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Vol. 221. Issue 3.
Pages 169-179 (March 2021)
Special article
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Executive summary: Updates to the dietary treatment of prediabetes and type 2 diabetes mellitus
Resumen ejecutivo: actualización en el tratamiento dietético de la prediabetes y la diabetes mellitus tipo 2
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V. Pascual Fustera, A. Pérez Pérezb, J. Carretero Gómezc, A. Caixàs Pedragósd, R. Gómez-Huelgase, P. Pérez-Martínezf,
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pabloperez@uco.es

Corresponding author.
a Centro de Salud Palleter, Universidad CEU-Cardenal Herrera, Castellón, Grupo de Trabajo Nutrición y Estilo de Vida, Sociedad Española de Arteriosclerosis (SEA), Spain
b Servicio de Endocrinología y Nutrición, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Sociedad Española de Diabetes (SED), Spain
c Servicio Medicina Interna, Hospital Comarcal de Zafra, Badajoz. Grupo de Diabetes, Obesidad y Nutrición, Sociedad Española de Medicina Interna (SEMI), Spain
d Servicio de Endocrinología y Nutrición, Hospital Universitari Parc Taulí. Departament de Medicina, Universitat Autònoma de Barcelona. Institut Investigació Innovació Parc Taulí (I3PT), Sabadell, Sociedad Española de Diabetes (SED), Spain
e Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga, Málaga, Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Grupo de Diabetes, Obesidad y Nutrición, Sociedad Española de Medicina Interna (SEMI), Spain
f Unidad de Lípidos y Arterioesclerosis, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Córdoba, Universidad de Córdoba. 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). Grupo de Diabetes, Obesidad y Nutrición, Sociedad Española de Medicina Interna (SEMI), Grupo de Educación para la Salud, Sociedad Española de Medicina Interna (SEMI), Spain
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Table 1. Initial distribution of carbohydrates according to diabetes treatment.
Table 2. Dietary treatment of prediabetes and type 2 diabetes. Recommendations.
Table 3. Recommendations on different foods in the prevention and treatment of prediabetes and type 2 diabetes mellitus.
Table 4. Factors that hinder dietary adherence.
Table 5. Strategies for improving dietary adherence.
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Abstract

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).

Keywords:
Prediabetes
Diabetes
Diet
Carbohydrates
Obesity
Caloric content
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).

Palabras clave:
Prediabetes
Diabetes
Dieta
Hidratos de carbono
Obesidad
Contenido calórico
Full Text
Introduction

Prediabetes 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.1

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.2 In view of the foregoing, the Mediterranean diet,3 a low-carbohydrate (CH) diet,4 and a vegan-vegetarian diet5 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.1

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 (https://www.se-arteriosclerosis.org/guias-documentos-consenso), the Spanish Diabetes Society (https://www.sediabetes.org/grid/?tipo=cursos_formacion&categoria=consensos-guias-y-recomendaciones), and the Spanish Society of Internal Medicine (https://www.fesemi.org/actualizacion-en-el-tratamiento-de-la-prediabetes-y-la-diabetes-tipo-2-consenso-semi-sed-y-sea).

Dietary objectives in the population with prediabetes or type 2 diabetes

The 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.1,6–8

The specific objectives of diet in the population with prediabetes or DM2 are:

  • 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.8(Strong evidence).

  • 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.8(Strong evidence).

  • 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.8(Moderate evidence).

  • 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.8(Moderate evidence).

  • 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.8(Strong evidence).

Characteristics of the dietCaloric content

The 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.1

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 DM2.9,10

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.11,12

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.12

Models of a healthy diet for the treatment of diabetes

There are various dietary patterns that are considered healthy.13 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.14 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.15

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.16 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.17

The DASH diet, cited in the 2020 American Diabetes Association recommendations,1 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 study18 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.19

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.20 Another systematic review of randomized, controlled studies shows that vegetarian and vegan diets improve HbA1c and basal glucose in DM2.21

Distribution of carbohydrates for the treatment of diabetes

Studies that have attempted to determine the effects of meal frequency on health do not offer conclusive evidence, regardless of energy and nutrient intake,22 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.23 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. 24 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 Table 1, an example of meal distribution based on DM2 treatment is proposed.25

Table 1.

