November 9, 2018

Diabetes Prevention for Middle-Aged Female at Risk for Type 2 Diabetes

Diabetes has become one of the most prevalent diseases in the United States, ranked 7th in the leading

causes of death per the CDC. (1) Western medicine has focused primarily on the tertiary prevention for

reducing complications of diabetes once it’s been diagnosed, but using primary and secondary prevention

can be much more beneficial to interrupt diabetes development altogether. While a lot of research is still

being conducted to understand and establish the most appropriate prevention and treatment for diabetes

incidence, there are certainly some behaviors that are recognized to slow down or cease the development

of diabetes. These behaviors include losing weight through healthful eating and physical activity.

Healthful eating involves the consideration of consuming a specific macronutrient composition,

carbohydrates, lipids, protein, and alcohol.

Many studies have primarily focused on a single macronutrient to aid weight loss and prevent chronic

diseases such as diabetes and cardiovascular disease; however, much of the evidence has proven to be

somewhat contradictory. One study analyzed the difference between a low-fat, high carb diet, a moderate

fat, moderate carbohydrate diet, or a high-fat, low carb diet. Protein was held constant for all three groups.

Researchers found that the low-fat, high carb diet was less likely to induce excessive weight gain and had

a reduced risk for cardiometabolic issues than the other two diets (2). On the other hand, some studies

indicated that diets high in other macronutrients are more beneficial for weight loss. In contrast, another

study examined the effect of a high-protein versus a high carbohydrate diet on weight loss and relevant

lab values. This study concluded that there was no significant difference between the two diets on weight

loss nor serum lab results, suggesting that both a high-protein and a high-carb diet can promote weight

loss especially when limiting saturated fat, which acts as a substitute when carbs are lacking in the diet

(3). Even though the recommended macronutrient composition varies between researchers, there might be
some evidence that most researchers can agree on, which is the reduction in caloric intake and physical

activity to aid weight loss. Another study investigated the change in weight loss and body composition by

altering macronutrient proportions, which included a control group with no diet and no exercise, a high

energy diet, a very low carbohydrate and high protein diet, a low carbohydrate and moderate protein diet,

and lastly a high carbohydrate and low protein diet. Following 14 weeks of intervention, all groups that

engaged in regular exercise and restricted calories lost weight, which indicates that macronutrient

composition is less significant for weight loss and overall health (4). Overall, while the distribution of

macronutrients might not predict weight loss or health, the quality, amount, and variance of nutrients may

have a stronger impact on preventing diabetes; however, a macronutrient composition of about 50 percent

carbohydrates, 30 percent protein, and 20 percent fat typically allows for proper nutrient distribution.

Many fad diets demonize carbohydrates, but it’s important to note that carbs function as the body’s

primary source of energy. The type and quality of the carbohydrate matters greatly because quality carbs

like fruits, vegetables, and whole grains also provide the body with essential nutrients, which aid in

preventing diabetes and improving overall health. Carbohydrates are made up of simple sugars and

complex carbs, which are differentiated by size. Simple sugars consist of monosaccharaides and

disaccharides whereas complex carbs consist of longer chain sugar molecules including starch and fiber.

Simple sugars and starch contribute mostly to energy metabolism through glycolysis and fiber contributes

mostly to satiety. In one study, a high-carbohydrate diet, a metformin group, and a placebo group was

analyzed in participants at risk for type 2 diabetes. The group consuming a high-carbohydrate diet saw

better weight loss results when participants consumed foods containing dietary fiber including fruits,

vegetables, and whole grains. Most importantly, the findings suggested that greater carbohydrate intake,

consisting of dietary fiber in addition to an overall calorie reduction yielded the greatest weight loss.

While these dietary alterations made positive weight loss reductions, confounding variables including

socioeconomic status and access to healthful foods, physical activity, and prior nutrition education may

have played a role as well (5). Another study followed middle-aged participants free of cardiovascular

disease, cancer, and diabetes for 12 years. Those who consumed more whole grains and dietary fiber
weighed less than the participants who consumed more refined grains. Additionally, participants who

consumed more whole grains also exhibited increased physical activity, decreased smoking habits, and

greater consumption of protein, dietary fiber, fruits, and vegetables, which may have interfered with any

causal relationship between consumption of whole grains and weight loss (6). Another important

component of carbohydrates to consider is glycemic index, which is defined as the “measure of the blood

glucose raising potential of the carbohydrate content of a food compared to a reference food (generally

pure glucose)” (7). To study the association between glycemic index and body weight, researchers

collected a 7-day dietary and activity recall from 572 healthy adults. The researchers concluded that while

glycemic index was not a significant predictor of energy intake, it was positively and independently

associated with BMI (8). These findings argue that the quality of carbohydrates is the most significant

indicator of weight loss and suggest avoiding refined carbohydrates such as white bread, pastries or added

sugars, which the body uses less efficiently than natural sugars.

