What Are the Major Food Components in a Diabetes Diet?

An exhaustive discussion of the many dietary elements that a diabetic must observe from day to day. Includes a table listing examples of healthful foods and their specific benefits.

Carbohydrates

Compared to fats and protein, carbohydrates have the greatest impact on blood sugar, but different carbohydrates have different effects. Carbohydrates are either complex (as in starches) or simple (as in fruits and sugars). One gram of carbohydrates equals four calories. The current general recommendation is that carbohydrates should provide between 50% and 60% of the daily caloric intake.

Complex Carbohydrates. In all cases, complex carbohydrates found in whole grains and vegetables are preferred over those found in starch-heavy foods, such as pastas, white-flour products, and potatoes. In one study, substituting special starch-free bread for normal bread resulted in a significant decline in blood glucose and hemoglobin A1c in type 2 diabetes.

Fiber. Fiber is an important component of many complex carbohydrates. It is found only in plants, particularly vegetables, fruits, whole grains, nuts, and legumes (beans and peas). Fiber cannot be digested but passes through the intestines, drawing water with it and is eliminated as part of feces content. The following are specific advantages from high-fiber diets (up to 55 grams a day) for people with diabetes:

• Studies suggest that diets rich in fiber from whole grains reduce the risk for type 2 diabetes. Sources include dark breads, brown rice, and bran.

• Insoluble fiber (found in wheat bran, whole grains, seeds, and fruit and vegetables) may help achieve weight loss.

• Soluble fiber (found in dried beans, oat bran, barley, apples, citrus fruits, and potatoes), has important benefits for the heart, particularly for achieving healthy cholesterol levels and possibly benefiting blood pressure as well. Simply regularly adding breakfast cereal to a diet appears to reduce cholesterol levels. A new form of barley may have three times the soluble fiber as oats and, in one study, was more effective than oats in controlling blood glucose and insulin. People who increase their levels of soluble fiber should also increase water and fluid intake.

• Although the effect of fiber on diabetes itself is uncertain, a 2000 study reported that a high intake of fiber (50 grams), predominantly soluble, by patients with type 2 diabetes was associated with improved control of glucose and insulin levels compared to a lower-fiber group (about 24 grams).

Fiber supplements, such as Metamucil, Fiberall, and Perdiem do not appear to achieve the same benefits as foods naturally high in soluble fiber. Glucomannan, a natural high fiber powder obtained from a root, however, is showing promise in helping control blood glucose levels, cholesterol, and blood pressure.

Sugar. No difference appears to exist between complex carbohydrates and simple sugars in their ability to raise blood glucose levels and in diets. Fructose (sugar molecule found in fruits) may produce a slower increase in glucose than sucrose (table sugar). This does not mean that diabetics should increase their sugar intake, but people with diabetes can now add fresh fruits to their diets, which have significant health benefits, in higher amounts than previously thought. Still, even fruit intake should be moderate. Long-term studies suggest that over time a high intake of fructose may increase triglycerides (a fat molecule that appears to be harmful to the heart). (In general, excess calories from any sugar will increase triglycerides and harmful cholesterol levels.) Sugar itself adds calories and increases blood glucose levels quickly. It provides no other nutrients. People with diabetes should still avoid products listing more than 5 grams of sugar per serving. If specific amounts are not listed, patients should avoid products with sugar listed as one of the first four ingredients on the label. That being said, the Canadian Diabetes Association has adopted a more liberal attitude, recognizing that many diabetics "cheat." So to a limited extent, satisfying that urge by substituting calories of complex carbohydrates with sweets may be okay.

Artificial Sweeteners

Artificial sweeteners include saccharin, aspartame (Nutra-Sweet, Equal), sucralose (Splenda) and acesulfame K Sucralose, the most recent sweetener works well in baking, unlike most other artificial sweeteners. Early studies found that large amounts of saccharin cause bladder cancer in rats, but the rats were fed huge amounts that do not apply to human diets. (Nevertheless, evidence suggests that those who have six or more servings may have an increased risk.) Aspartame has come under scrutiny because of rare reports of neurologic disorders, including headaches or dizziness, associated with its use. It has been studied more intensively than any other food additive, however, and concern about any major health dangers is unfounded.

