Executive summary: Updates to the dietary treatment of prediabetes and type 2 diabetes mellitus

Pascual Fuster, V.; Pérez Pérez, A.; Carretero Gómez, J.; Caixàs Pedragós, A.; Gómez-Huelgas, R.; Pérez-Martínez, P.

doi:10.1016/j.rceng.2020.10.002

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CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Grupo de Trabajo Nutrición y Estilo de Vida, Sociedad Española de Arteriosclerosis (SEA). 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RA: rapid-acting insulin analogs; NPH: neutral protamine hagedorn; basal insulin: glargine U:100, glargine U:300, degludec, detemir." ] ] ] "textoCompleto" => "IntroductionPrediabetes and type 2 diabetes mellitus (DM2) are diseases whose increasing prevalence in the population have made them into a serious public health problem. From a clinical point of view, control of these metabolic abnormalities directly affects cardiovascular morbidity and mortality, making it necessary to propose effective prevention and treatment strategies.Adequate lifestyle changes significantly reduce the cardiovascular (CV) risk factors associated with prediabetes and type 2 diabetes mellitus. Therefore, healthy eating habits, regular physical activity, abstaining from using tobacco, and good sleep habits are recommended for managing these conditions.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>There is solid evidence that plant-based diets that are low in saturated fatty acids, cholesterol, and sodium and high in fiber, potassium, and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> In view of the foregoing, the Mediterranean diet,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> a low-carbohydrate (CH) diet,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and a vegan-vegetarian diet<a class="elsevierStyleCrossRef" href="#bib0025">5</a> are of note.Additionally, given the relationship between nutrition and these metabolic pathologies, it is fundamental to target efforts at preventing weight gain, reducing excess weight in the case of individuals with overweight or obesity, and personalizing treatment to promote patient empowerment.In this document, we will carry out an updated review which provides useful evidence and recommendations organized into a hierarchy of levels. We have used evidence from clinical trials, where possible; observational studies on clinical evidence or surrogate markers; and expert consensus. Based on the above, three types of recommendations will be made: (1) strong, based on clinical trials and meta-analyses that include quality criteria; (2) moderate, supported by prospective cohort studies and cases and control studies; and (3) weak, justified by expert consensus and opinions or based on extensive clinical practice.In summary, evidence has brought to light the fact that a high proportion of adults present with prediabetes or DM2, with the consequent increase in CV risk in the short- and medium-term. Lifestyle, especially diet, constitutes the main basis of treatment for improving glucose, lipid, and blood pressure control and reducing the high cardiovascular morbidity and mortality present in these individuals.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>This document is an executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in individuals with prediabetes or DM2. The full review is available on the webpages of the Spanish Society of Arteriosclerosis (<a href="https://www.se-arteriosclerosis.org/guias-documentos-consenso">https://www.se-arteriosclerosis.org/guias-documentos-consenso</a>), the Spanish Diabetes Society (<a href="https://www.sediabetes.org/grid/?tipo=cursos_formacion%26categoria=consensos-guias-y-recomendaciones">https://www.sediabetes.org/grid/?tipo=cursos_formacion&categoria=consensos-guias-y-recomendaciones</a>), and the Spanish Society of Internal Medicine (<a href="https://www.fesemi.org/actualizacion-en-el-tratamiento-de-la-prediabetes-y-la-diabetes-tipo-2-consenso-semi-sed-y-sea">https://www.fesemi.org/actualizacion-en-el-tratamiento-de-la-prediabetes-y-la-diabetes-tipo-2-consenso-semi-sed-y-sea</a>).Dietary objectives in the population with prediabetes or type 2 diabetesThe general objective of dietary treatment in individuals with prediabetes or DM2 is to help them modify nutritional habits to prevent and/or delay the disease, improve their metabolic control, treat complications and associated diseases or comorbidities, and maintain or improve quality of life. Within this general objective are specific objectives that are applicable to the majority of the population with DM2 or who are at risk of developing it and which are supported by solid data.<a class="elsevierStyleCrossRefs" href="#bib0005">1,6–8</a>The specific objectives of diet in the population with prediabetes or DM2 are:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040">•Preventing and/or delaying progression to DM2 in individuals with prediabetes. Programs which combine a healthy diet and physical activity are effective in decreasing the incidence of DM2 and improving CV risk factors, with the most intensive programs being the most effective.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>(Strong evidence).</li><li class="elsevierStyleListItem" id="lsti0045">•Achieving and maintaining an individualized glycemic control target. Different nutritional interventions in individuals with DM2, including a reduction in energy intake, allow for absolute decreases in glycosylated hemoglobin (HbA1c) of 0.3%–2.0% at three to six months. This benefit can be maintained or improved if the intervention lasts > 12 months. This improvement is greater in subjects who are recently diagnosed and/or those with higher initial HbA1c levels. Likewise, they allow for decreasing the dose and/or amount of antidiabetic drugs.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>(Strong evidence).</li><li class="elsevierStyleListItem" id="lsti0050">•Reaching and maintaining an individualized weight target. In adults with DM2, nutritional therapy allows for reducing weight (2.4–6.2kg) or does not modify it.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>(Moderate evidence).</li><li class="elsevierStyleListItem" id="lsti0055">•Achieving and maintaining individualized lipid control and blood pressure targets. Nutritional interventions in individuals with normal or nearly normal values improve or do not modify the lipid and blood pressure profile.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>(Moderate evidence).</li><li class="elsevierStyleListItem" id="lsti0060">•Maintaining or improving quality of life. In individuals with DM2, the implementation of nutritional therapy significantly improves their perception of their health status, increases knowledge and motivation, and decreases emotional stress.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>(Strong evidence).</li></ul>Characteristics of the dietCaloric contentThe objective of the diet’s calorie content is to achieve and maintain a reasonable body weight. Reasonable is understood as a more realistic—rather than ideal—weight that is achievable and can be maintained over the short- and long-term.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>The majority (around 80%) of individuals with DM2 have obesity. Therefore, a reduction in weight is, initially, the main therapeutic objective. Obesity, especially abdominal obesity, is the main factor in developing DM2 in subjects who are genetically predisposed to it. Prevention of obesity constitutes the principal measure for reducing incidence of DM2. There is solid evidence on the efficacy of moderate weight loss (5%–10%) in the prevention or delay of progression from prediabetes to DM2.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a>A moderate reduction in calories (≥500kcal/day) along with physical exercise, modification of dietary habits, and psychological support are effective measures that are most used for reaching and maintaining moderate, gradual weight loss. However, the clinical benefits of weight loss are progressive and increase as greater reductions are achieved.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>An alternative for individuals with DM2 and obesity who do not manage to lose weight within a structured program and for select subjects is a very low calorie diet (<800kcal/day), generally liquid, for short periods of time (<3 months) followed by a progressive reintroduction of food. This achieves marked weight loss and, in parallel, remission of DM2 at one year in 50% of subjects.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Models of a healthy diet for the treatment of diabetesThere are various dietary patterns that are considered healthy.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The most well-known patterns are the Mediterranean diet, the Dietary Approaches to Stop Hypertension (DASH) diet, a low CH diet, and a vegetarian diet.The Mediterranean diet is based on the consumption of vegetables, fruit, legumes, nuts, seeds, and whole grains; moderate-high consumption of olive oil (as the main source of fat); low-moderate consumption of dairy products, fish, and poultry; and low consumption of red meat.The diet has proven effective in improving glucose control and CV risk factors.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Compared to the diet based on the American Diabetes Association recommendations, both the traditional Mediterranean diet and a low CH diet decrease HbA1c and triglyceride levels whereas only a Mediterranean diet that is low in CH improves plasma levels of cholesterol associated with low-density lipoproteins and cholesterol associated with high-density lipoproteins in subjects with overweight and DM2 after one year of treatment.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>In a systematic review, a low CH diet was more effective than a low-fat diet in reducing HbA1c in the short-term, but not at two years.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> A randomized, multicentric study conducted in Spain in individuals with high CV risk entitled Prevención con Dieta Mediterránea (Predimed) found that nearly half of those diagnosed with DM2 at the start of the study showed a benefit in the reduction of cardiovascular events with the Mediterranean diet supplemented with extra-virgin olive oil or assorted nuts as compared to another lower-fat diet recommended by the American Heart Association.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>The DASH diet, cited in the 2020 American Diabetes Association recommendations,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> emphasizes the consumption of fruit, vegetables, low-fat dairy products, cereals and whole grains, poultry, fish, and nuts. It also recommends reduced consumption of saturated fat, red meat, and sugary drinks in addition to low sodium intake. However, only one randomized controlled study<a class="elsevierStyleCrossRef" href="#bib0090">18</a> of those cited by the American Diabetes Association was conducted in patients with DM2 and it only lasted for a short period (eight weeks). It shows a significant improvement in weight, basal glucose levels, blood pressure, cholesterol associated with high-density and low-density lipoproteins, and HbA1c. A systematic review and meta-analysis of prospective cohort studies which included individuals with DM2 showed that adherence to the DASH diet is associated with a reduction in cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>The vegetarian diet pattern includes ovo-lacto vegetarianism, lacto vegetarianism, ovo vegetarianism, and vegan diets. Observational studies find a lower prevalence of DM2 in vegetarian subjects than in the general population whereas interventional studies conducted in individuals with DM2 observe that vegetarian diets lead to a greater reduction in weight, basal glucose, and HbA1c; better lipid control; and a lower need for antidiabetic drugs than a conventional low-calorie diet.