Initial distribution of carbohydrates according to diabetes treatment.

Treatment  Number of servings/day 
Diet alone or diet and noninsulin hypoglycemic agents  Three main servings 
Diet and basal insulin (glargine or detemir or degludec)  Three main servings 
Diet and one or two doses of intermediate or premixed insulin (biphasic insulins)   
One dose at night  Three main servings+bedtime supplement 
One dose in the morning  Three main servings+mid-morning supplement 
Two doses  Three main servings+mid-morning and bedtime supplement 
Diet and basal-bolus insulin indication with injections or an insulin pump  Three main servings/flexible with carbohydrate counting 

In Fig. 1, the distribution of CH throughout the day according to the indications and action profiles of insulins is shown.

Figure 1.

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.

(0.17MB).

In Table 2, recommendations regarding the dietary treatment of prediabetes and DM2 along with the level of evidence which supports them are indicated.

Table 2.

Dietary treatment of prediabetes and type 2 diabetes. Recommendations.

  • 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)

  • 2.

    Dietary patterns to consider for individuals with DM2 according to their preferences:

    • a

      The Mediterranean diet to reduce cardiovascular events (strong evidence) and improve glycemic control (moderate evidence)

    • b

      The 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)

    • c

      A 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)

  • 3.

    Individuals with DM2 should maintain a regular meal schedule and spacing in order to optimize glycemic control (weak evidence)

  • 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)

 
Food in the prevention and treatment of prediabetes and type 2 diabetes mellitus

In Table 3, 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.

Table 3.

Recommendations on different foods in the prevention and treatment of prediabetes and type 2 diabetes mellitus.

Edible fats 
Substituting dietary sources of saturated fat with unsaturated fat improves the lipid profile, glycemic control, and insulin resistance26 
Moderate evidence 
The Mediterranean diet has been shown to reduce basal and postprandial glycemia, improve metabolic control and body weight, and prevent cardiovascular (CV) events.27,28Moderate evidence 
The most recommendable fat for dressings and daily cooking use is virgin olive oil13,17Moderate evidence 
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 frying29Weak evidence 
Meat 
Meat consumption (less than four servings per week) does not appear to be harmful to CV risk or DM2,30–33 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.34 Choosing lean cuts of meat and removing the skin and visible fat before cooking is preferableWeak evidence 
Consumption of processed meat is related to risk of CV events, colorectal cancer, DM2, and all-cause mortality.30–33 Consumption of cured meat and other processed meat is not advisedModerate evidence 
Eggs 
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,35–38 although some series limit their intake to a maximum of three per week13Weak evidence 
Fish 
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 recommendable39,40Moderate evidence 
Dairy products 
Consumption of cheese is not associated with an increase in CV risk41,42Moderate evidence 
Consumption of dairy products, especially yogurt,41,46 has been shown to lead to a reduction in risk of DM243–45Moderate evidence 
Consumption of dairy products, regardless of their fat content, does not increase CV risk.41,42 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 
Grains 
Consumption of whole grains reduces the risk of DM2 and cardiovascular mortality.47–49 Consumption of whole grains rather than refined grains is recommendableModerate evidence 
Consumption of white or brown rice has not been associated with greater CV risk50,51 or an increase in risk of DM2, although it has been associated with a greater risk of metabolic syndrome51Weak evidence 
Legumes 
In the context of a Mediterranean diet, a higher consumption of legumes, especially lentils, appears to be associated with a lower risk of DM252Weak evidence 
Consumption of legumes is associated with lower overall CV risk and risk of ischemic cardiopathy.53 Consumption of one serving of legumes at least four times per week is recommendable13Moderate evidence 
Tubers 
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.13 Daily consumption of potatoes (especially if they are fried) can lead to an increase in risk of DM254,55Moderate evidence 
Nuts 
Consumption of moderate amounts of nuts (30g/day) has been associated with lower cardiovascular morbidity and mortality.17,56 In individuals with DM2, habitual consumption of nuts reduces the risk of cardiovascular mortality and overall mortality57Habitual consumption of nuts can be advised for the general population and subjects with hypercholesterolemia or hypertension, obesity, and/or DM2.13 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 
Fruit and vegetables 
Greater consumption of fruit and vegetables is a measure that can help prevent CV events58Consumption 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 
Chocolate and cacao 
Consumption of dark chocolate with ≥ 70% cacao is associated with a reduction in risk of AMI, CVA, DM2, and mortality due to CV events59,60The 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 
Processed food 
Consumption of ultraprocessed food is related to a greater risk of DM2; total, coronary, and cerebrovascular CV events; and all-cause mortality61–63Ultraprocessed food should be avoided in the diet. In its place, consumption of fresh, unprocessed, or minimally processed food should be promotedModerate evidence 
Salt 
Excess sodium consumption is related to the presence of chronic kidney disease, obesity, hypertension, and cardiovascular mortality64Consumption of up to 2.3g of sodium per day is recommended.6 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 
Coffee and tea 
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.65,66 Consumption of coffee is inversely associated with risk of DM2.67Consumption of coffee or tea with added sugar should be limited as much as possibleModerate evidence 
Alcoholic beverages 
Compared to abstinence or excessive consumption of alcoholic beverages, moderate consumption is associated with a reduction in CV risk and DM268,69Moderate evidence 
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)1Weak evidence 
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.)70Moderate evidence 
Beverages with added sugars and artificial sweeteners 
Frequent consumption of drinks with added sugars is associated with an increase in the risk of obesity, metabolic syndrome, prediabetes, and DM271Strong evidence 
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 DM21,13,70Moderate evidence 
Herbal, vitamin, or mineral supplements 
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 deficiency6Weak evidence 
Dietary adherence: implementation of strategies to improve it