Protein

In general, experts recommend that proteins should provide 12% to 20% of calories. Some believe that anyone with diabetes other than pregnant women should restrict protein to about 0.4 grams for every pound of their ideal body weight, about 10% of daily calories. One gram of protein contains four calories. Protein is commonly recommended as part of a bedtime snack to maintain normal blood sugar levels during the night, although studies are mixed over whether it adds any protective benefits against nighttime hypoglycemia. If it does, only small amounts (14 grams) may be needed to stabilize blood glucose levels.

Reducing proteins may help slow the progression of kidney disease, and one 1999 study indicated that a strict-low protein diet may even delay the need for dialysis in patients with kidney failure. (It should be noted that a diet that is severely low in both protein and salt diet while coupled with high fluid intake increases the risk for hyponatremia, a rare condition that can cause fatigue, confusion, and, in extreme cases, can be life-threatening.)

Fish. Fish is still probably the best source of protein for people with diabetes. It has many advantages:

• In one study, fish protein protected rats on high-fat diets against insulin resistance, while plant protein had no effect.

• A number of studies have reported that eating fish or shellfish at least once a week reduces the risk of sudden death from dangerous heart-rhythm abnormalities by more than one half. Oily fish, such as salmon, halibut, swordfish, and tuna, appear to be particularly beneficial. (Studies of people who take fish oil supplements, which contain omega-3 fatty acids, have found no similar benefits, indicating that fish contain other protective substances.)

• Other research indicates that eating fish reduces triglycerides and lipoprotein (a).

• Eating fish also appears to protect the nervous system and may reduce risks for other disorders, including rheumatoid arthritis, asthma, ulcerative colitis, and some types of cancers.

At this time, most studies indicate that eating moderate amounts (one or two servings weekly) of fish offers the most benefits. Some studies found that very high amounts (five or six servings weekly) can be harmful. This risk may be due to the presence of mercury in many kinds of fish (salmon is one exception).

Soy. Soy is an excellent food. It is rich in both soluble and insoluble fiber, omega-3 fatty acids, and provides all essential proteins. Soybeans also contain natural estrogens called isoflavones, which have positive effects on lipid levels. A number of studies have indicated that subjects that consume about 40 grams of soy protein each day reduce LDL by 13%, triglycerides by 11%, and increase HDL by 2%. Four ounces of tofu equals about eight to 13 grams of soy, and a soy burger contains about 18 grams. Powdered soy protein that contains at least 60 mg of isoflavones may provide similar benefits. Tablets of individual isoflavones found in soy, however, do not appear to offer any advantages. (Note: soy sauce contains only a trace amount of soy and is very high in sodium.) Of possible concern, a high intake of soy during pregnancy may have some adverse effect on the fetus, although only animal studies have suggested this. More research is important.

Meat. For heart protection, one 1999 study suggested that it didn't matter if you chose fish, poultry, beef, or pork as long as the meat was lean. (Saturated fat in meat is the primary danger to the heart.) The fat content of meat varies depending on the type and cut. It is best to eat skinless chicken or turkey; the leanest cuts of pork (loin and tenderloin), veal, and beef are nearly comparable to chicken in calories and fat and their effect on LDL and HDL levels. It should be noted, however, that even chicken and lean meat do not improve cholesterol levels, and, in terms of cardiac health, fish is a more desirable choice.

Fats and Oils

General Recommendations for Fat Intake. About two-thirds of cholesterol in the body does not come from cholesterol in food but is manufactured by the liver, its production stimulated by saturated fat (mostly found in animal products). The dietary key to managing cholesterol, then, lies in understanding fats and oils. When it comes to studying the effects of fat on the body, however, the problem is compounded by its complex nature. All fats and oils found in foods are made up of chains of molecules composed of carbon and glycerol called fatty acids and which are bound by hydrogen atoms. There are three major chains:

• Monounsaturated fatty acids. One pair of carbon atoms is missing hydrogen bonds. Found in plant products.