Lipids or fats are another highly controversial, but important nutrient to the human diet to keep the

body functioning properly and efficiently. Dietary lipids are more energy dense than carbs and are

considered an important energy source as well providing nutrients and structural components to build

membranes and hormones. About 90 percent of dietary lipids are consumed in the form of triglycerides,

which are structurally made up of one glycerol backbone and three fatty acid chains. The other 10 percent

are consumed as phospholipids and cholesterol, but because the body can synthesize them, they are not

essential to the diet. Similar to dietary carbohydrates, some types of fats are beneficial and some are

harmful. The two different categories of fats include saturated fat and unsaturated fat, which are

characterized by the presence of double bonds and can be broken down into monounsaturated,

polyunsaturated, and trans fat. Saturated fats are typically solid at room temperature are found in dairy

products, red meat, and coconut oil. Sources of unsaturated fats include vegetables like avocado, nuts,

seeds, and fish. A meta-analysis study investigated the correlation between polyunsaturated fat intake and

cardiovascular disease by observing consumption of fatty acids in human adults with and without

cardiovascular disease across varying studies. There was an overall decline of 10 to 13 percent for the risk
of cardiovascular disease in participants who consumed more polyunsaturated fats. Trials that could not

differentiate between polyunsaturated fat intake and other dietary, lifestyle or medication intervention

were excluded from the analysis; however, some confounding variables may still have existed like

environmental risk factors, genetics, and inaccurate recording of dietary intake(9). Another type of fat to

monitor is cholesterol, which derive mostly from animal-based foods. Because of this, cholesterol is a

non-essential lipid. There are a few different types of cholesterol including LDL and HDL. Formed from

VLDL after traveling through circulation, LDL cholesterol is a less dense lipoprotein than VLDL that is

used by membranous cells in need or for synthesizing steroid hormones. High LDL levels can be of

concern because build up can block arterial walls. HDL is a type of lipoprotein synthesized by the liver

that acts to scavenge free cholesterol built up on arterial walls, which is why it is considered the “good”

cholesterol. One study analyzed the effects of following a high cholesterol, high fat diet or a low

cholesterol, low fat diet for 14 days. Fasting oral glucose tolerance tests and blood samples were taken,

which revealed that fasting levels of glucose and insulin in the blood were not statistically significant, but

glucose spikes were lower and there was a 10 percent decrease in total blood cholesterol in the low

cholesterol, low fat diet. The researchers concluded that participants who consumed the high cholesterol,

high fat diet were more prone to developing type 2 diabetes in the future with a relative risk of 1.36 (95%

CI1.17-1.59); however, it is unclear whether there is a causal relationship between the fat or the

cholesterol intake on type 2 diabetes incidence (10). In another study, which investigated the difference

between a very low-carbohydrate ketogenic diet versus low-fat diet for weight loss found that the low-

carb ketogenic diet was associated with greater weight loss and decreased cardiovascular risks, but

increased levels of HDL and LDL cholesterol (11). As mentioned before, since these two studies had

opposing conclusions on weight loss outcomes from a low-fat diet versus a high-fat diet, this finding

supports the claim that macronutrient composition may not be the primary solution to weight reduction,

but rather minimizing overall calories and consuming high quality, less processed foods to reduce the risk

of diabetes.
 Protein has many crucial responsibilities, functioning as enzymes, hormones, structural components,

energy storage, movement and transportation devices, and facilitating the immune system. This makes

protein an extremely essential component to the human diet. Just like carbs and fats, quality and variety of

protein is necessary to feed the body with all the proper nutrients. Protein quality refers to how well a

dietary protein supplies the necessary amino acid building blocks to meet the body’s needs while protein

complementation involves consuming a variety of proteins to compensate for each protein’s lack of

specific amino acids. Following digestion and absorption, broken down proteins become amino acid

units, which can either be used for synthesis of proteins like enzymes, transporters, or hormones, used to

synthesize deficient nonessential amino acids, or catabolized for energy (usually when consumed in

excess). Intakes of each amino acid is required to carry out these necessary bodily functions. One meta-

analysis studied the effects of dietary protein intake, specifically animal versus plant-based protein on the

risk for type 2 diabetes. The results indicated that animal protein intake was associated with a higher risk

of type 2 diabetes whereas plant protein intake was associated with both reduction and risk for type 2

diabetes. The greatest risk reduction was about 6 percent of total energy intake coming from plant protein.