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Another systematic review of randomized, controlled studies shows that vegetarian and vegan diets improve HbA1c and basal glucose in DM2.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>Distribution of carbohydrates for the treatment of diabetesStudies that have attempted to determine the effects of meal frequency on health do not offer conclusive evidence, regardless of energy and nutrient intake,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> but other, more recent studies support a reduction in meal frequency.In a randomized crossover study conducted in subjects with DM2 treated with oral hypoglycemic drugs, the distribution of food in two large meals per day (breakfast and lunch) offered benefits in terms of weight and glycemic control compared to distribution in six daily meals.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> In a randomized study on individuals with DM2 treated with insulin on an undefined regimen which compared an isocaloric diet in three meals versus six meals, Jakubowicz et al. <a class="elsevierStyleCrossRef" href="#bib0120">24</a> showed that a diet distributed in three meals offered benefits in regard to weight loss, decrease of HbA1c, and glucose in general as well as in a reduction in appetite and insulin requirements.Based on the available evidence, we believe that the distribution of CH should be based on the type of hypoglycemic pharmacological treatment, the glycemic profile, and the patient’s habits and, later, adjusted based on the results of glycemic control monitoring. In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, an example of meal distribution based on DM2 treatment is proposed.<a class="elsevierStyleCrossRef" href="#bib0125">25</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, the distribution of CH throughout the day according to the indications and action profiles of insulins is shown.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, recommendations regarding the dietary treatment of prediabetes and DM2 along with the level of evidence which supports them are indicated.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Food in the prevention and treatment of prediabetes and type 2 diabetes mellitusIn <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, recommendations on the consumption of different foods in the prevention and treatment of prediabetes and DM2 along with the existing level of evidence are summarized.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Dietary adherence: implementation of strategies to improve itDietary adherence in individuals with DM2 is very low. In general, as with pharmacological treatment, the factors which most contribute to a lack of adherence are a lack of health literacy, perception of the disease itself, the complexity of treatment, financial limitations, psychological factors, and a lack of social support. In <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>, we summarize the main factors that hinder dietary compliance in individuals with DM2.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The interventions in which health professionals take into consideration patients’ cultural beliefs, family, and social surroundings as well as multifactorial interventions that include different elements related to knowledge and perception of the disease and the diet along with support and follow-up are those that allow for better dietary adherence among individuals with DM2.<a class="elsevierStyleCrossRef" href="#bib0360">72</a> In <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>, strategies that must be considered in order to improve dietary adherence and the level of evidence which supports them are shown.<a class="elsevierStyleCrossRefs" href="#bib0005">1,7,26</a><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>The future of nutrition. ConclusionsCurrently, there is solid evidence that plant-based dietary patterns—mainly the Mediterranean diet, a vegan-vegetarian diet, the DASH diet, and a low CH diet—form the basis of treatment for improving control of risk factors and reducing the high cardiovascular morbidity and mortality of individuals with prediabetes or DM2.In recent years, the urgent need to transform the food system has been proposed. A new model claims that, in addition to the traditional concept of a diet needing to be healthy for the population, a diet must also be healthy for the planet. In this regard, in line with the recommendations of multiple corporations and with the scientific backing of the Lancet Commission, Willet et al. have proposed a “planetary health diet” that is able to conserve the planet’s ecosystem and reduce noncommunicable diseases, among them DM2.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> It is a flexitarian, plant-based diet that includes fruit, varied vegetables, legumes, whole grains, nuts, and small amounts of animal protein. Red meat and its derivatives significantly contribute to global warming, land degradation, and water consumption. Likewise, ultraprocessed foods, whether meat-based or not, and the great majority of prepared foods contain components such as added sugars or trans fats and should be kept out of our diet. They should be avoided and consumption of food rich in vegetable protein should be increased.Food’s contribution to global warming depends on both its production and its transportation. Therefore, we should eat seasonal, local food, avoiding food produced far away. Lifestyle, which includes regular, sustained physical activity and a diet that follows the recommended guidelines, constitutes the main therapeutic tool for improving glycemic, lipid, and blood pressure control and reducing the associated high cardiovascular morbidity and mortality that individuals with prediabetes and DM2 present with.FundingNone.Conflicts of interestThe authors declare that they do not have any conflicts of interest in regard to the content of this work." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1472006" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1340563" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1472005" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1340564" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Dietary objectives in the population with prediabetes or type 2 diabetes" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Characteristics of the diet" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Caloric content" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Models of a healthy diet for the treatment of diabetes" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Distribution of carbohydrates for the treatment of diabetes" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Food in the prevention and treatment of prediabetes and type 2 diabetes mellitus" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Dietary adherence: implementation of strategies to improve it" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "The future of nutrition. Conclusions" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-09-18" "fechaAceptado" => "2020-10-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1340563" "palabras" => array:6 [ 0 => "Prediabetes" 1 => "Diabetes" 2 => "Diet" 3 => "Carbohydrates" 4 => "Obesity" 5 => "Caloric content" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1340564" "palabras" => array:6 [ 0 => "Prediabetes" 1 => "Diabetes" 2 => "Dieta" 3 => "Hidratos de carbono" 4 => "Obesidad" 5 => "Contenido calórico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Adequate lifestyle changes significantly reduce the cardiovascular risk factors associated with prediabetes and type 2 diabetes mellitus. Therefore, healthy eating habits, regular physical activity, abstaining from using tobacco, and good sleep hygiene are recommended for managing these conditions. There is solid evidence that diets that are plant-based; low in saturated fatty acids, cholesterol, and sodium; and high in fiber, potassium, and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects. In view of the foregoing, the Mediterranean diet, the DASH diet, a low-carbohydrate diet, and a vegan-vegetarian diet are of note. Additionally, the relationship between nutrition and these metabolic pathologies is fundamental in targeting efforts to prevent weight gain, reducing excess weight in the case of individuals with overweight or obesity; and personalizing treatment to promote patient empowerment.This document is the executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in people with prediabetes or type 2 diabetes mellitus. The full review is available on the webpages of the Spanish Society of Arteriosclerosis (SEA, for its initials in Spanish), the Spanish Diabetes Society (SED, for its initials in Spanish), and the Spanish Society of Internal Medicine (SEMI, for its initials in Spanish)." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los cambios adecuados del estilo de vida reducen significativamente los factores de riesgo cardiovascular asociados a la prediabetes y diabetes mellitus tipo 2, por lo que en su manejo se debe recomendar un patrón saludable de alimentación, actividad física regular, sin consumo de tabaco, y una buena higiene del sueño. Hay una sólida evidencia de que los patrones alimentarios de base vegetal, bajos en ácidos grasos saturados, colesterol y sodio, con un alto contenido en fibra, potasio y ácidos grasos insaturados son beneficiosos y reducen la expresión de los factores de riesgo cardiovascular en estos sujetos. En este contexto destacan la dieta mediterránea, la dieta DASH, la dieta baja en hidratos de carbono y la dieta vegano-vegetariana. Adicionalmente en la relación entre nutrición y estas patologías metabólicas es fundamental dirigir los esfuerzos a prevenir la ganancia de peso o a reducir su exceso en caso de sobrepeso u obesidad, y personalizar el tratamiento para favorecer el empoderamiento del paciente.Este documento es un resumen ejecutivo de una revisión actualizada que incluye las principales recomendaciones para mejorar la calidad nutricional de la alimentación en las personas con prediabetes o diabetes mellitus tipo 2, disponible en las páginas web de la Sociedad Española de Arteriosclerosis (SEA), la Sociedad Española de Diabetes (SED) y la Sociedad Española de Medicina Interna (SEMI)." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Pascual Fuster V, Pérez Pérez A, Carretero Gómez J, Caixàs Pedragós A, Gómez-Huelgas R, Pérez-Martínez P, Resumen ejecutivo: actualización en el tratamiento dietético de la prediabetes y la diabetes mellitus tipo 2. Rev Clin Esp. 2021;221:169–179." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 2088 "Tamanyo" => 174523 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Distribution of carbohydrates over 24h according to the indications and action profiles of insulins. RA: rapid-acting insulin analogs; NPH: neutral protamine hagedorn; basal insulin: glargine U:100, glargine U:300, degludec, detemir." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of servings/day \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diet alone or diet and noninsulin hypoglycemic agents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three main servings \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diet and basal insulin (glargine or detemir or degludec) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three main servings \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diet and one or two doses of intermediate or premixed insulin (biphasic insulins) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One dose at night \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three main servings+bedtime supplement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One dose in the morning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three main servings+mid-morning supplement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Two doses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three main servings+mid-morning and bedtime supplement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diet and basal-bolus insulin indication with injections or an insulin pump \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Three main servings/flexible with carbohydrate counting \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2533061.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Initial distribution of carbohydrates according to diabetes treatment." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.In individuals with prediabetes or DM2 and overweight or obesity, a hypocaloric, nutritionally balanced diet is recommended in order to maintain a lower, healthier weight (strong evidence)</li><li class="elsevierStyleListItem" id="lsti0010">2.Dietary patterns to consider for individuals with DM2 according to their preferences:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">aThe Mediterranean diet to reduce cardiovascular events (strong evidence) and improve glycemic control (moderate evidence)</li><li class="elsevierStyleListItem" id="lsti0020">bThe DASH diet to improve glycemic control (weak evidence), blood pressure in patients with diabetes (weak evidence), and LDL-c (moderate evidence) and to reduce cardiovascular events (moderate evidence)</li><li class="elsevierStyleListItem" id="lsti0025">cA vegan or vegetarian diet to improve glycemic control (moderate evidence), weight (weak evidence), and the lipid profile including LDL-c (moderate evidence) and to reduce the risk of myocardial infarction (moderate evidence)</li></ul></li><li class="elsevierStyleListItem" id="lsti0030">3.Individuals with DM2 should maintain a regular meal schedule and spacing in order to optimize glycemic control (weak evidence)</li><li class="elsevierStyleListItem" id="lsti0035">4.In individuals with DM2 who use fixed doses of insulin, a consistent CH intake pattern in terms of schedule and amount adapted to the insulin action profile may improve glycemia and reduce the risk of hypoglycemia (moderate evidence)</li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2533059.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Dietary treatment of prediabetes and type 2 diabetes. Recommendations." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Edible fats \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Substituting dietary sources of saturated fat with unsaturated fat improves the lipid profile, glycemic control, and insulin resistance26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The Mediterranean diet has been shown to reduce basal and postprandial glycemia, improve metabolic control and body weight, and prevent cardiovascular (CV) events.<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The most recommendable fat for dressings and daily cooking use is virgin olive oil<a class="elsevierStyleCrossRefs" href="#bib0065">13,17</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At high temperatures, sunflower, corn, and soy oils undergo oxidative phenomena with the production of free radicals and other proinflammatory molecules. Therefore, they should not be used for frying<a class="elsevierStyleCrossRef" href="#bib0145">29</a>Weak evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meat \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meat consumption (less than four servings per week) does not appear to be harmful to CV risk or DM2,<a class="elsevierStyleCrossRefs" href="#bib0150">30–33</a> although with the objective of improving a diet’s sustainability, it is advisable that the population as a whole reduces meat consumption and increases plant-based foods.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> Choosing lean cuts of meat and removing the skin and visible fat before cooking is preferableWeak evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of processed meat is related to risk of CV events, colorectal cancer, DM2, and all-cause mortality.<a class="elsevierStyleCrossRefs" href="#bib0150">30–33</a> Consumption of cured meat and other processed meat is not advisedModerate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eggs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of eggs is not harmful and can form part of a healthy diet. There does not appear to be sufficient evidence to restrict their consumption for the objective of reducing CV risk or improving metabolic control,<a class="elsevierStyleCrossRefs" href="#bib0175">35–38</a> although some series limit their intake to a maximum of three per week<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Weak evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fish \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Higher consumption of fish has cardiovascular prevention effects. Fish or seafood intake at least three times per week, two of which in the form of oily fish, is recommendable<a class="elsevierStyleCrossRefs" href="#bib0195">39,40</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dairy products \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of cheese is not associated with an increase in CV risk<a class="elsevierStyleCrossRefs" href="#bib0205">41,42</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of dairy products, especially yogurt,<a class="elsevierStyleCrossRefs" href="#bib0205">41,46</a> has been shown to lead to a reduction in risk of DM2<a class="elsevierStyleCrossRefs" href="#bib0215">43–45</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of dairy products, regardless of their fat content, does not increase CV risk.<a class="elsevierStyleCrossRefs" href="#bib0205">41,42</a> Limiting consumption of full-fat dairy products does not appear to be appropriate for the objective of reducing incidence of DM2 or CV events. Consuming at least two servings of full-fat or fat-free dairy products per day is recommendable, although the consumption of dairy products with added sugar is not advisable. In the event one is attempting to reduce the caloric content of the diet, low-fat or fat-free dairy products should preferably be chosenModerate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grains \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of whole grains reduces the risk of DM2 and cardiovascular mortality.<a class="elsevierStyleCrossRefs" href="#bib0235">47–49</a> Consumption of whole grains rather than refined grains is recommendableModerate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of white or brown rice has not been associated with greater CV risk<a class="elsevierStyleCrossRefs" href="#bib0250">50,51</a> or an increase in risk of DM2, although it has been associated with a greater risk of metabolic syndrome<a class="elsevierStyleCrossRef" href="#bib0255">51</a>Weak evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Legumes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the context of a Mediterranean diet, a higher consumption of legumes, especially lentils, appears to be associated with a lower risk of DM2<a class="elsevierStyleCrossRef" href="#bib0260">52</a>Weak evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of legumes is associated with lower overall CV risk and risk of ischemic cardiopathy.<a class="elsevierStyleCrossRef" href="#bib0265">53</a> Consumption of one serving of legumes at least four times per week is recommendable<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tubers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate consumption of up to two to four servings of tubers per week is recommended. They should preferably be roasted or boiled, with commercially processed potatoes and those with added salt limited to very occasional consumption.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Daily consumption of potatoes (especially if they are fried) can lead to an increase in risk of DM2<a class="elsevierStyleCrossRefs" href="#bib0270">54,55</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nuts \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of moderate amounts of nuts (30g/day) has been associated with lower cardiovascular morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0085">17,56</a> In individuals with DM2, habitual consumption of nuts reduces the risk of cardiovascular mortality and overall mortality<a class="elsevierStyleCrossRef" href="#bib0285">57</a>Habitual consumption of nuts can be advised for the general population and subjects with hypercholesterolemia or hypertension, obesity, and/or DM2.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Frequent consumption (daily or at least three times per week) of a handful of raw nuts (equivalent to about 30g) is advisable. Avoid salted nutsStrong evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fruit and vegetables \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Greater consumption of fruit and vegetables is a measure that can help prevent CV events<a class="elsevierStyleCrossRef" href="#bib0290">58</a>Consumption of at least five servings of fruit and vegetables per day is advised. Consumption should be varied and preparations that add sugars or fats during cooking should be avoidedModerate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chocolate and cacao \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of dark chocolate with ≥ 70% cacao is associated with a reduction in risk of AMI, CVA, DM2, and mortality due to CV events<a class="elsevierStyleCrossRefs" href="#bib0295">59,60</a>The majority of cacao-derived products on the market have sugars and other added fats and are not recommendableModerate amounts (up to 30g/day) of dark chocolate with ≥ 70% cacao can be consumedWeak evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Processed food \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consumption of ultraprocessed food is related to a greater risk of DM2; total, coronary, and cerebrovascular CV events; and all-cause mortality<a class="elsevierStyleCrossRefs" href="#bib0305">61–63</a>Ultraprocessed food should be avoided in the diet. In its place, consumption of fresh, unprocessed, or minimally processed food should be promotedModerate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Salt \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excess sodium consumption is related to the presence of chronic kidney disease, obesity, hypertension, and cardiovascular mortality<a class="elsevierStyleCrossRef" href="#bib0320">64</a>Consumption of up to 2.3g of sodium per day is recommended.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Alternatives to salt include using lemon juice, aromatic herbs, spices, or garlic in cooking. Consumption of prepared food, canned food, salt preserves, carbonated beverages, and cured meats must be limited, as they often have a higher sodium contentModerate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coffee and tea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Habitual consumption of up to five cups of coffee per day (filtered or instant, caffeinated or decaffeinated) or tea (green or black) is beneficial for cardiovascular health.