• Polyunsaturated fatty acids. Two or more pairs of carbon atoms are missing hydrogen bonds. Found in plant products.

• Saturated fatty acids. All carbon atoms have the maximum hydrogen bonds. Found in animal products.

The oils and fats that people and animals eat are nearly always mixtures of all three fatty acids, but one type usually predominates. In addition, there are three chemical subgroups of polyunsaturated fatty acids called essential fatty acids: they are omega-3 and omega-6, and polyunsaturated fatty acids and omega-9 monounsaturated fatty acids.

To complicate matters, there are also trans-fatty acids. Most of these are not natural fats but are manufactured by adding hydrogen atoms, a process known as hydrogenation, to polyunsaturated fatty acids. These subgroups are being heavily researched for their specific effects on health.

All fats, both good ones and bad, add the same calories. In order to calculate daily fat intake, multiply the number of fat grams eaten by 9 (one fat gram is equal to 9 calories, whether it's saturated or unsaturated) and divide by the number of total daily calories desired. One teaspoon of oil, butter, or other fats equals about five grams of fat.

Although there is much controversy on the overall effects of fat on health, virtually all experts strongly advise limiting intake of saturated fats and trans-fatty acids (found in commercial baked goods and fast foods). Other fatty acids, however, appear to offer benefits.

Harmful Fats. Reducing consumption of saturated fats and trans-fatty acids is the first essential step in managing cholesterol levels through diet.

Saturated Fats. Saturated fats are found predominantly in animal products, including meat and dairy products. They are strongly associated with higher cholesterol levels. (The so-called tropical oils, palm, coconut, and cocoa butter, are also high in saturated fats. Evidence is lacking, however, about their effects on the heart. The countries with the highest palm-oil intake, Costa Rica and Malaysia, also have much lower heart disease rates and cholesterol levels than Western nations.)

Trans-fatty Acids. Most trans-fatty acids are also dangerous for the heart and may pose a risk for certain cancers. They are created during a process aimed at stabilizing polyunsaturated oils to prevent them from becoming rancid and to keep them solid at room temperature. Some experts believe that these partially hydrogenated fats are even worse than saturated fats because they both increase LDL and reduce HDL cholesterol levels and may have harmful effects on the linings of the arteries. One study of 80,000 nurses reported that women whose total fat consumption was 46% of total caloric intake had no greater risk in general for a heart attack than did those for whom fat represented 30% of calories consumed. Women whose diets were high in trans-fatty acids, however, had a 53% increased risk for heart attack compared to those who consumed the least of those fats. Hydrogenated fats are used in stick margarine and in many fast foods and baked goods, including most commercially-produced white breads. (Liquid margarine is not hydrogenated and is recommended, as is margarine labeled "trans-fatty acid free.") The FDA has now required that food labels include information on trans-fatty acids.

Beneficial Fats and Oils. It should be noted that some fat is essential for health, and fat is essential for healthy development in children. Public attention has mainly focused on the possible benefits or hazards of monounsaturated (MUFA) and polyunsaturated (PUFA) fats. Polyunsaturated fats are found in safflower, sunflower, corn, cottonseed oils, and fish, while monounsaturated fats are mostly present in olive, canola, and peanut oils and in most nuts. Studies, however, do not all agree on their effects. For example, early studies indicate that monounsaturated fats help to maintain healthy HDL levels while polyunsaturated fats reduce them. In general, evidence is not clear on the effects of either MUFA or PUFA on blood glucose and insulin. Some studies have found no effect. In one study, however, sunflower oil, a PUFA, was associated with deterioration in glucose control as well as higher cholesterol levels. Researchers are most interested in the smaller fatty-acid building blocks contained in these oils called essential fatty acids, which may have more specific effects on lipids: three important fatty acids are omega-3, omega-6, and omega-9. Food oils often contain a combination of these building blocks, which may account for the mixed results observed in people consuming them.

