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Diabetes and the Nutrition and Diets for Its Prevention and Treatment: A
Systematic Review and Dietetic Perspective
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Health Sciences Research
2020; 6(1): 5-19
http://www.aascit.org/journal/hsr
ISSN: 2375-379X
Diabetes and the Nutrition and Diets for Its

Prevention and Treatment: A Systematic Review
and Dietetic Perspective
Chinaza Godswill Awuchi1, 2, *, Chinelo Kate Echeta2, Victory Somtochukwu Igwe2
1
Department of Physical Sciences, Kampala International University, Kampala, Uganda
2
Department of Food Science and Technology, Federal University of Technology Owerri, Owerri, Nigeria
Email address
*
Corresponding author
Citation
Chinaza Godswill Awuchi, Chinelo Kate Echeta, Victory Somtochukwu Igwe. Diabetes and the Nutrition and Diets for Its Prevention and
Treatment: A Systematic Review and Dietetic Perspective. Health Sciences Research. Vol. 6, No. 1, 2020, pp. 5-19.
Received: December 21, 2019; Accepted: January 9, 2020; Published: February 4, 2020
Abstract: The systematic review widely focused on diabetes and the developments in nutrition and diets required to prevent
or control all types of diabetes. Diabetes is characterized by high blood sugar level over prolonged period. If left untreated,
diabetes causes many health complications. Acute complications can include hyperosmolar hyperglycemic state, diabetic
ketoacidosis, or even death. Serious long-term health complications include chronic kidney disease, foot ulcers, damage to the
eyes, cardiovascular disease, and stroke. Diabetes occurs due to either the inability of the pancreas to produce enough insulin,
or the body cells improperly responding to the insulin produced. Type 1, Type 2, and the Gestational diabetes are the three
major types of diabetes mellitus, although there is a collection of other specific types. The Type 1 diabetes results from the
failure of pancreas to produce enough insulin due to the loss of beta cells caused by an autoimmune response. Type 2 diabetes
begins with the insulin resistance, a condition in which the cells fail to properly respond to insulin. As the disease keeps
progressing, a lack of insulin may develop. A combination of insufficient exercise and excessive body weight is the most
common cause. Gestational diabetes is third major form, and occurs when a pregnant woman without previous history of
diabetes develops high blood sugar levels. Adequate dieting, with good nutrition and regular exercise are very important in
preventing or controlling diabetes. Prevention and treatment of diabetes involve maintaining healthy diet, regular physical
exercise, normal body weight, and also avoiding use of tobacco. Maintaining a healthy diet, low-fat diet, low-calorie diet,
paleolithic diet, very low carbohydrate diet, raw foodism, and/or ketogenic diet can help prevent or manage diabetes.
Keywords: Diabetes Mellitus, Diabetes Causes, Diabetes Prevention, Nutrition and Diets for Diabetes Prevention,
Nutrition and Diets for Diabetes Control
stroke, foot ulcers, damage to the eyes, and chronic kidney

1. Introduction disease. Diabetes is as a result of either pancreas not making
Diabetes mellitus (DM), commonly called diabetes, is a enough insulin, or cells of the body improperly responding to
group of metabolic disorders and diseases characterized by the insulin produced [3].
high blood sugar levels over prolonged period. The There are three main types of diabetes, and a collection of
symptoms of high blood glucose (sugar) levels include “other specific types”. Diabetes type 1 results from failure of
increased thirst, increased hunger, and frequent urination [1]. pancreas to produce enough insulin caused by loss of beta
Diabetes can cause many complications if not carefully cells. Diabetes type 1 was earlier referred to as the juvenile
treated and controlled. So far, there is no known cure for diabetes or insulin-dependent diabetes mellitus (IDDM). The
diabetes. Acute complications can include hyperosmolar loss of beta cells is as a result of an autoimmune response
hyperglycemic state, diabetic ketoacidosis, or death [1]. [4]. The cause of the autoimmune response is unknown [1].