<a class="elsevierStyleCrossRefs" href="#bib0325">65,66</a> Consumption of coffee is inversely associated with risk of DM2.<a class="elsevierStyleCrossRef" href="#bib0335">67</a>Consumption of coffee or tea with added sugar should be limited as much as possibleModerate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alcoholic beverages \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Compared to abstinence or excessive consumption of alcoholic beverages, moderate consumption is associated with a reduction in CV risk and DM2<a class="elsevierStyleCrossRefs" href="#bib0340">68,69</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The maximum acceptable consumption is up to one fermented beverage per day for women and up to two for men (a unit is equivalent to one 330-mL beer or one 150-mL glass of wine)<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Weak evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alcohol consumption should not be promoted in individuals who do not consume it nor is any consumption tolerable in those who have a medical history that contraindicates alcohol intake (liver disease, hypertriglyceridemia, history of addiction, etc.)<a class="elsevierStyleCrossRef" href="#bib0350">70</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Beverages with added sugars and artificial sweeteners \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent consumption of drinks with added sugars is associated with an increase in the risk of obesity, metabolic syndrome, prediabetes, and DM2<a class="elsevierStyleCrossRef" href="#bib0355">71</a>Strong evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The substitution of drinks with added sugars with water or sugar-free drinks reduces energy intake and the risk of obesity, metabolic syndrome, prediabetes, and DM2<a class="elsevierStyleCrossRefs" href="#bib0005">1,13,70</a>Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Herbal, vitamin, or mineral supplements \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">There is not sufficient evidence to recommend the use of herbal, vitamin, or mineral supplements in patients with DM2 who do not have an associated deficiency<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Weak evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2533060.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations on different foods in the prevention and treatment of prediabetes and type 2 diabetes mellitus." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Related to the design and prescription of the diet \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of recommendations whose utility is not established, for example: glycemic indexes, “fad diets,” etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of standard diets that are inflexible, monotonous, and not adapted to the patient's characteristics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Proposal of unrealistic objectives \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lack of patient involvement in the design of the diet and lack of inclusion of individual preferences \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Related to healthcare professionals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prescription by professionals who are not involved in or connected to the diabetology team \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lack of knowledge and, most of all, conviction about the diet’s importance and feasibility \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insufficient patient instruction on the diet’s importance, objectives, and management \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Related to the disease and social surroundings (emotional aspects) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Habit of using food to cope with problems \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Temptation related to social events and special meals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difficulty controlling quantities and ingredients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Desire not to comply with it \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Feeling of not being able to eat like individuals without diabetes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Temptation to temporarily abandon the diet (take a vacation) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Putting other aspects that are considered priorities before it \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lack of support/understanding of family and friends \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lack of information \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2533057.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Factors that hinder dietary adherence." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Measures to improve design and prescription(weak evidence) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Simplify the diet. Only consider firmly established recommendations to avoid confusion and contradiction between different prescriptions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Design the diet individually based on the characteristics of the patient, the diabetes, and its treatment as well as the patient’s capacities and possibilities \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Create a formal prescription for the diet that is similar to a prescription for pharmacological treatment and is incorporated into the rest of the therapeutic measures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Select the system or dietary pattern to communicate recommendations according to the characteristics of the patient, diabetes treatment, capacity for learning, clinical goals, etc. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nutritional education(strong evidence) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The educational process must be personalized and, at least in part, carried out individually by nursing staff who provide education on diabetes or by dietitians with experience in the treatment of diabetes and who form part of the team \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Implementation in three to six sessions during the first six months and then evaluate the need for additional sessions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Behavioral strategies(weak evidence) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Demonstrate conviction about the diet’s importance to the patient. Do not undervalue the diet compared to other therapeutic measures and ask about diet at each visit \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Set objectives that are achievable in the short-term, flexible, and which have a high probability of being achieved \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Avoid speaking of failures and focus on what can be done to achieve the objectives \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Value changes in habits, even if glycemic control, weight, or lipid concentrations have not changed to the extent expected \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Praise having reached desired objectives or simply positive changes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluate possible obstacles to compliance and ensure the patient is committed to resolving the problem and searching for solutions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Promote the participation of the partner and family members, especially those who prepare food \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous evaluation and advising(weak evidence) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nutritional therapy in DM2 is an ongoing process that requires periodic evaluation and support \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">During follow-up, evaluate adherence to recommendations and the need to adapt them to changes in the patient's diabetes or life \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2533058.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Strategies for improving dietary adherence." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:72 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "5. 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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of carbohydrates over 24<span class="elsevierStyleHsp" style=""></span>h according to the indications and action profiles of insulins&#46; RA&#58; rapid-acting insulin analogs&#59; NPH&#58; neutral protamine hagedorn&#59; basal insulin&#58; glargine U&#58;100&#44; glargine U&#58;300&#44; degludec&#44; detemir&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0040" class="elsevierStylePara elsevierViewall">Prediabetes and type 2 diabetes mellitus &#40;DM2&#41; are diseases whose increasing prevalence in the population have made them into a serious public health problem&#46; From a clinical point of view&#44; control of these metabolic abnormalities directly affects cardiovascular morbidity and mortality&#44; making it necessary to propose effective prevention and treatment strategies&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Adequate lifestyle changes significantly reduce the cardiovascular &#40;CV&#41; risk factors associated with prediabetes and type 2 diabetes mellitus&#46; Therefore&#44; healthy eating habits&#44; regular physical activity&#44; abstaining from using tobacco&#44; and good sleep habits are recommended for managing these conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">There is solid evidence that plant-based diets that are low in saturated fatty acids&#44; cholesterol&#44; and sodium and high in fiber&#44; potassium&#44; and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In view of the foregoing&#44; the Mediterranean diet&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> a low-carbohydrate &#40;CH&#41; diet&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and a vegan-vegetarian diet<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> are of note&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Additionally&#44; given the relationship between nutrition and these metabolic pathologies&#44; it is fundamental to target efforts at preventing weight gain&#44; reducing excess weight in the case of individuals with overweight or obesity&#44; and personalizing treatment to promote patient empowerment&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In this document&#44; we will carry out an updated review which provides useful evidence and recommendations organized into a hierarchy of levels&#46; We have used evidence from clinical trials&#44; where possible&#59; observational studies on clinical evidence or surrogate markers&#59; and expert consensus&#46; Based on the above&#44; three types of recommendations will be made&#58; &#40;1&#41; strong&#44; based on clinical trials and meta-analyses that include quality criteria&#59; &#40;2&#41; moderate&#44; supported by prospective cohort studies and cases and control studies&#59; and &#40;3&#41; weak&#44; justified by expert consensus and opinions or based on extensive clinical practice&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In summary&#44; evidence has brought to light the fact that a high proportion of adults present with prediabetes or DM2&#44; with the consequent increase in CV risk in the short- and medium-term&#46; Lifestyle&#44; especially diet&#44; constitutes the main basis of treatment for improving glucose&#44; lipid&#44; and blood pressure control and reducing the high cardiovascular morbidity and mortality present in these individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">This