• Omega-3 fatty acids: They are further categorized as alpha-linolenic acid (sources include canola oil, soybeans, flaxseed, olive oil, and many nuts and seeds) and docosahexaenoic and eicosapentaenoic acids (sources are oily fish and breast milk).

Alpha-linolenic Acid. Studies have indicated that vegetable oils containing alpha-linolenic acids are heart protective. Extra virgin olive oil has been associated with lower blood pressure. A 2000 study further reported olive oil (as opposed to sunflower oil) may have specific benefits for people with diabetes type 2. Many studies have singled out nuts, which contain omega-3 fatty acids, fiber, and other important substances as being particularly beneficial for the heart by lowering LDL and total cholesterol without increasing triglycerides.

Docosahexaenoic and Eicosapentaenoic Acids. Fish oils, which contain docosahexaenoic and eicosapentaenoic acids, do not have much effect on cholesterol but they may benefit the lining of blood vessel (the endothelium) and therefore improve blood flow. In one animal study, fish oil improved insulin sensitivity. [See also Protein, above.]

• Omega-6 polyunsaturated fatty acids: They are further categorized as linoleic acid (sources are flaxseed, corn, safflower, soybean, and canola oil) or arachidonic acids. PUFA oils containing linoleic constitute most of the oils consumed in the U.S. Some studies have found greater protection against heart disease from omega-6-oils than omega-3, but omega-6 is also associated with increased production of compounds called eicosanoids, which enhance tumor growth in animals.

• Omega-9 fatty acids: (Source is olive oil).

Studies indicate that, in a healthy balance, all of these fatty acids are essential to life. For example, both omega-3 and omega-9 fatty acids contain chemicals that block the harmful eicosanoids found in omega-6 fatty acids. Research suggests, however, that our current Western diet contains an unhealthy ratio (10 to 1) of omega-6 to omega-3 fatty acids. The bottom line, then, is to try to obtain a better balance of fatty acids without consuming too many calories.

Fat Substitutes. Fat substitutes added to commercial foods or used in baking deliver some of the desirable qualities of fat, but do not add as many calories. They include the following:

• Some replacers, such as the cellulose gel Avicel, Carrageenan (made from seaweed), guar gum, and gum arabic, have been used for decades in many commercial foods.

• Plant substances known as sterols have long been known to reduce cholesterol by impairing its absorption in the intestinal tract. A sterol called sitostanol, also called stanol, is now being used in margarines (Benecol, Take Control). Benecol is derived from pine bark and Take Control from soybeans; both are effective. Studies on stanol margarines are reporting that either two servings a day as part of a low-fat diet can lower LDL and total cholesterol. Of concern is the possibility that stanol may block absorption of important fat-soluble nutrients, including vitamins A, E, and D and carotenoids (compounds, such as beta carotene, that convert to vitamin A). One study suggested that it had no effect on the vitamins but did impair absorption of beta carotene. In people already on a low-fat diet, the addition of this margarine may not produce much additional benefit.

• Olestra (Olean) passes through the body without leaving behind any calories from fat. (It should be noted, however, that foods containing olestra still have calories from carbohydrates and proteins.) A 2000 study reported healthful changes in cholesterol levels in people who had been eating olestra for a year. Early reports of cramps and diarrhea after eating food containing olestra have not proven to be significant. Of greater concern is the fact that even small amounts of olestra deplete the body of certain vitamins and nutrients that are important for protection against serious diseases, including cancer. The FDA requires that the missing vitamins be added back to olestra products, but not other nutrients.

• Under investigation are fat substitutes derived from beta-glucan, the soluble fiber found in oats and barley (e.g., Nu-Trim). They may have health benefits beyond reducing calories and replacing hydrogenated or saturated fats.