Serious long-term complications are cardiovascular disease, Type 2 diabetes begins with the insulin resistance, a
6 Chinaza Godswill Awuchi et al.: Diabetes and the Nutrition and Diets for Its Prevention and Treatment:
A Systematic Review and Dietetic Perspective
condition where cells fail to properly respond to insulin. As dermadromes [12].

the disease progresses, lack of insulin may develop. This
form was previously known as "adult-onset diabetes" or
"non-insulin-dependent diabetes mellitus" (NIDDM). The
most common cause is combination of excessive body weight
(obesity) and insufficient exercise [1]. Gestational diabetes is
the third most common form, and occurs when a pregnant
woman without previous history of diabetes mellitus
develops high blood sugar levels [1].
Prevention and treatment of diabetes involve maintaining
healthy diet, regular physical exercise, normal body weight,
and also avoiding tobacco use. Control of blood pressure, eye
care, and maintaining proper foot care are important for
individuals with the disease [1]. Type 1 diabetes must be
properly managed with insulin injections. The type 2 diabetes
may be treated with medication with or without insulin. The
Insulin and some oral medication can cause low blood sugar
[5]. Weight loss surgery in individuals with obesity is
sometimes very effective measure in people with type 2
diabetes. Gestational diabetes often resolves after birth of the
baby [6]. Diabetic patients are advised to avoid sugars and
sugary soft drinks. They may instead opt for diet soft drinks
sweetened with sugar substitutes such as sugar alcohols [7, 8] Figure 1. Overview of the most important symptoms of diabetes.
which contribute little or no-calorie.
In 2017, an estimated 425 million individuals had diabetes 2.1.1. Diabetic Emergencies
worldwide [2], with type 2 diabetes making up around 90% Individuals (usually with type 1 diabetes) can also
of the cases [9]. This represents 8.8% of adult population, experience the episodes of diabetic ketoacidosis (DKA).
with equal rates in both men and women. Trends suggest that DKA is a metabolic disturbance characterized by vomiting,
the rates will continue to rise [2]. Diabetes at least doubles an abdominal pain, and nausea, deep breathing known as
individual's risk of early death. In 2017 alone, diabetes Kussmaul breathing, the smell of acetone on the breath, and
resulted in about 3.2 to 5.0 million deaths [2]. The global in severe cases decreased level of consciousness [13]. A rare
economic costs of diabetes-related health expenditures in but equally severe likelihood is hyperosmolar hyperglycemic
2017 were estimated at US$727 billion [2]. Average medical state (or HHS), which is more common in the case of type 2
expenditures among individuals with diabetes are around 2.3 diabetes and is mostly the result of dehydration [13].
times higher [10]. Treatment-related hypoglycemia (low blood sugar) is
common in individuals with type 1 diabetes (and also type 2)
2. Diabetes Mellitus (DM) depending on the medication used. Most cases can be mild and
are not regarded as medical emergencies. The effects can range
2.1. Signs and Symptoms of Diabetes from the feelings of unease, trembling, increased appetite, and
sweating in mild cases to the more serious effects such as
The classic symptoms of untreated diabetes include
changes in behavior such as aggressiveness, unconsciousness,
unintended weight loss, polydipsia (increased thirst),
seizures, confusion, and (rarely) permanent, irreversible brain
polyphagia (increased hunger), and polyuria (increased
damage or even death in severe cases [14]. Rapid breathing
urination) [11]. Symptoms may develop rapidly (in weeks or
and sweating, pale skin, cold are characteristic of low blood
months) in type 1 diabetes, whereas they usually develop
sugar (hypoglycemia) but not definitive. The mild to moderate
much more slowly (years or decades) and may be absent or
cases can easily be self-treated by consuming foods or drinking
subtle in type 2 diabetes. Some other symptoms of diabetes
beverages high in sugar; but not sugar substitutes used as sugar
are tiredness and weight loss.
replacement [8]. Severe cases can result in unconsciousness
Several other signs and symptoms mark the onset of
and have to be treated with injections with glucagon or
diabetes though they are not specific to diabetes. In addition
intravenous glucose, as soon as possible.