document is an executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in individuals with prediabetes or DM2&#46; The full review is available on the webpages of the Spanish Society of Arteriosclerosis &#40;<a href="https://www.se-arteriosclerosis.org/guias-documentos-consenso">https&#58;&#47;&#47;www&#46;se-arteriosclerosis&#46;org&#47;guias-documentos-consenso</a>&#41;&#44; the Spanish Diabetes Society &#40;<a href="https://www.sediabetes.org/grid/?tipo=cursos_formacion%26categoria=consensos-guias-y-recomendaciones">https&#58;&#47;&#47;www&#46;sediabetes&#46;org&#47;grid&#47;&#63;tipo&#61;cursos&#95;formacion&#38;categoria&#61;consensos-guias-y-recomendaciones</a>&#41;&#44; and the Spanish Society of Internal Medicine &#40;<a href="https://www.fesemi.org/actualizacion-en-el-tratamiento-de-la-prediabetes-y-la-diabetes-tipo-2-consenso-semi-sed-y-sea">https&#58;&#47;&#47;www&#46;fesemi&#46;org&#47;actualizacion-en-el-tratamiento-de-la-prediabetes-y-la-diabetes-tipo-2-consenso-semi-sed-y-sea</a>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Dietary objectives in the population with prediabetes or type 2 diabetes</span><p id="par0075" class="elsevierStylePara elsevierViewall">The general objective of dietary treatment in individuals with prediabetes or DM2 is to help them modify nutritional habits to prevent and&#47;or delay the disease&#44; improve their metabolic control&#44; treat complications and associated diseases or comorbidities&#44; and maintain or improve quality of life&#46; Within this general objective are specific objectives that are applicable to the majority of the population with DM2 or who are at risk of developing it and which are supported by solid data&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#8211;8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The specific objectives of diet in the population with prediabetes or DM2 are&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Preventing and&#47;or delaying progression to DM2 in individuals with prediabetes&#46; Programs which combine a healthy diet and physical activity are effective in decreasing the incidence of DM2 and improving CV risk factors&#44; with the most intensive programs being the most effective&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleBold">&#40;Strong evidence&#41;</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Achieving and maintaining an individualized glycemic control target&#46; Different nutritional interventions in individuals with DM2&#44; including a reduction in energy intake&#44; allow for absolute decreases in glycosylated hemoglobin &#40;HbA<span class="elsevierStyleInf">1c</span>&#41; of 0&#46;3&#37;&#8211;2&#46;0&#37; at three to six months&#46; This benefit can be maintained or improved if the intervention lasts &#62; 12 months&#46; This improvement is greater in subjects who are recently diagnosed and&#47;or those with higher initial HbA<span class="elsevierStyleInf">1c</span> levels&#46; Likewise&#44; they allow for decreasing the dose and&#47;or amount of antidiabetic drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleBold">&#40;Strong evidence&#41;</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Reaching and maintaining an individualized weight target&#46; In adults with DM2&#44; nutritional therapy allows for reducing weight &#40;2&#46;4&#8211;6&#46;2<span class="elsevierStyleHsp" style=""></span>kg&#41; or does not modify it&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleBold">&#40;Moderate evidence&#41;</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Achieving and maintaining individualized lipid control and blood pressure targets&#46; Nutritional interventions in individuals with normal or nearly normal values improve or do not modify the lipid and blood pressure profile&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleBold">&#40;Moderate evidence&#41;</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Maintaining or improving quality of life&#46; In individuals with DM2&#44; the implementation of nutritional therapy significantly improves their perception of their health status&#44; increases knowledge and motivation&#44; and decreases emotional stress&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleBold">&#40;Strong evidence&#41;</span>&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Characteristics of the diet</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Caloric content</span><p id="par0110" class="elsevierStylePara elsevierViewall">The objective of the diet&#8217;s calorie content is to achieve and maintain a reasonable body weight&#46; Reasonable is understood as a more realistic&#8212;rather than ideal&#8212;weight that is achievable and can be maintained over the short- and long-term&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The majority &#40;around 80&#37;&#41; of individuals with DM2 have obesity&#46; Therefore&#44; a reduction in weight is&#44; initially&#44; the main therapeutic objective&#46; Obesity&#44; especially abdominal obesity&#44; is the main factor in developing DM2 in subjects who are genetically predisposed to it&#46; Prevention of obesity constitutes the principal measure for reducing incidence of DM2&#46; There is solid evidence on the efficacy of moderate weight loss &#40;5&#37;&#8211;10&#37;&#41; in the prevention or delay of progression from prediabetes to DM2&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">A moderate reduction in calories &#40;&#8805;500<span class="elsevierStyleHsp" style=""></span>kcal&#47;day&#41; along with physical exercise&#44; modification of dietary habits&#44; and psychological support are effective measures that are most used for reaching and maintaining moderate&#44; gradual weight loss&#46; However&#44; the clinical benefits of weight loss are progressive and increase as greater reductions are achieved&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">An alternative for individuals with DM2 and obesity who do not manage to lose weight within a structured program and for select subjects is a very low calorie diet &#40;&#60;800<span class="elsevierStyleHsp" style=""></span>kcal&#47;day&#41;&#44; generally liquid&#44; for short periods of time &#40;&#60;3 months&#41; followed by a progressive reintroduction of food&#46; This achieves marked weight loss and&#44; in parallel&#44; remission of DM2 at one year in 50&#37; of subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Models of a healthy diet for the treatment of diabetes</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are various dietary patterns that are considered healthy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The most well-known patterns are the Mediterranean diet&#44; the <span class="elsevierStyleItalic">Dietary Approaches to Stop Hypertension</span> &#40;DASH&#41; diet&#44; a low CH diet&#44; and a vegetarian diet&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleBold">Mediterranean diet</span> is based on the consumption of vegetables&#44; fruit&#44; legumes&#44; nuts&#44; seeds&#44; and whole grains&#59; moderate-high consumption of olive oil &#40;as the main source of fat&#41;&#59; low-moderate consumption of dairy products&#44; fish&#44; and poultry&#59; and low consumption of red meat&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The diet has proven effective in improving glucose control and CV risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Compared to the diet based on the American Diabetes Association recommendations&#44; both the traditional Mediterranean diet and a low CH diet decrease HbA1c and triglyceride levels whereas only a Mediterranean diet that is low in CH improves plasma levels of cholesterol associated with low-density lipoproteins and cholesterol associated with high-density lipoproteins in subjects with overweight and DM2 after one year of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In a systematic review&#44; a low CH diet was more effective than a low-fat diet in reducing HbA<span class="elsevierStyleInf">1c</span> in the short-term&#44; but not at two years&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> A randomized&#44; multicentric study conducted in Spain in individuals with high CV risk entitled <span class="elsevierStyleItalic">Prevenci&#243;n con Dieta Mediterr&#225;nea</span> &#40;Predimed&#41; found that nearly half of those diagnosed with DM2 at the start of the study showed a benefit in the reduction of cardiovascular events with the Mediterranean diet supplemented with extra-virgin olive oil or assorted nuts as compared to another lower-fat diet recommended by the American Heart Association&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleBold">DASH diet</span>&#44; cited in the 2020 American Diabetes Association recommendations&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> emphasizes the consumption of fruit&#44; vegetables&#44; low-fat dairy products&#44; cereals and whole grains&#44; poultry&#44; fish&#44; and nuts&#46; It also recommends reduced consumption of saturated fat&#44; red meat&#44; and sugary drinks in addition to low sodium intake&#46; However&#44; only one randomized controlled study<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> of those cited by the American Diabetes Association was conducted in patients with DM2 and it only lasted for a short period &#40;eight weeks&#41;&#46; It shows a significant improvement in weight&#44; basal glucose levels&#44; blood pressure&#44; cholesterol associated with high-density and low-density lipoproteins&#44; and HbA<span class="elsevierStyleInf">1c</span>&#46; A systematic review and meta-analysis of prospective cohort studies which included individuals with DM2 showed that adherence to the DASH diet is associated with a reduction in cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleBold">vegetarian diet</span> pattern includes ovo-lacto vegetarianism&#44; lacto vegetarianism&#44; ovo vegetarianism&#44; and vegan diets&#46; Observational studies find a lower prevalence of DM2 in vegetarian subjects than in the general population whereas interventional studies conducted in individuals with DM2 observe that vegetarian diets lead to a greater reduction in weight&#44; basal glucose&#44; and HbA1c&#59; better lipid control&#59; and a lower need for antidiabetic drugs than a conventional low-calorie diet&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Another systematic review of randomized&#44; controlled studies shows that vegetarian and vegan diets improve HbA<span class="elsevierStyleInf">1c</span> and basal glucose in DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Distribution of carbohydrates for the treatment of diabetes</span><p id="par0160" class="elsevierStylePara elsevierViewall">Studies that have attempted to determine the effects of meal frequency on health do not offer conclusive evidence&#44; regardless of energy and nutrient intake&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> but other&#44; more recent studies support a reduction in meal frequency&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In a randomized crossover study conducted in subjects with DM2 treated with oral hypoglycemic drugs&#44; the distribution of food in two large meals per day &#40;breakfast and lunch&#41; offered benefits in terms of weight and glycemic control compared to distribution in six daily meals&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> In a randomized study on individuals with DM2 treated with insulin on an undefined regimen which compared an isocaloric diet in three meals versus six meals&#44; Jakubowicz et al&#46; <a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> showed