Role of Diet in Prediabetes: Time to Prevent a Preventable Disease

Introduction

Diabetes is the fastest growing non-communicable disease (NCD) in the world.1 Diabetes is difficult to treat and is expensive to manage. Not just adults, diabetes now seems to target teenagers and children as well.1

Epidemiology

India is considered the diabetes capital of the world.2 In 2014, more than 422 million people had diabetes worldwide.3 In India, in 2015 there were 69.2 million people living with diabetes and of these, it remained undiagnosed in more than 36 million.4

Diabetes, if not properly managed, can lead to several complications such as1:

  • Cardiovascular disease
  • Stroke
  • Nephropathy
  • Peripheral vascular disease
  • Blindness
  • Lower limb amputations

Risk Factors for Development of Diabetes

Diabetes poses an economic and social burden to the nation.2  Indians are predisposed to diabetes due to their genetic susceptibility as well as various environmental factors such as obesity, regional adiposity, and higher percentage of body fat.5  By 2025, it is expected that most people with diabetes in developing countries would be in the 45 to 64 years age bracket and thus have a major impact on the economic productivity of the nation.2  The rise in prevalence of diabetes and other NCDs is due to a combination of factors such as6:

  • Sedentary lifestyle
  • Obesity
  • Rapid urbanization
  • Unhealthy diet habits
  • Tobacco use

Prediabetes: A Preventable Condition

Prediabetes, on the other hand, is an intermediate state of hyperglycaemia where the glycaemic parameters are above the normal but below the defined diabetes threshold.7 Prediabetics have an increased risk of progression to diabetes; approximately 30% within 10 years.8,9

When β-cell fails to compensate for increased insulin resistance, hyperglycaemia develops which progresses into diabetes as β-cell failure worsens.10 However, prediabetes is a reversible condition.8

Risk factors associated with development of prediabetes

The risk factors are same for prediabetes as well as diabetes. According to American Diabetes Association (ADA) some of the factors responsible for the development of prediabetes are as following: 

  • Obesity (Body mass index ≥25 kg/m2)
  • Lack of physical activity.
  • Previous history of Impaired fasting glucose/ Impaired glucose tolerance (IFG or IGT), HbA1c ≥5.7%
  • Hypertension and hyperlipidaemia
  • History of cardiovascular conditions
  • History of type 2 diabetes mellitus (T2DM) in first degree relative such as parents or siblings
  • Women diagnosed with gestational diabetes mellitus
  • Age above 45 years
  • Women with polycystic ovarian syndrome

Other than progression into full-blown diabetes, prediabetes is also associated with the development of nephropathy, neuropathy, diabetic retinopathy and the risk of macrovascular disease.11 Various environmental factors responsible for diabetes can be easily modified, and hence diabetes can largely be prevented.5 WHO recommends the following steps to prevent or delay the onset of type II diabetes3:

  • Eating a healthy diet
  • Maintaining a normal body weight
  • Being physically active
  • Avoiding tobacco use

Lifestyle Interventions to Prevent Diabetes

Changes in lifestyle can dramatically reduce the chances of developing type II diabetes. Excess weight is the single most important factor responsible for developing type II diabetes.10 Obesity increases the risk of developing type II diabetes almost by 20 to 40 times and a loss of 7% to 10% of weight can decrease the risk of developing type II diabetes by 50%.1 A healthy lifestyle that includes physical activity and a healthy diet that helps achieve weight loss is of crux in reducing the risk of type II diabetes.10

Improving Diet Patterns

Due to the increasing burden of NCDs, the WHO Global Strategy on Diet, Physical Activity and Health was developed in 2004.12  It states that unhealthy diets and physical inactivity are the leading causes of major NCDs.12  Its recommendations include the following12:

  1. To achieve a healthy weight and energy balance
  2. To eliminate trans-fatty acids in the diet, and use good polyunsaturated fats rather than saturated fats
  3. To choose a diet rich in whole grains, legumes and fruits and vegetables
  4. To decrease the use of refined sugars and of salt from all sources

Diet constitutes an important aspect in the prevention or delay the onset of diabetes in prediabetics as well.10

According to National Cholesterol Education Program (NCEP) recommendations, prediabetics or people with a high risk of diabetes are required to decrease their energy intake, trans fats and saturated fat consumption.10

A study by Stentz et al. showed 100% remission of prediabetes with a diet high in proteins and a significant improvement in the metabolic parameters compared with a diet high in carbohydrates.13  The high-protein diet markedly augmented insulin sensitivity and reduced cardiovascular risk compared with a high-carbohydrate diet.13  High-protein diets suppress hunger, induce satiety and maintain lean body mass. It also helps preserving β-cell function.13