to the known signs and symptoms above, they also include
blurred vision, slow healing of cuts, itchy skin, headache, and 2.1.2. Complications and Risks of Diabetes
fatigue. Prolonged high blood glucose may cause glucose All forms of diabetes increase the risks of long-term
absorption in lens of the eye, which results in changes in its complications. These usually develop after several years (10
shape, leading to changes in vision. Long-term vision loss to 20) but may be the first symptoms in people who have
may also be caused by diabetic retinopathy. Numerous skin otherwise not received diagnosis before that time.
rashes that occur in diabetes are collectively called diabetic Retinopathy, neuropathy, and nephropathy are the potential
Health Sciences Research 2020; 6(1): 5-19 7
complications of diabetes. Major long-term complications scarring, and eventually chronic kidney diseases, sometimes
relate to the damage to the blood vessels. Diabetes doubles requiring kidney transplantation or dialysis. Damage to the
the risks of cardiovascular diseases and about 75% of death body nerves (called diabetic neuropathy) is the most common
in individuals with diabetes are caused by coronary artery diabetes complication [16]. The symptoms can include pain,
disease [15]. Other macro-vascular diseases include altered pain sensation, tingling, and numbness, which can
peripheral artery disease, and stroke. result in damage to the skin. A number of diabetes-related
The primary complications of diabetes as a result of foot problems (such as the diabetic foot ulcers) can occur,
damage in the small blood vessels are damage to the eyes, and may be difficult to treat, sometimes requiring
nerves, and kidneys. Damage to the eyes, called diabetic amputation. In addition, proximal diabetic neuropathy causes
retinopathy, is caused by the damage to blood vessels in the a painful muscle atrophy and weakness. Also, there is a link
eye retina, and can result in gradual loss of vision and between diabetes and cognitive deficit. Compared to
eventual blindness [16]. Diabetes also increases the risks of individuals without diabetes, people with the disease have a
having cataracts, glaucoma, and other eye problems. People 1.2 – 1.5-fold higher rate of decline in cognitive functions.
with diabetes are recommended to visit an eye specialist or Having diabetes, particularly when on insulin, increases risk
doctor once a year. The damage to the kidneys (called of falls in older individuals [17].
diabetic nephropathy) can lead to urine protein loss, tissue
2.2. Causes of Diabetes
Table 1. Comparison of type 1 and 2 diabetes.
Feature Type 1 diabetes Type 2 diabetes

Age at onset Mostly in children Mostly in adults
Autoantibodies Usually present Absent
Body size Thin or normal Often obese
Concordance in identical twins 50% 90%
Endogenous insulin Low or absent Normal, decreased or increased
Ketoacidosis Common Rare
Onset Sudden Gradual
Prevalence ~10% ~90%
The term "diabetes", without reservation, refers to diabetes unpredictable and irregular high blood sugar levels, and also
mellitus. Normally, diabetes mellitus is broadly classified the potential for serious low blood sugar levels or diabetic
into four categories: type 1, type 2, the gestational diabetes, ketoacidosis. Other complications include impaired counter-
and the "other specific types". "Other specific types" are a regulatory response to a low blood sugar level, infection,
group of few dozen individual causes. Diabetes mellitus is a endocrinopathies (e.g., Addison's disease), and gastroparesis
more variable disease than once thought and people may (which results in erratic absorption of dietary carbohydrates).
have combinations of forms [18]. These phenomena are understood to occur no more regularly
than in 1% - 2% of people with type 1 diabetes.