that a diet distributed in three meals offered benefits in regard to weight loss&#44; decrease of HbA<span class="elsevierStyleInf">1c</span>&#44; and glucose in general as well as in a reduction in appetite and insulin requirements&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Based on the available evidence&#44; we believe that the distribution of CH should be based on the type of hypoglycemic pharmacological treatment&#44; the glycemic profile&#44; and the patient&#8217;s habits and&#44; later&#44; adjusted based on the results of glycemic control monitoring&#46; In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; an example of meal distribution based on DM2 treatment is proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">In <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; the distribution of CH throughout the day according to the indications and action profiles of insulins is shown&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">In <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; recommendations regarding the dietary treatment of prediabetes and DM2 along with the level of evidence which supports them are indicated&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Food in the prevention and treatment of prediabetes and type 2 diabetes mellitus</span><p id="par0185" class="elsevierStylePara elsevierViewall">In <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; recommendations on the consumption of different foods in the prevention and treatment of prediabetes and DM2 along with the existing level of evidence are summarized&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dietary adherence&#58; implementation of strategies to improve it</span><p id="par0190" class="elsevierStylePara elsevierViewall">Dietary adherence in individuals with DM2 is very low&#46; In general&#44; as with pharmacological treatment&#44; the factors which most contribute to a lack of adherence are a lack of health literacy&#44; perception of the disease itself&#44; the complexity of treatment&#44; financial limitations&#44; psychological factors&#44; and a lack of social support&#46; In <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#44; we summarize the main factors that hinder dietary compliance in individuals with DM2&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">The interventions in which health professionals take into consideration patients&#8217; cultural beliefs&#44; family&#44; and social surroundings as well as multifactorial interventions that include different elements related to knowledge and perception of the disease and the diet along with support and follow-up are those that allow for better dietary adherence among individuals with DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> In <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#44; strategies that must be considered in order to improve dietary adherence and the level of evidence which supports them are shown&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7&#44;26</span></a></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">The future of nutrition&#46; Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">Currently&#44; there is solid evidence that plant-based dietary patterns&#8212;mainly the Mediterranean diet&#44; a vegan-vegetarian diet&#44; the DASH diet&#44; and a low CH diet&#8212;form the basis of treatment for improving control of risk factors and reducing the high cardiovascular morbidity and mortality of individuals with prediabetes or DM2&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In recent years&#44; the urgent need to transform the food system has been proposed&#46; A new model claims that&#44; in addition to the traditional concept of a diet needing to be healthy for the population&#44; a diet must also be healthy for the planet&#46; In this regard&#44; in line with the recommendations of multiple corporations and with the scientific backing of the <span class="elsevierStyleItalic">Lancet Commission</span>&#44; Willet et al&#46; have proposed a &#8220;planetary health diet&#8221; that is able to conserve the planet&#8217;s ecosystem and reduce noncommunicable diseases&#44; among them DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> It is a flexitarian&#44; plant-based diet that includes fruit&#44; varied vegetables&#44; legumes&#44; whole grains&#44; nuts&#44; and small amounts of animal protein&#46; Red meat and its derivatives significantly contribute to global warming&#44; land degradation&#44; and water consumption&#46; Likewise&#44; ultraprocessed foods&#44; whether meat-based or not&#44; and the great majority of prepared foods contain components such as added sugars or trans fats and should be kept out of our diet&#46; They should be avoided and consumption of food rich in vegetable protein should be increased&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Food&#8217;s contribution to global warming depends on both its production and its transportation&#46; Therefore&#44; we should eat seasonal&#44; local food&#44; avoiding food produced far away&#46; Lifestyle&#44; which includes regular&#44; sustained physical activity and a diet that follows the recommended guidelines&#44; constitutes the main therapeutic tool for improving glycemic&#44; lipid&#44; and blood pressure control and reducing the associated high cardiovascular morbidity and mortality that individuals with prediabetes and DM2 present with&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Funding</span><p id="par0215" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest in regard to the content of this work&#46;</p></span></span>"
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          "titulo" => "Characteristics of the diet"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Caloric content"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Models of a healthy diet for the treatment of diabetes"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Distribution of carbohydrates for the treatment of diabetes"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Food in the prevention and treatment of prediabetes and type 2 diabetes mellitus"
        ]
        8 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Dietary adherence&#58; implementation of strategies to improve it"
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "The future of nutrition&#46; Conclusions"
        ]
        10 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Funding"
        ]
        11 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicts of interest"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-09-18"
    "fechaAceptado" => "2020-10-26"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1340563"
          "palabras" => array:6 [
            0 => "Prediabetes"
            1 => "Diabetes"
            2 => "Diet"
            3 => "Carbohydrates"
            4 => "Obesity"
            5 => "Caloric content"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1340564"
          "palabras" => array:6 [
            0 => "Prediabetes"
            1 => "Diabetes"
            2 => "Dieta"
            3 => "Hidratos de carbono"
            4 => "Obesidad"
            5 => "Contenido cal&#243;rico"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Adequate lifestyle changes significantly reduce the cardiovascular risk factors associated with prediabetes and type 2 diabetes mellitus&#46; Therefore&#44; healthy eating habits&#44; regular physical activity&#44; abstaining from using tobacco&#44; and good sleep hygiene are recommended for managing these conditions&#46; There is solid evidence that diets that are plant-based&#59; low in saturated fatty acids&#44; cholesterol&#44; and sodium&#59; and high in fiber&#44; potassium&#44; and unsaturated fatty acids are beneficial and reduce the expression of cardiovascular risk factors in these subjects&#46; In view of the foregoing&#44; the Mediterranean diet&#44; the DASH diet&#44; a low-carbohydrate diet&#44; and a vegan-vegetarian diet are of note&#46; Additionally&#44; the relationship between nutrition and these metabolic pathologies is fundamental in targeting efforts to prevent weight gain&#44; reducing excess weight in the case of individuals with overweight or obesity&#59; and personalizing treatment to promote patient empowerment&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This document is the executive summary of an updated review that includes the main recommendations for improving dietary nutritional quality in people with prediabetes or type 2 diabetes mellitus&#46; The full review is available on the webpages of the Spanish Society of Arteriosclerosis &#40;SEA&#44; for its initials in Spanish&#41;&#44; the Spanish Diabetes Society &#40;SED&#44; for its initials in Spanish&#41;&#44; and the Spanish Society of Internal Medicine &#40;SEMI&#44; for its initials in Spanish&#41;&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los cambios adecuados del estilo de vida reducen significativamente los factores de riesgo cardiovascular asociados a la prediabetes y diabetes mellitus tipo 2&#44; por lo que en su manejo se debe recomendar un patr&#243;n saludable de alimentaci&#243;n&#44; actividad f&#237;sica regular&#44; sin consumo de tabaco&#44; y una buena higiene del sue&#241;o&#46; Hay una s&#243;lida evidencia de que los patrones alimentarios de base vegetal&#44; bajos en &#225;cidos grasos saturados&#44; colesterol y sodio&#44; con un alto contenido en fibra&#44; potasio y &#225;cidos grasos insaturados son beneficiosos y reducen la expresi&#243;n de los factores de riesgo cardiovascular en estos sujetos&#46; En este contexto destacan la dieta mediterr&#225;nea&#44; la dieta DASH&#44; la dieta baja en hidratos de carbono y la dieta vegano-vegetariana&#46; Adicionalmente en la relaci&#243;n entre nutrici&#243;n y estas patolog&#237;as metab&#243;licas es fundamental dirigir los esfuerzos a prevenir la ganancia de peso o a reducir su exceso en caso de sobrepeso u obesidad&#44; y personalizar el tratamiento para favorecer el empoderamiento del paciente&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Este documento es un resumen ejecutivo de una revisi&#243;n actualizada que incluye las principales recomendaciones para mejorar la calidad nutricional de la alimentaci&#243;n en las personas con prediabetes o diabetes mellitus tipo 2&#44; disponible en las p&#225;ginas web de la Sociedad Espa&#241;ola de Arteriosclerosis &#40;SEA&#41;&#44; la Sociedad Espa&#241;ola de Diabetes &#40;SED&#41; y la Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Pascual Fuster V&#44; P&#233;rez P&#233;rez A&#44; Carretero G&#243;mez J&#44; Caix&#224;s Pedrag&#243;s A&#44; G&#243;mez-Huelgas R&#44; P&#233;rez-Mart&#237;nez P&#44; Resumen ejecutivo&#58; actualizaci&#243;n en el tratamiento diet&#233;tico de la prediabetes y la diabetes mellitus tipo 2&#46; Rev Clin Esp&#46; 2021&#59;221&#58;169&#8211;179&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of carbohydrates over 24<span class="elsevierStyleHsp" style=""></span>h according to the indications and action profiles of insulins&#46; RA&#58; rapid-acting insulin analogs&#59; NPH&#58; neutral protamine hagedorn&#59; basal insulin&#58; glargine U&#58;100&#44; glargine U&#58;300&#44; degludec&#44; detemir&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of servings&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diet alone or diet and noninsulin hypoglycemic agents</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three main servings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diet and basal insulin &#40;glargine or detemir or