Potential confounders of this meta-analysis might include physical inactivity, genetic predisposition,

caloric intake, and quality of other types of macronutrients consumed(12). This finding indicates that

while quality of protein is significant, balance is also. Too much or too little protein can also be associated

with risks for chronic disease. A similar article investigating the association between dietary protein

intake and type 2 diabetes observed similar results. Dietary recalls were collected from middle-aged

Chinese adults, who were categorized into different groups depending on their main source of protein: red

meat, legumes, seafood, and refined grains. Participants who consumed plant-based proteins had an

inverse relationship with type 2 diabetes and participants who consumed red meat and refined grains had

a positive relationship with types 2 diabetes (13). Another study researched the function of beta-cells,

which produce insulin in response to a plant-based dietary intervention. Beta cell function and efficiency

was measured by postprandial insulin secretion at baseline and after 16 weeks for a plant-based diet group

and a control group, both of whom were asked to make as little changes as possible to their physical
activity habits. The researchers concluded that the plant-based diet group had lower BMI, increased beta

cell sensitivity to glucose, and improved fasting insulin sensitivity (14). Overall, consuming a variety of

quality, less-processed proteins is essential for meeting the needs of the body’s various functions.

While alcohol may not technically be considered a nutrient, there are some properties present that

allow it to act like a nutrient including its use as an energy source and its influence on micro and

macronutrient absorption. Similar to the three other macronutrients, alcohol has a recommended intake

and like most foods, the recommended intake reflects a balance of nutrients. A study published by the

Journal of Diabetes investigated alcohol consumption and the incidence of diabetes-related complications

linked with depressive symptoms on adults with type 2 diabetes. The researchers found that individuals

with a higher alcohol intake were shown to have higher risks of neuropathy and coronary artery disease,

which are a couple of the complications related to diabetes incidence. Other factors that might influence

diabetes risk in this study are the incidence of depression and its effect on motivation and diabetes-related

complications, environment, genetic predisposition for alcoholic behaviors, depression, or diabetes

complications, socioeconomic status, and other health-related complications (15). The Diabetes

Prevention Program also conducted a study on alcohol consumption and the risk of diabetes. Diabetes

Prevention Program participants were shown to have impaired glucose tolerance, elevated fasting glucose,

and a BMI of 24 or higher. Similar to previous study mentioned earlier, the methods included a placebo

group, a metformin group, and a lifestyle intervention group. Alcohol consumption was measured at

baseline and then again at one year. The findings from this study revealed that moderate daily

consumption of alcohol was associated with a lower risk of diabetes incidence. Higher alcohol

consumption was also shown to have lower rates of diabetes incidence in the metformin and lifestyle

intervention groups (16). Consistent with previous findings, a meta-analysis of observational studies

investigating the consumption of alcohol on the risk for type 2 diabetes found that a moderate

consumption, ranging from 6 to 48 grams per day reduced the risk of type 2 diabetes by 30 percent.

Additionally, there was no risk reduction observed in heavy drinkers (≥48 g/day) as well as those who

consumed less than 6 grams per day (17).

 Through extensive research for diabetes prevention, it’s clear that there is no one way to tackle

one of the most dangerous chronic illnesses in America, but there are some approaches that are shown to

be effective. Diets slightly higher in carbohydrates, consisting of fruits, vegetables, whole grains, and

fiber has shown to be the most effective in long term weight loss. It’s also important to occupy the rest of

the meal with healthy fats like unsaturated fats, some saturated fats like dairy, and proteins, primarily

plant-based proteins. Alcohol, just like the three other macronutrients should be consumed in moderation,

ranging from 6 to 48 grams per day. Overall, the best way to prevent diabetes is to consume a diet with a

variety of quality food sources and a reduction in caloric intake for weight loss. A macronutrient

distribution that reflects these recommendations is about 50 to 60 percent carbohydrates, filled by fruits,

vegetables, whole grains, and dietary fiber, 30 percent plant-based and some white-meat protein, and 20

percent unsaturated and some saturated fat.

 References

1. Murphy SL, Xu J, Kochanek KD, Curtin SC, Arias E. Deaths: Final data for 2015. NVSS 2017;

66. https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_06.pdf

2. Wan Y, Wang F, Yuan J, Li J, Jiang D, Zhang J, Huang T, Zheng J, Mann J, Li D. Effects of

macronutrient distribution on weight and related cardiometabolic profile in healthy non-obese

Chinese: A 6-month, randomized controlled-feeding trial. EBioMed 2017; 22: 200-7. Doi:

10.1016/j.ebiom.2017.06.017.