2.2.1. Type 1 Diabetes Type 1 diabetes is partly hereditary, with multiple genes,
The type 1 diabetes is characterized by the loss of the including some HLA genotypes, known to have influence on
insulin-producing beta cells of pancreatic islets, resulting in the risks of diabetes. In genetically susceptible individuals,
insulin deficiency. Type 1 can be further classified as the onset of diabetes can also be triggered by at least one
idiopathic or immune-mediated. The majority of type 1 environmental factor, such as diet or a viral infection. Several
diabetes has the nature of immune-mediated, in which T cell- viruses have been implicated, however, to date there is no
mediated autoimmune attack results in loss of beta cells and stringent or reliable evidence to support the hypothesis in
consequently insulin [19]. It causes around 10% of diabetes humans [20, 21]. Some traditionalists claim that some
mellitus cases in the North America and the Europe. Most alkaloids are therapeutic against diabetes [22]. Among
affected individuals are otherwise healthy and of healthy dietary factors, data suggest that a protein present in gluten,
weight when onset takes place. Sensitivity and called gliadin, may play a role in development of type 1
responsiveness to insulin are often normal, especially in early diabetes, although the mechanism is not completely
stages. Though it has been referred to as the juvenile diabetes understood [23].
due to its frequent onset in children, majority of people Type 1 diabetes mellitus (type 1 DM) can occur at any age,
currently living with type 1 diabetes are adults. and significant proportion is commonly diagnosed during
The term "Brittle" diabetes, also called labile diabetes or adulthood. The latent autoimmune diabetes of adults (the
unstable diabetes, was traditionally used to describe the LADA) is a diagnostic term applied when the type 1 diabetes
recurrent and dramatic swings in glucose level, often develops in adults; and it has a slower onset than same
occurring for no just apparent reason in the insulin-dependent condition in children. With this difference given, some use
diabetes. However, the term has no biologic basis and ought the informal term "type 1.5 diabetes" to refer to this
not to be used. Type 1 diabetes can be accompanied by condition. Adults with the LADA are frequently
misdiagnosed initially as having type 2 diabetes, relying on malformations, and macrosomia (high birth weight).
age rather than cause [24]. Increased levels of insulin in fetus's blood may inhibit the
fetal surfactant production and cause an infant respiratory
2.2.2. Type 2 Diabetes distress syndrome. High blood bilirubin levels may result
The type 2 diabetes is characterized by an insulin from the destruction of red blood cell. In severe cases,
resistance, which can be combined with relatively reduced perinatal death can occur, most commonly due to poor
secretion of insulin. The defective responsiveness of the body placental perfusion as a result of vascular impairment. Labor
tissues to insulin is understood to involve the insulin induction might be indicated with a decreased placental
receptors. However, the specific defects are unknown. function. Caesarean section may be done if there is an
Diabetes mellitus cases due to known defect are classified increased risk of injury connected with macrosomia, such as
separately. The type 2 diabetes is the most seen and common the shoulder dystocia, or marked fetal distress [31].
type of diabetes mellitus [1]. Many individuals with type 2
diabetes have the evidence of prediabetes (impaired glucose 2.2.4. Other Types of Diabetes Rarely
tolerance and/or impaired fasting glucose) before meeting Encountered
criteria for type 2 diabetes [25]. The progression of The maturity-onset diabetes of the young (the MODY) is
prediabetes to the overt type 2 diabetes can be reversed or an unusual autosomal dominant inherited form of diabetes, as
slowed by medications and/or lifestyle changes that reduce a result of one of various single-gene mutations causing
the liver's glucose production or improve insulin sensitivity defects in production of insulin [32]. It is significantly less
[26]. Type 2 diabetes mellitus is mostly caused by lifestyle common than type 1, type 2, and GDM, constituting 1 to 2%
factors and genetics. Many lifestyle factors are known to be of all cases. The name MODY refers to the early hypotheses
contribute to the development of the type 2 diabetes, as to its nature. Occurring due to a defective gene, the disease
including obesity (a body mass index, BMI, of greater than varies in the age at presentation and in the severity according
30), poor diet, stress, urbanization, and lack of physical to specific gene defect; as a result there are at least 13
activity. Excess body fat is connected with 30% of the cases MODY subtypes. People with MODY commonly can control
in those of Japanese and Chinese descent, 100% of Pacific it without using insulin [33].