Dietary 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 Table 4, we summarize the main factors that hinder dietary compliance in individuals with DM2.

Table 4.

Factors that hinder dietary adherence.

Related to the design and prescription of the diet 
Use of recommendations whose utility is not established, for example: glycemic indexes, “fad diets,” etc. 
Use of standard diets that are inflexible, monotonous, and not adapted to the patient's characteristics 
Proposal of unrealistic objectives 
Lack of patient involvement in the design of the diet and lack of inclusion of individual preferences 
Related to healthcare professionals 
Prescription by professionals who are not involved in or connected to the diabetology team 
Lack of knowledge and, most of all, conviction about the diet’s importance and feasibility 
Insufficient patient instruction on the diet’s importance, objectives, and management 
Related to the disease and social surroundings (emotional aspects) 
Habit of using food to cope with problems 
Temptation related to social events and special meals 
Difficulty controlling quantities and ingredients 
Desire not to comply with it 
Feeling of not being able to eat like individuals without diabetes 
Temptation to temporarily abandon the diet (take a vacation) 
Putting other aspects that are considered priorities before it 
Lack of support/understanding of family and friends 
Lack of information 

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 DM2.72 In Table 5, strategies that must be considered in order to improve dietary adherence and the level of evidence which supports them are shown.1,7,26

Table 5.

Strategies for improving dietary adherence.

Measures to improve design and prescription(weak evidence) 
Simplify the diet. Only consider firmly established recommendations to avoid confusion and contradiction between different prescriptions 
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 
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 
Select the system or dietary pattern to communicate recommendations according to the characteristics of the patient, diabetes treatment, capacity for learning, clinical goals, etc. 
Nutritional education(strong evidence) 
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 
Implementation in three to six sessions during the first six months and then evaluate the need for additional sessions 
Behavioral strategies(weak evidence) 
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 
Set objectives that are achievable in the short-term, flexible, and which have a high probability of being achieved 
Avoid speaking of failures and focus on what can be done to achieve the objectives 
Value changes in habits, even if glycemic control, weight, or lipid concentrations have not changed to the extent expected 
Praise having reached desired objectives or simply positive changes 
Evaluate possible obstacles to compliance and ensure the patient is committed to resolving the problem and searching for solutions 
Promote the participation of the partner and family members, especially those who prepare food 
Continuous evaluation and advising(weak evidence) 
Nutritional therapy in DM2 is an ongoing process that requires periodic evaluation and support 
During follow-up, evaluate adherence to recommendations and the need to adapt them to changes in the patient's diabetes or life 
The future of nutrition. Conclusions

Currently, 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 DM2.34 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.

Funding

None.

Conflicts of interest

The authors declare that they do not have any conflicts of interest in regard to the content of this work.

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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.

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