degludec&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three main servings&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diet and one or two doses of intermediate or premixed insulin &#40;biphasic insulins&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>One dose at night&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three main servings<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>bedtime supplement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>One dose in the morning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three main servings<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>mid-morning supplement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Two doses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three main servings<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>mid-morning and bedtime supplement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diet and basal-bolus insulin indication with injections or an insulin pump</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Three main servings&#47;flexible with carbohydrate counting&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Initial distribution of carbohydrates according to diabetes treatment&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0005" class="elsevierStylePara elsevierViewall">In individuals with prediabetes or DM2 and overweight or obesity&#44; a hypocaloric&#44; nutritionally balanced diet is recommended in order to maintain a lower&#44; healthier weight <span class="elsevierStyleBold">&#40;strong evidence&#41;</span></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Dietary patterns to consider for individuals with DM2 according to their preferences&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">a</span><p id="par0015" class="elsevierStylePara elsevierViewall">The Mediterranean diet to reduce cardiovascular events <span class="elsevierStyleBold">&#40;strong evidence&#41;</span> and improve glycemic control <span class="elsevierStyleBold">&#40;moderate evidence&#41;</span></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">b</span><p id="par0020" class="elsevierStylePara elsevierViewall">The DASH diet to improve glycemic control <span class="elsevierStyleBold">&#40;weak evidence&#41;</span>&#44; blood pressure in patients with diabetes <span class="elsevierStyleBold">&#40;weak evidence&#41;</span>&#44; and LDL-c <span class="elsevierStyleBold">&#40;moderate evidence&#41;</span> and to reduce cardiovascular events <span class="elsevierStyleBold">&#40;moderate evidence&#41;</span></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">c</span><p id="par0025" class="elsevierStylePara elsevierViewall">A vegan or vegetarian diet to improve glycemic control <span class="elsevierStyleBold">&#40;moderate evidence&#41;</span>&#44; weight <span class="elsevierStyleBold">&#40;weak evidence&#41;</span>&#44; and the lipid profile including LDL-c <span class="elsevierStyleBold">&#40;moderate evidence</span>&#41; and to reduce the risk of myocardial infarction <span class="elsevierStyleBold">&#40;moderate evidence&#41;</span></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Individuals with DM2 should maintain a regular meal schedule and spacing in order to optimize glycemic control <span class="elsevierStyleBold">&#40;weak evidence&#41;</span></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">In individuals with DM2 who use fixed doses of insulin&#44; a consistent CH intake pattern in terms of schedule and amount adapted to the insulin action profile may improve glycemia and reduce the risk of hypoglycemia <span class="elsevierStyleBold">&#40;moderate evidence&#41;</span></p></li></ul>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dietary treatment of prediabetes and type 2 diabetes&#46; Recommendations&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edible fats</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Substituting dietary sources of saturated fat with unsaturated fat improves the lipid profile&#44; glycemic control&#44; and insulin resistance<span class="elsevierStyleSup">26</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The Mediterranean diet has been shown to reduce basal and postprandial glycemia&#44; improve metabolic control and body weight&#44; and prevent cardiovascular &#40;CV&#41; events&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The most recommendable fat for dressings and daily cooking use is virgin olive oil<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;17</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>At high temperatures&#44; sunflower&#44; corn&#44; and soy oils undergo oxidative phenomena with the production of free radicals and other proinflammatory molecules&#46; Therefore&#44; they should not be used for frying<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Weak evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Meat</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Meat consumption &#40;less than four servings per week&#41; does not appear to be harmful to CV risk or DM2&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;33</span></a> although with the objective of improving a diet&#8217;s sustainability&#44; it is advisable that the population as a whole reduces meat consumption and increases plant-based foods&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Choosing lean cuts of meat and removing the skin and visible fat before cooking is preferable<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Weak evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of processed meat is related to risk of CV events&#44; colorectal cancer&#44; DM2&#44; and all-cause mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;33</span></a> Consumption of cured meat and other processed meat is not advised<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Eggs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of eggs is not harmful and can form part of a healthy diet&#46; There does not appear to be sufficient evidence to restrict their consumption for the objective of reducing CV risk or improving metabolic control&#44;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;38</span></a> although some series limit their intake to a maximum of three per week<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Weak evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Fish</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Higher consumption of fish has cardiovascular prevention effects&#46; Fish or seafood intake at least three times per week&#44; two of which in the form of oily fish&#44; is recommendable<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Dairy products</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of cheese is not associated with an increase in CV risk<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of dairy products&#44; especially yogurt&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;46</span></a> has been shown to lead to a reduction in risk of DM2<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#8211;45</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of dairy products&#44; regardless of their fat content&#44; does not increase CV risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a> Limiting consumption of full-fat dairy products does not appear to be appropriate for the objective of reducing incidence of DM2 or CV events&#46; Consuming at least two servings of full-fat or fat-free dairy products per day is recommendable&#44; although the consumption of dairy products with added sugar is not advisable&#46; In the event one is attempting to reduce the caloric content of the diet&#44; low-fat or fat-free dairy products should preferably be chosen<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Grains</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of whole grains reduces the risk of DM2 and cardiovascular mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#8211;49</span></a> Consumption of whole grains rather than refined grains is recommendable<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of white or brown rice has not been associated with greater CV risk<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#44;51</span></a> or an increase in risk of DM2&#44; although it has been associated with a greater risk of metabolic syndrome<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Weak evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Legumes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>In the context of a Mediterranean diet&#44; a higher consumption of legumes&#44; especially lentils&#44; appears to be associated with a lower risk of DM2<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Weak evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of legumes is associated with lower overall CV risk and risk of ischemic cardiopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> Consumption of one serving of legumes at least four times per week is recommendable<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tubers</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderate consumption of up to two to four servings of tubers per week is recommended&#46; They should preferably be roasted or boiled&#44; with commercially processed potatoes and those with added salt limited to very occasional consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Daily consumption of potatoes &#40;especially if they are fried&#41; can lead to an increase in risk of DM2<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Nuts</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of moderate amounts of nuts &#40;30<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; has been associated with lower cardiovascular morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;56</span></a> In individuals with DM2&#44; habitual consumption of nuts reduces the risk of cardiovascular mortality and overall mortality<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a><span class="elsevierStyleHsp" style=""></span>Habitual consumption of nuts can be advised for the general population and subjects with hypercholesterolemia or hypertension&#44; obesity&#44; and&#47;or DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Frequent consumption &#40;daily or at least three times per week&#41; of a handful of raw nuts &#40;equivalent to about 30<span class="elsevierStyleHsp" style=""></span>g&#41; is advisable&#46; Avoid salted nuts<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Strong evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Fruit and vegetables</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Greater consumption of fruit and vegetables is a measure that can help prevent CV events<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a><span class="elsevierStyleHsp" style=""></span>Consumption of at least five servings of fruit and vegetables per day is advised&#46; Consumption should be varied and preparations that add sugars or fats during cooking should be avoided<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Chocolate and cacao</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of dark chocolate with &#8805; 70&#37; cacao is associated with a reduction in risk of AMI&#44; CVA&#44; DM2&#44; and mortality due to CV events<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59&#44;60</span></a><span class="elsevierStyleHsp" style=""></span>The majority of cacao-derived products on the market have sugars and other added fats and are not recommendable<span class="elsevierStyleHsp" style=""></span>Moderate amounts &#40;up to 30<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; of