Islanders and Pima Indians, and 60 to 80% of cases in Some diabetes cases are caused by body's tissue receptors
individuals of European and African descent. Even those unresponsive to insulin (even when the levels of insulin are
who are not obese usually have a high waist-hip ratio. normal, and is what separates it from the type 2 diabetes);
The dietary factors also have influence on the risk of this form is quite uncommon. Genetic mutations
developing type 2 diabetes. Excessive consumption of sugar- (mitochondrial or autosomal) can lead to defects in the
sweetened drinks is associated with an increased risk [28]. function of beta-cell. Abnormal insulin actions may also have
The type of fats and oils in the diet is also important; been determined genetically in some cases. Any disease
saturated fat and trans fats increase the risk, while causing extensive damage to the pancreas can lead to
monounsaturated and polyunsaturated fat decrease the risk diabetes; for example, cystic fibrosis and chronic
[27]. Eating too much white rice may also increase the risk of pancreatitis. Diseases associated with excessive insulin-
diabetes, while other whole grains substitution including antagonistic hormones secretion can cause diabetes (which is
brown rice for white rice may lower the risks of diabetes. normally resolved once the excess hormone is removed).
Lack of physical activity is understood to cause 7% of cases Some toxins damage pancreatic beta cells and a number of
[29]. Reduced secretion and absorption of insulin leads to drugs impair insulin secretion, while others increase insulin
high blood glucose levels. resistance (especially the glucocorticoids which may provoke
"steroid diabetes"). ICD-10 (1992) diagnostic entity, the
2.2.3. Gestational Diabetes malnutrition-related diabetes mellitus (MRDM), was
Gestational diabetes mellitus (or GDM) is similar to type 2 deprecated by the WHO when the current taxonomy was
diabetes in various respects, involving a combination of announced in 1999 [34].
relatively insufficient insulin secretion and responsiveness. The following is a list of disorders and impairments that
GDM occurs in about 2 to 10% of all pregnancies and may may increase the risks of diabetes:
disappear or improve after delivery. However, after a) Genetic defects of β-cell function
pregnancy about 5 to 10% of women with gestational a. The maturity-onset diabetes of the young
diabetes mellitus are found to have diabetes mellitus, most b. The Mitochondrial DNA mutations
commonly type 2 diabetes. GDM is entirely treatable, but b) Genetic defects in insulin action or insulin processing
requires a careful medical supervision all through the a. Defects in proinsulin conversion
pregnancy. Management may include blood glucose b. The insulin receptor mutations
monitoring, dietary changes, and in most cases, insulin may c. The insulin gene mutations
be required [30]. c) Exocrine pancreatic defects
Though it may be short-term, untreated gestational a. Cystic fibrosis
diabetes mellitus can damage the health of the mother or b. Fibrocalculous pancreatopathy
fetus. Risks to the baby include congenital abnormalities of c. Hemochromatosis
the heart and central nervous system, skeletal muscle
d. Pancreatectomy and muscle cells [3].

e. Pancreatic neoplasia Mechanism of insulin release in the normal pancreatic beta
f. The Chronic pancreatitis cells. The insulin production is relatively constant within beta
d) Endocrinopathies cells. Its release is usually triggered by food, mostly food
a. Cushing syndrome containing absorbable glucose. Insulin is released normally
b. Glucagonoma into the blood by the β-cells (beta cells), found in the islets of
c. Growth hormone excess (acromegaly) the Langerhans in the pancreas, as a response to rising blood
d. Hyperthyroidism glucose levels, typically after eating food. Insulin is used by
e. Hypothyroidism approximately two-thirds of the cells of the body to absorb
f. Pheochromocytoma glucose from blood for use as fuel, for storage, or for
e) Infections conversion to other required molecules. Lower glucose levels
a. Cytomegalovirus infection result in reduced insulin release from the β-cells and in the
b. Coxsackievirus B glycogen breakdown to glucose. This process is mostly
f) Drugs controlled by the glucagon, a hormone which acts opposite to
a. Glucocorticoids insulin [35].
