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EDIT, sorry the link asks for a password; I have copied & pasted the article below:
September 10, 2009 â?? By following a low-carbohydrate, Mediterranean diet rather than a low-fat diet, newly diagnosed diabetic patients may postpone the need for drugs to control this disease, a study suggests [1].
After four years, with continued nutritional advice, only 44% of newly diagnosed diabetic patients on a Mediterranean diet vs 70% of those on a low-fat diet required drug therapy as well as diet to control their diabetes. Patients on the Mediterranean also showed greater improvement in some cardiovascular risk factors.
“Perhaps most important, the findings reinforce the message that benefits of lifestyle interventions should not be overlooked, despite the drug-intensive style of medicine fueled by the current medical literature,” the authors write.
The study, by Dr Katherine Esposito (Second University of Naples, Naples, Italy) and colleagues, is published in the September 1, 2009 issue of the Annals of Internal Medicine.
“The study confirms that lifestyle changes are a basic part of managing diabetes,” Dr Christine Laine, editor of the Annals of Internal Medicine, told heartwire , adding that it also “suggests that people might be better off if the dietary advice they receive is in line with the Mediterranean diet.”
Intense Nutritionist Support
While a Mediterranean diet improves risk factors for cardiac disease and diabetes and the American Diabetes Association (ADA) recommends a low-carbohydrate or a low-fat diet for overweight people with type 2 diabetes, few studies have directly compared these diets in diabetes.
To investigate the effectiveness of the two diets in delaying antihyperglycemic therapy, the researchers randomized 215 overweight patients (53% men) seen in a Naples hospital who were newly diagnosed with type 2 diabetes.
The patients were sedentary, had a mean age of 52 years (range 30 to 75 years), a body-mass index greater than 25 kg/m2 (mean 29.6 kg/m2), and a hemoglobin A1c level of less than 11%. Most (77%) had an HbA1c level greater than 7%.
The primary study outcome was time to introduction of antihyperglycemic therapy–predetermined to start when HbA1c levels were more than 7% at two measurements three months apart.
Secondary outcomes included weight change, glycemic control, and attaining ADA coronary-risk-factor goals (HbA1c <7%; blood pressure <130/80 mm Hg; and low-density lipoprotein [LDL] cholesterol <2.59 mmol/L).
Participants first received advice about the importance of diet and exercise and–of note–were taught how to prepare meals at home.
They were then randomly assigned to one of two diets for four years:
A Mediterranean diet, which included lots of vegetables and whole grains, with little red meat but with poultry and fish instead, where <50% of calories were from complex carbohydrates and >30% of calories were from fat, largely olive oil.
A low-fat diet based on American Heart Association guidelines, which included lots of whole grains and restricted sweets, fats, and high-fat snacks, where <30% of calories were from fat.
Participants received frequent counseling sessions from dieticians–monthly for one year, then every two months for three years–and kept food-intake diaries.
HbA1c levels were determined at baseline and every three months.
Of the 155 patients who had an elevated HbA1c level of >7% at baseline, only 22 patients still had an elevated HbA1c level after three months, and all patients had lower levels after six months on either diet.
This is “quite a dramatic improvement without pharmacotherapy,” American College of Cardiology spokesperson Dr Elizabeth Klodas, editor-in-chief of Cardiosmart.org, commented to heartwire.
Patients in both diet groups lost weight and had declines in plasma glucose and HbA1c levels, but the reductions were greater in the Mediterranean-diet group.
The Mediterranean diet delayed the need for antihypertensive drug therapy independent of weight change. More participants in the Mediterranean diet met all three ADA goals and had consistently greater increases in high-density lipoprotein (HDL) cholesterol levels and decreases in triglycerides.
The four-year study period is long for diet trials, Laine commented. “People had much more intense nutritionist support than is typically available to patients in most US settings,” she added, noting that it remains to be determined whether dietary advice from a physician without nutritionist support would deliver such good results.
“Diet Cannot Be Overlooked”
The study shows that “diet and other lifestyle practices of our patients cannot be overlooked,” Klodas said. “I donâ??t think we spend enough time teaching patients about diet and lifestyle and really reinforcing what a big difference that can make to their outcomes.”
Learning about portion sizes and the nutritional value of whole foods as opposed to low-fat, highly processed foods and then seeing HbA1c numbers improve as a result of lifestyle changes can be very motivating for patients, she added.
“[Patient management is] a synergistic combination between lifestyle change and medical therapy, and if we just concentrate on medical therapy alone we’ll never obtain the best possible outcomes,” according to Klodas.