People should try to limit even reduced-fat foods and fat substitutes in their diets. Although one might believe that eating reduced-fat or fat substitute products means consuming fewer calories, this is often not the case. Many commercial, lowered-fat products have extra calories from sugar and other carbohydrates. A study has found that people who consume foods that contain fat substitutes do not learn to dislike fatty foods, while people who learn to cook using foods naturally lacking or low in fat eventually lose their taste for high fat diets.

Some Examples of Healthy Foods

Dietary Cholesterol

The story on cholesterol found in the diet is not entirely straightforward. Cholesterol is found only in animal tissues, with high amounts occurring in meat, dairy products, egg yolks, and shellfish. The American Heart Association recommends no more than 300 mg of cholesterol per day. One study estimated, however, that reducing dietary cholesterol intake by 100 mg/day would only produce a 1% decrease in cholesterol levels. Of note, however, are studies indicating that although dietary cholesterol itself does not appear to increase the risk for heart disease in most individuals, people with diabetes, especially type 2, may be an exception. Until more research is done, they should consider avoiding eating eggs or other high-cholesterol foods (such as shrimp) more often than once a week.

Vitamins

Antioxidant Properties. Currently, the most important benefit claimed for vitamins A, C, E, and many of the carotenoids and phytochemicals is their role as antioxidants, which are scavengers of particles known as oxygen-free radicals (also sometimes called oxidants). These chemically active particles are by-products of many of the body's normal chemical processes. Their numbers are increased by environmental assaults, such as smoking, chemicals, toxins, and stress. In higher levels, oxidants can be very harmful:

• They can damage cell membranes and interact with genetic material, possibly contributing to the development of a number of disorders including diabetes, cancer, heart disease, cataracts, and even the aging process itself.

• Oxygen-free radicals can also enhance the dangerous properties of low-density lipoprotein (LDL) cholesterol, a major player in the development of atherosclerosis.

Antioxidant vitamins (A, C, and E), carotenoids, and many phytochemicals can neutralize free radicals and may reduce or even prevent some of their damage. Unfortunately, although it is clear that vitamins are required to prevent deficiency diseases, the possible benefits of higher-dose supplements are still unproven in most cases. To date, there is no strong evidence that antioxidant supplements offer any real protection. In some cases, high doses may be harmful. [See Special Warning on High-Dose Antioxidant Supplements, below.]

Vitamin E. Vitamin E may prevent blood clots and the formation of fatty plaques and cell proliferation on the walls of the arteries. Long-term studies of people who took vitamin E supplements, however, are mixed. Many have found little or no benefits. One major 2000 study, for example, reported that patients who took a natural vitamin E at 400 IU for four to six years did not gain any protection against cardiovascular disease. Of interest, however, is a very small 2000 study reporting that when people with type 2 diabetes took high doses (1,200 IU) of vitamin E, they had less evidence of inflammation in blood vessels, an indicator for a higher risk of heart disease and stroke. Other studies have found similar results for people with type 1 diabetes after long term vitamin E supplementation as well as beneficial effects on cholesterol levels. Some experts, in fact, recommend life-long vitamin E supplements specifically for people with type 1 diabetes. Different vitamin E compounds, such as gamma tocopherol or tocotrienol may have benefits that the standard synthetic supplement (dl alpha tocopherol) does not. Studies are fairly consistent in indicating that eating foods rich in natural vitamin E may be protective.

Vitamin C. Vitamin C appears to maintain blood vessel flexibility and to improve circulation in the arteries of smokers. Generally such findings have occurred in the laboratory. There is no evidence, however, that supplements of vitamin C offer any actual protection against heart disease. And there is some evidence that high doses may even speed up existing damaging processes in the arteries.