3. Clifton PM, Keogh JB, Noakes M. Long-term effects of a high-protein weight loss diet. Am J

Clin Nutr 2008; 87: 23-29.

4. Kerksick CM, Wismann-Bunn J, Fogt D, Thomas AR, Taylor L, Campbell BI, Wilborn CD,

Harvey T, Roberts MD, La Bounty P, et al. Changes in weight loss, body composition and

cardiovascular disease risk after altering macronutrient distributions during a regular exercise

program in obese women. Nutr J 2010; 9:59. doi: 10.1186/1475-2891-9-59.

5. Sylvetsky AC, Edelstein SL, Walford G, Boyko EJ, Horton ES, Ibebuogu UN, Knowlder WC,

Montez MG, Temprosa M, Hoskin M, et al. A high-carbohydrate, high-fiber, low-fat diet results

in weight loss among adults at high risk of type 2 diabetes. J Nutr 2017; 147: 2060-6. doi:

10.3945/jk.117.252395.

6. Liu S, Willett WC, Manson JE, Hu FB, Rosner B, Colditz G. Relation between changes in intakes

of dietary fiber and grain products and changes in weight and development of obesity among

middle-aged women. Am J Clin Nutr 2003; 78: 920-7.

7. Hidgon J, Drake V, Delage B, Liu S. Glycemic index and glycemic load. OSU 2003.

https://lpi.oregonstate.edu/mic/food-beverages/glycemic-index-glycemic-load

8. Ma Y, Olendzki B, Chiriboga D, Hebert JR, Li Y, Li W, Campbell M, Gendreau K, Ockene IS.

Association between dietary carbohydrates and body weight. Am J Epidemiol 2005; 161: 359-67.
9. Abdelhamid AS, Martin N, Bridges C, Brainard JS, Wang X, Brown TJ, Hanson S, Jimoh OF,

Ajabnoor SM, Deane KH, et al. Polyunsaturated fatty acids for the primary and secondary

prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 7. doi:

10.1002/14651858.CD012345.pub2.

10. Tricó D, Trifiró S, Mengozzi A, Morgantini C, Baldi S, Mari A, Natali A. Reducing cholesterol

and fat intake improves glucose tolerance by enhancing beta cell function in nondiabetic subjects.

J Clin Endocrinol Metab 2018; 103: 622-31. doi: 10.1210/jc.2017-02089.

11. Bueno NB, de Melo IS, de Oliveira SL, da Rocha Ataide T. Very-low-carbohydrate ketogenic

diet v. low-fat diet for long-term weight loss: a meta-analysis of randomized controlled trials. Br J

Nutr 2013; 110: 1178-87.

12. Zhao LG, Zhang QL, Liu XL, Wu H, Zheng JL, Xiang YB. Dietary protein intake and risk of

type 2 diabetes; a dose-response meta-analysis of prospective studies. Eur J Nutr 2018. doi:

10.1007/s00394-018-1737-7.

13. Ke Q, Chen C, He F, Ye Y, Bai X, Cai L, Xia M. Association between dietary protein intake and

type 2 diabetes varies by dietary pattern. Diabetol Metab Syndr 2018; 10: 48. doi:

10.1186/s13098-018-0350-5.

14. Kahleova H, Tura A, Hill M, Holubkov R, Barnard ND. A plant-baesd dietary intervention

improves beta-cell function and insulin resistance in overweight adults: A 16-week randomized

clinical trial. Nutrients 2018; 10. doi: 10.3390/nu10020189.

15. Elgendy R, Deschenes SS, Bruns RJ, Levy M, Schmitz N. Alcohol Consumption, depressive

symptoms, and the incidence of diabetes-related complications. J Diabetes 2018. doi:

10.1111/1753-0407.12822.

16. Crandall JP, Polsky S, Howard AA, Perreault L, Bray GA, Barrett-Connor E, Brown-Friday J,

Whittington T, Foo S, Ma Y, et al. Alcohol consumption and diabetes risk in the Diabetes

Prevention Program. Am J Clin Nutr 2009; 90: 595-601. doi: 10.3945/ajcn.2008.27382.

17. Koppes LLJ, Dekker JM, Hendriks HFJ, Bouter LM, Heine RJ. Moderate alcohol consumption

lowers the risk of type 2 diabetes: A meta-analysis of prospective observational studies. Diabetes

Care 2005; 28: 719-725. https://doi.org/10.2337/diacare.28.3.719