dark chocolate with &#8805; 70&#37; cacao can be consumed<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Weak evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Processed food</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consumption of ultraprocessed food is related to a greater risk of DM2&#59; total&#44; coronary&#44; and cerebrovascular CV events&#59; and all-cause mortality<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">61&#8211;63</span></a><span class="elsevierStyleHsp" style=""></span>Ultraprocessed food should be avoided in the diet&#46; In its place&#44; consumption of fresh&#44; unprocessed&#44; or minimally processed food should be promoted<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Salt</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Excess sodium consumption is related to the presence of chronic kidney disease&#44; obesity&#44; hypertension&#44; and cardiovascular mortality<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a><span class="elsevierStyleHsp" style=""></span>Consumption of up to 2&#46;3<span class="elsevierStyleHsp" style=""></span>g of sodium per day is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Alternatives to salt include using lemon juice&#44; aromatic herbs&#44; spices&#44; or garlic in cooking&#46; Consumption of prepared food&#44; canned food&#44; salt preserves&#44; carbonated beverages&#44; and cured meats must be limited&#44; as they often have a higher sodium content<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Coffee and tea</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Habitual consumption of up to five cups of coffee per day &#40;filtered or instant&#44; caffeinated or decaffeinated&#41; or tea &#40;green or black&#41; is beneficial for cardiovascular health&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">65&#44;66</span></a> Consumption of coffee is inversely associated with risk of DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a><span class="elsevierStyleHsp" style=""></span>Consumption of coffee or tea with added sugar should be limited as much as possible<span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Alcoholic beverages</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Compared to abstinence or excessive consumption of alcoholic beverages&#44; moderate consumption is associated with a reduction in CV risk and DM2<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#44;69</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The maximum acceptable consumption is up to one fermented beverage per day for women and up to two for men &#40;a unit is equivalent to one 330-mL beer or one 150-mL glass of wine&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Weak evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcohol consumption should not be promoted in individuals who do not consume it nor is any consumption tolerable in those who have a medical history that contraindicates alcohol intake &#40;liver disease&#44; hypertriglyceridemia&#44; history of addiction&#44; etc&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Beverages with added sugars and artificial sweeteners</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frequent consumption of drinks with added sugars is associated with an increase in the risk of obesity&#44; metabolic syndrome&#44; prediabetes&#44; and DM2<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Strong evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The substitution of drinks with added sugars with water or sugar-free drinks reduces energy intake and the risk of obesity&#44; metabolic syndrome&#44; prediabetes&#44; and DM2<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;13&#44;70</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Moderate evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Herbal&#44; vitamin&#44; or mineral supplements</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>There is not sufficient evidence to recommend the use of herbal&#44; vitamin&#44; or mineral supplements in patients with DM2 who do not have an associated deficiency<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleBold"><span class="elsevierStyleHsp" style=""></span>Weak evidence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Recommendations on different foods in the prevention and treatment of prediabetes and type 2 diabetes mellitus&#46;</p>"
        ]
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      4 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Table "
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Related to the design and prescription of the diet</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Use of recommendations whose utility is not established&#44; for example&#58; glycemic indexes&#44; &#8220;fad diets&#44;&#8221; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Use of standard diets that are inflexible&#44; monotonous&#44; and not adapted to the patient&#39;s characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Proposal of unrealistic objectives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lack of patient involvement in the design of the diet and lack of inclusion of individual preferences&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Related to healthcare professionals</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prescription by professionals who are not involved in or connected to the diabetology team&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lack of knowledge and&#44; most of all&#44; conviction about the diet&#8217;s importance and feasibility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufficient patient instruction on the diet&#8217;s importance&#44; objectives&#44; and management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Related to the disease and social surroundings &#40;emotional aspects&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Habit of using food to cope with problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Temptation related to social events and special meals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Difficulty controlling quantities and ingredients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Desire not to comply with it&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feeling of not being able to eat like individuals without diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Temptation to temporarily abandon the diet &#40;take a vacation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Putting other aspects that are considered priorities before it&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lack of support&#47;understanding of family and friends&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lack of information&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2533057.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Factors that hinder dietary adherence&#46;</p>"
        ]
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      5 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
            "detalle" => "Table "
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Measures to improve design and prescription</span><span class="elsevierStyleBold">&#40;weak evidence&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Simplify the diet&#46; Only consider firmly established recommendations to avoid confusion and contradiction between different prescriptions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Design the diet individually based on the characteristics of the patient&#44; the diabetes&#44; and its treatment as well as the patient&#8217;s capacities and possibilities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Create a formal prescription for the diet that is similar to a prescription for pharmacological treatment and is incorporated into the rest of the therapeutic measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Select the system or dietary pattern to communicate recommendations according to the characteristics of the patient&#44; diabetes treatment&#44; capacity for learning&#44; clinical goals&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Nutritional education</span><span class="elsevierStyleBold">&#40;strong evidence&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The educational process must be personalized and&#44; at least in part&#44; carried out individually by nursing staff who provide education on diabetes or by dietitians with experience in the treatment of diabetes and who form part of the team&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Implementation in three to six sessions during the first six months and then evaluate the need for additional sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Behavioral strategies</span><span class="elsevierStyleBold">&#40;weak evidence&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Demonstrate conviction about the diet&#8217;s importance to the patient&#46; Do not undervalue the diet compared to other therapeutic measures and ask about diet at each visit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Set objectives that are achievable in the short-term&#44; flexible&#44; and which have a high probability of being achieved&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Avoid speaking of failures and focus on what can be done to achieve the objectives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Value changes in habits&#44; even if glycemic control&#44; weight&#44; or lipid concentrations have not changed to the extent expected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Praise having reached desired objectives or simply positive changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Evaluate possible obstacles to compliance and ensure the patient is committed to resolving the problem and searching for solutions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Promote the participation of the partner and family members&#44; especially those who prepare food&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Continuous evaluation and advising</span><span class="elsevierStyleBold">&#40;weak evidence&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nutritional therapy in DM2 is an ongoing process that requires periodic evaluation and support&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>During follow-up&#44; evaluate adherence to recommendations and the need to adapt them to changes in the patient&#39;s diabetes or life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Strategies for improving dietary adherence&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:72 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "5&#46; Facilitating behavior change and well-being to improve health outcomes&#58; standards of medical care in diabetes-2020"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "American Diabetes Association"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/dc20-S005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diabetes Care"
                        "fecha" => "2020"
                        "volumen" => "43"
                        "paginaInicial" => "S48"
                        "paginaFinal" => "S65"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31862748"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A comprehensive review of the literature supporting recommendations from the Canadian diabetes association for the use of a plant-based diet for management of type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46; Rinaldi"
                            1 => "E&#46;E&#46; Campbell"
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