B Vitamins. Several important studies have demonstrated a link between deficiencies in the B vitamins folic acid (folate), B6, and B12 and elevated blood levels of an amino acid homocysteine, a risk factor for atherosclerosis and possibly for higher mortality rates in people with type 2 diabetes. Folic acid is particularly potent in reducing homocysteine levels. (Eating green vegetables and legumes, enriched cereals and grains, and orange juice, which are rich in folate, can also reduce them.) It is not clear yet, that reducing homocysteine levels will actually protect against heart disease. Major studies are under way and early results of small studies are promising. Another important B vitamin is niacin (Vitamin B3), which has special benefits for patients with unhealthy cholesterol levels. There has been some concern that high levels may actually have adverse effects on glucose control. One 2000 study, however, found that niacin improves cholesterol and triglyceride levels with no significant effect on glucose levels.

Special Warning on High-Dose Antioxidant Supplements

Some studies are now suggesting that excessive use of antioxidant supplements may interfere with other nutrients or convert into pro-oxidants and become harmful. Of particular concern are studies that have found an increase in lung cancer and overall mortality rate among smokers who took beta carotene supplements. A 2000 study further reported a higher risk for cancer in male smokers who took multivitamins plus A, C, or E. In determining reasons for this disturbing effect, one animal study suggested that beta carotene increased enzymes in the lungs that actually promote cancerous changes. And, even more worrisome, in people with existing cancer, high doses of antioxidant vitamins, such as vitamin C or beta carotene, may actually protect cancer cells (just as they do healthy cells). Some evidence also exists that high doses of vitamin C may speed up atherosclerosis.

Minerals

Magnesium. Magnesium deficiency may have some role in insulin resistance and high blood pressure. One study reported that low magnesium levels as measured in blood tests were associated with a higher risk for type 2 diabetes in whites but not in African Americans. Dietary intake of magnesium, however, did not appear to play any role in increasing or reducing risk for either population group. It is more likely that diabetes may cause magnesium loss. No supplements are recommended at this time for patients with adequate levels of magnesium. For people taking diuretics for high blood pressure, extra potassium may be needed, but in other cases, including certain kidney problems, an overload of potassium may occur, so no regular supplements are recommended without consulting a physician.

Chromium. Some studies have reported an association between deficiencies in the mineral chromium and a higher risk for type 2 diabetes. Studies on fat rats that were given chromium reported improvement in insulin sensitivity and glucose metabolism. Studies on human type 2 patients, however, reported few benefits and some adverse side effects.

Many type 2 diabetics are also deficient in zinc; more studies are needed to establish the benefits or risks of taking supplements. Zinc has some toxic side effects, and some studies have associated high zinc intake with prostate cancer.

Salt and Sodium

Salt can raise blood pressure, and people with diabetes should limit salt intake, particularly if they have hypertension, are overweight, or both. Overweight people who have a high sodium intake may be at increased risk for death from heart disease. High salt diets in people who are sensitive to its effects may harm the kidney and brain, even independently of high blood pressure. Restricting salt also enhances the benefits of nearly all standard antihypertensive drugs by reducing potassium loss, and may help protect against kidney disease in patients who are also taking calcium-blocker drugs.

Although it is not clear whether restricting sodium adds any benefits for most people whose diets are rich in fruits, vegetables, and low-fat dairy products and who are not salt-sensitive, it is always wise to aim for a maximum of 2,000 mg sodium intake. Simply eliminating table and cooking salt can be beneficial. Salt alternatives, such as Cardia, containing mixtures of potassium, sodium, and magnesium are now available but are costly. It should be noted, however, that about 75% of the salt in the typical American diet comes from processed or commercial foods, so the benefits of table-salt substitutes are likely to be very modest. Some sodium is essential to protect the heart, but most experts agree that the amount is significantly less than that found in the average American diet.

Caffeine and Alcohol

Alcohol. Studies in 1999 and 2000 have suggested that light to moderate alcohol intake (one or two glasses a day) may have specific benefits for people with type 2 diabetes. In one it was associated with a reduced risk for death from heart disease, and in the other it protected against type 2 diabetes itself. Wine particularly appears to have health benefits. In one study, drinking red wine at meals even reduced blood glucose levels in some cases. (Alcohol itself had no effect on blood glucose or insulin.) In those taking insulin or sulfonylureas, however, alcohol may cause a hypoglycemic reaction, of which the drinker may not be aware. Pregnant women or those at risk for alcohol abuse should not drink alcohol.