The table shows the recommended and not recommended dietary patterns for glucose metabolism and diabetes mellitus.5,10

Dietary Pattern for Type II Diabetes

Dietary intake to increase Dietary intake to decrease
  • Food rich in unsaturated fatty acids
  • Dietary fibre
  • Whole grains, fruits, vegetables
  • Low fat dairy products and low-fat cheeses
  • Lean meat
  • Trans-fat and saturated fat
  • Fish, poultry, tree nuts and legumes
  • Red meat
  • Salt
  • Sugar-sweetened beverages and fruit juices

Regular physical activity

Based on the result of a meta-analysis, the American Diabetes Association (ADA) has recommended physical activity of moderate intensity for 150 minutes per week for prediabetics.10 Activity improves the ability of muscles to use insulin and absorb glucose.1 Regular exercise also helps in reducing blood pressure which in turn reduces the risk of development of diabetes.

Role of Healthcare Providers

The diagnosis of prediabetes provides an opportunity to the healthcare providers (HCPs) to identify the individuals that carry a high risk of developing diabetes. Individuals with prediabetes must be encouraged to maintain a healthy body weight.  An HCP must counsel such individuals for adapting healthy lifestyle such as indulging in regular physical activities and adapting healthy diet patterns to help reduce the body weight in order to prevent or delay the onset of diabetes and its associated complications.10,14

Conclusion

To prevent progression of prediabetes to full-blown diabetes, lifestyle interventions to achieve an ideal body weight along with moderate activity has been recommended by ADA and form an integral part of management of diabetes.11,14  In addition, diet forms an important aspect in the management of diabetic patients, and hence adoption of a healthy dietary pattern is important for prevention of type II diabetes.

 

References

  1. Harvard T.H. Chan School of Public Health. The nutrition source: simple steps to preventing diabetes [Internet]; 2017 [cited 2017 October 24]. Available from: https://www.hsph.harvard.edu/nutritionsource/diabetes-prevention/preventing-diabetes-full-story/.
  2. Yesudian CAK, Grepstad M, Visintin E, Ferrario A. The economic burden of diabetes in India: a review of the literature. Globalizat Health 2014;10:80. doi:10.1186/s12992-014-0080-x.
  3. World Health Organization. Diabetes: Fact sheet [Internet]; 2017 [cited 2017 October 24]. Available from http://www.who.int/mediacentre/factsheets/fs312/en/.
  4. World Health Organization. World Health Day 2016: Diabetes [Internet]; 2017 [cited 2017 October 24]. http://www.searo.who.int/india/mediacentre/events/2016/en/
  5. Asif M. The prevention and control the type-2 diabetes by changing lifestyle and dietary pattern. J Educ Health Promot. 2014;3:1. doi:10.4103/2277-9531.127541.
  6. World Health Organization. Diabetes [Internet]; 2017 [cited 2017 October 24]. Available from http://www.searo.who.int/india/topics/diabetes_mellitus/en/.
  7. Tuso P. Prediabetes and lifestyle modification: time to prevent a preventable disease. Perm J 2014;18(3):88-93.
  8. Murray MT. Diabetes mellitus. In: Pizzorno JL, Murray MT, editors. Textbook of natural medicine. 4th ed. St. Louis: Churchill Livingstone; 2013. p. 1320-48.
  9. Bock G, Man CD, Campioni M, Chittilapilly E, Basu R, Toffolo G, et al. Pathogenesis of pre-diabetes: mechanisms of fasting and postprandial hyperglycemia in people with impaired fasting glucose and/or impaired glucose tolerance. Diabetes 2006;55:3536-49.
  10. Eikenberg JD, Davy BM. Prediabetes: a prevalent and treatable, but often unrecognized clinical condition. J Acad Nutr Diet. 2013;113(2):213–18.
  11. Bansal N. Prediabetes diagnosis and treatment: a review. World J Diabetes 2015;6(2):296-303.
  12. World Health Organization. Global strategy on diet, physical activity and health [Internet]; 2004 [cited 2017 October 24]. http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf.
  13. Stentz FB, Brewer A, Wan J, Garber C, Daniels B, Sands C, et al. Remission of pre-diabetes to normal glucose tolerance in obese adults with high protein versus high carbohydrate diet: randomized control trial. BMJ Open Diabetes Res Care 2016;4:e000258.
  14. Unger J, White R. Diabetes mellitus. In: Rakel RE, Rakel DP, editors. Textbook of family medicine. 9th ed. Philadelphia, PA: Elsevier; 2014. p. 782-816.e3.

 

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