The authors declare no conflicts of interest. The work was supported in part by the Second University of Naples.
References
- Esposito K, Maiorino MI, Ciotola M, et al. Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes. Ann Intern Med 2009; 151:306-314. Abstract
Clinical Context
“What is the best diet for me to follow, doctor?”
This is a question heard in thousands of physicians’ offices every day, and the answer can be difficult. Although dietary considerations vary significantly from patient to patient, many patients are interested in diets that promote weight loss and a healthier cardiovascular profile. A study by Shai and colleagues, which appeared in the July 17, 2008, issue of the New England Journal of Medicine, compared a low-fat diet vs a low-carbohydrate diet and the Mediterranean diet in a randomized trial. Researchers focused on obese patients and found that the low-carbohydrate and Mediterranean diets promoted superior weight reductions vs the low-fat diet. The low-carbohydrate diet was associated with the most favorable changes in the lipid profile, and the Mediterranean diet was most effective in improving plasma glucose and insulin levels among the subgroup of participants with diabetes.
The current study extends the work by Shai and colleagues by comparing the Mediterranean diet vs a low-fat diet among adults with type 2 diabetes.
Study Highlights
Adults between the ages of 30 and 75 years eligible for study participation had newly diagnosed type 2 diabetes and had not received treatment with antihyperglycemic medications. All participants had a body mass index greater than 25 kg/m2 and an HbA1c level less than 11%. Finally, all participants exercised for less than 1 hour per week and were not receiving medications that could adversely affect glucose control.
All participants received instruction on a healthy diet and exercise. In addition, they were randomly assigned to receive specific instruction on a Mediterranean or low-fat diet. Both diets included maximal daily energy recommendations of 1800 kcal/day among men and 1500 kcal/day among women.
The Mediterranean diet was designed so that less than half of daily energy was in the form of complex carbohydrates. No less than 30% of calories came from fat, with olive oil providing the majority of added fat calories.
The low-fat diet emphasized consumption of less than 30% of total calories from fat and no more than 10% of total calories from saturated fat.
Participants received continued professional dietary advice monthly for the first year and bimonthly thereafter.
The primary outcome of the study was the time to introduction of medical therapy for diabetes. Medical therapy was initiated for participants who maintained an HbA1c level greater than 7% during 3 months.
Researchers also followed body mass index, waist circumference, serum glucose levels, serum insulin levels, serum lipid levels, blood pressure, and measures of insulin sensitivity. The intervention period was 4 years.
215 adults underwent randomization, and 20 were lost to follow-up during the course of the study. The mean age of participants was 52 years, and half were men. The mean baseline body mass index was 29 kg/m2, and the mean HbA1c level was 7.7%. Baseline data were similar between the low-fat and Mediterranean diet groups.
Physical activity, the use of antihypertensive and lipid-lowering medications, and total caloric intake remained similar between the 2 randomized groups during the trial period.
44% of participants receiving the Mediterranean diet required medical therapy for diabetes by the end of the trial, a significantly smaller proportion vs subjects receiving the low-fat diet (70%). This analysis was virtually unchanged when accounting for changes in body weight.
Hemoglobin A1c levels were consistently lower in the Mediterranean vs the low-fat diet groups, and the Mediterranean diet group experienced greater improvements in insulin sensitivity.
Participants in both groups lost weight during the first year, but reductions in weight and waist circumference favored the Mediterranean diet group (mean difference between groups, â??2 kg and â??1.3 cm, respectively). However, there were no differences in anthropometric outcomes between groups by study years 3 and 4.
Participants receiving the Mediterranean diet experienced greater increases in HDL cholesterol levels and stronger reductions in serum triglyceride levels vs subjects receiving the low-fat diet.
Similar proportions of participants in both intervention groups met goal values for LDL cholesterol and blood pressure.
Rates of adverse events were also similar in comparing the randomized groups.
Clinical Implications
A previous randomized trial found that obese adults lost more weight with a low-carbohydrate or Mediterranean diet vs a low-fat diet. Compared with the low-fat diet, the low-carbohydrate diet was associated with superior lipid outcomes, and the Mediterranean diet was associated with superior outcomes among patients with diabetes.
The current study finds that the Mediterranean diet was associated with better glycemic control, a reduction in the need for medical therapy for diabetes, and improvements in the lipid profile vs a low-fat diet among adults newly diagnosed with type 2 diabetes. Blood pressure control was similar between the 2 diet groups.