Caffeinated Beverages

• Tea. Tea may have a very positive effect on the heart. Although it contains caffeine, it also is rich in flavonoids and other substances that offer protection against damaging forms of LDL. Green tea is often cited for its health benefits but black tea may also be beneficial. In one study, higher intake of black tea, particularly by women, was associated with a reduced risk for severe coronary artery disease. Tea also contains folic acid, which reduces homocysteine levels, a possible factor in coronary artery disease.

• Coffee. Regular intake of coffee has a harmful effect on blood pressure in people with existing hypertension. (Caffeine causes a temporary increase in blood pressure in everyone, which is thought to be harmless in people with normal blood pressure.) Unfiltered coffee (Turkish coffee, Scandinavian boiled or French pressed coffee, and espresso) contains an alcohol called cafestol, which may raise cholesterol levels. Filtered coffee does not contain this residue. Of some concern is a study that reports high levels of homocysteine in people who drink many cups of coffee per day (decaf does not raise these levels). Homocysteine is a possible factor in coronary artery disease. On the other hand, coffee, like red wine, contains phenol, which helps prevent oxidation of LDL cholesterol. A 1999 study reported an effect of caffeine on the brain that has implications for diabetes: it reduces blood flow in the brain even in the presence of sufficient glucose. People with diabetes who drink even two or three cups of coffee may actually believe they are hypoglycemic when their blood glucose levels are normal. One study suggested that this effect may actually help increase awareness of hypoglycemia in some people who have difficulty recognizing its symptoms.

RECENT LITERATURE

A prospective study of whole-grain intake and risk of type 2 diabetes mellitus in U.S. women. Am J Public Health. 2000 Sep;90(9):1409-15.

The effect of breakfast cereal on diet and serum cholesterol: a randomized trial in North Karelia, Finland. Eur J Clin Nutr. 1999 Sep;53(9):716-21.

Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus. N Engl J Med. 2000 May 11;342(19):1392-8.

Dietary treatment of diabetes mellitus. N Engl J Med. 2000 May 11;342(19):1440-1.

A randomized trial comparing the effect of casein with that of soy protein containing varying amounts of isoflavones on plasma concentrations of lipids and lipoproteins. Arch Intern Med. 1999 Sep 27;159(17):2070-6.

The lipid-lowering effect of lean meat diets falls far short of that of vegetarian diets. Arch Intern Med. 2000 Feb 14;160(3):395-6.

Comparison of the effects of lean red meat vs lean white meat on serum lipid levels among free-living persons with hypercholesterolemia: a long-term, randomized clinical trial. Arch Intern Med. 1999 Jun 28;159(12):1331-8.

Dietary fat saturation, but not the feeding state, modulates rates of cholesterol esterification in normolipidemic men. Metabolism. 1999 Oct;48(10):1210-5.

Effect of trans fatty acids on calcium influx into human arterial endothelial cells. Am J Clin Nutr. 1999 Nov;70(5):832-8.

Diet-induced change in fatty acid composition of plasma triacylglycerols is not associated with change in glucagon-like peptide 1 or insulin sensitivity in people with type 2 diabetes. Am J Clin Nutr. 2000 Nov;72(5):1111-8.

Effects of different forms of dietary hydrogenated fats on serum lipoprotein cholesterol levels. N Engl J Med. 1999 Jun 24;340(25):1933-40SM.

Olive oil and reduced need for antihypertensive medications. Arch Intern Med. 2000 Mar 27;160(6):837-42.

Nuts and their bioactive constituents: effects on serum lipids and other factors that affect disease risk. Am J Clin Nutr. 1999 Sep;70(3 Suppl):504S-511S.

Cholesterol-lowering effect of stanol ester in a US population of mildly hypercholesterolemic men and women: a randomized controlled trial. Mayo Clin Proc. 1999 Dec;74(12):1198-206.

Sitostanol administered in lecithin micelles potently reduces cholesterol absorption in humans. Am J Clin Nutr. 1999 Nov;70(5):826-31.

Retinol, vitamin D, carotenes and alpha-tocopherol in serum of a moderately hypercholesterolemic population consuming sitostanol ester margarine. Atherosclerosis. 1999 Aug;145(2):279-85.

Changes in diet, weight, and serum lipid levels associated with olestra consumption. Arch Intern Med. 2000 Sep 25;160(17):2600-4.

A prospective study of egg consumption and risk of cardiovascular disease in men and women. JAMA. 1999 Apr 21;281(15):1387-94 .

Vitamin E supplementation improves endothelial function in type I diabetes mellitus: a randomized, placebo-controlled study. J Am Coll Cardiol. 2000 Jul;36(1):94-102.

Vitamin E supplementation and cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000 Jan 20;342(3):154-60.

Effects of long-term supplementation with moderate pharmacologic doses of vitamin E are saturable and reversible in patients with type 1 diabetes. Am J Clin Nutr. 2000 Nov;72(5):1142-9.

Effect of a palm-oil-vitamin E concentrate on the serum and lipoprotein lipids in humans. Am J Clin Nutr. 1991 Apr;53(4 Suppl):1027S-1030S.

Effect of gamma-tocotrienol on blood pressure, lipid peroxidation and total antioxidant status in spontaneously hypertensive rats (SHR). Clin Exp Hypertens. 1999 Nov;21(8):1297-313.

Vitamin E Works As Anti-Inflammatory Agent In Type II Diabetes. Doctor's Guide, July 10, 2000.

Vitamin C status and mortality in U.S. adults. Am J Clin Nutr. 2000 Jul;72(1):139-45.

Hyperhomocysteinemia increases risk of death, especially in type 2 diabetes : 5-year follow-up of the Hoorn Study. Circulation. 2000 Apr 4;101(13):1506-11.

Effect of dietary patterns on serum homocysteine: results of a randomized, controlled feeding study. Circulation. 2000 Aug 22;102(8):852-7.

Effect of homocysteine-lowering treatment with folic acid plus vitamin B6 on progression of subclinical atherosclerosis: a randomised, placebo-controlled trial. Lancet. 2000 Feb 12;355(9203):517-22.

Effect of niacin on lipid and lipoprotein levels and glycemic control in patients with diabetes and peripheral arterial disease: the ADMIT study: A randomized trial. Arterial Disease Multiple Intervention Trial. JAMA. 2000 Sep 13;284(10):1263-70.

Alcohol consumption and risk of type 2 diabetes mellitus among U.S. male physicians. Arch Intern Med. 2000 Apr 10;160(7):1025-30.

Tea flavonoids may protect against atherosclerosis: the Rotterdam Study. Arch Intern Med. 1999 Oct 11;159(18):2170-4.

ABOUT WELL-CONNECTED

Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians, including faculty at Harvard Medical School and Massachusetts General Hospital. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information, and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition. The reports may not be copied without the express permission of the publisher.

Board of Editors

Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

Stephen A. Cannistra, MD, Oncology, Associate Professor of Medicine, Harvard Medical School; Director, Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center

Masha J. Etkin, MD, PhD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital

John E. Godine, MD, PhD, Metabolism, Harvard Medical School; Associate Physician, Massachusetts General Hospital

Daniel Heller, MD, Pediatrics, Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's Hospital

Paul C. Shellito, MD, Surgery, Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital

Theodore A. Stern, MD, Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital

Carol Peckham, Editorial Director

Cynthia Chevins, Publisher

Lea Kling, Update Editor

© 2000 Nidus Information Services, Inc., by arrangement. From Well-Connected Report: Diabetes Diet. December 2000. (Online) www.well-connected.com. Last reviewed 2001.
 

Original Article from MSN with WebMD http://content.health.msn.com/printing/article/1680.53090

Copyright 2002 Love Offering Inc. All rights reserved