b. Statins If the amount of insulin available is not sufficient, or if the
c. Thyroid hormone insulin itself is defective, or if cells poorly respond to the
d. β-adrenergic agonists effects of insulin (known as insulin resistance), then glucose
is improperly absorbed by the body cells which require it,
2.3. Pathophysiology and diagnosis and is not appropriately stored in the muscles and liver. The
Insulin is the major hormone that regulates the glucose net effect is poor protein synthesis, persistent high levels of
uptake from the blood into most body cells, especially liver, blood glucose, and other metabolic disorders, such as
muscle, and adipose tissue, except smooth muscle, wherein metabolic acidosis in the cases of complete insulin deficiency
insulin acts via IGF-1. Therefore, insulin deficiency or the [3].
insensitivity of insulin receptors play a key role in all forms When the blood glucose concentration remains high with
of diabetes. time, the kidneys reach threshold of reabsorption, causing the
The body obtains glucose from three key sources: the body to excrete glucose via urine (glycosuria) [36]. This
intestinal absorption of food; breakdown of glycogen increases osmotic pressure of the urine and inhibits the water
(glycogenolysis), a storage form of glucose in the liver; and reabsorption by the kidney, resulting in increased production
by gluconeogenesis, the generation of glucose from the non- of urine (polyuria) and increased loss of fluid. Lost blood
carbohydrate substrates in the body [3]. Insulin plays a volume is osmotically replaced from water in the body cells
crucial role in regulating the body glucose levels. Insulin can and other body compartments, resulting in dehydration and
inhibit the process of gluconeogenesis or the breakdown of increased thirst (polydipsia) [3]. Additionally, deficiency of
glycogen, it can stimulate storage of glucose in form of intracellular glucose stimulates appetite resulting in excessive
glycogen, and it can stimulate transport of glucose into fats food consumption (polyphagia).
Table 2. WHO diabetes diagnostic criteria.
Condition 2-hour glucose Fasting glucose HbA1c

Unit mmol/l (mg/dl) mmol/l (mg/dl) mmol/mol DCCT %
Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥48 ≥6.5
Impaired fasting glycaemia <7.8 (<140) ≥6.1 (≥110) & <7.0 (<126) 42-46 6.0–6.4
Impaired glucose tolerance ≥7.8 (≥140) <7.0 (<126) 42-46 6.0–6.4
Normal <7.8 (<140) <6.1 (<110) <42 <6.0
Diabetes mellitus is characterized by persistent or should be measured due to the ease of measurement and also
recurrent high blood sugar, and diagnosed by demonstrating the considerable time commitment of the formal glucose
any of the following: tolerance testing, which takes 2 hours to complete and
1) Fasting plasma glucose levels ≥ 7.0 mmol/l (126 mg/dl) provides no prognostic advantage over fasting test [38].
2) Glycated hemoglobin (HbA1C) ≥ 6.5 DCCT % (≥ 48 According to current definition, two fasting glucose
mmol/mol) [37]. measurements above 126 mg/dl (7.0 mmol/l) is considered
3) Plasma glucose levels ≥ 11.1 mmol/l (200 mg/dl) 2 diagnostic for diabetes mellitus (DM).
hours after a 75 g oral glucose load as in glucose According to the World Health Organization, persons with
tolerance test (OGTT) fasting glucose level from 110 - 125 mg/dl (6.1 - 6.9 mmol/l)
4) Symptoms of high blood sugarlevel and casual plasma are considered to have an impaired fasting glucose.
glucose ≥ 11.1 mmol/l (200 mg/dl) Individuals with plasma glucose at least 140 mg/dl (7.8
In the absence of unmistakable high blood sugar, a positive mmol/l), but not above 200 mg/dl (11.1 mmol/l), 2 hours
result should be confirmed by repeating any of the methods after a 75 g oral glucose load are considered to have an
above on a different day. Preferably, a fasting glucose level impaired glucose tolerance. Between these two prediabetic
states, the latter one in particular is major risk factor for the 2.5.1. Lifestyle
progression to full-blown diabetes mellitus (DM), and Those with diabetes can benefit from the education about
cardiovascular disease [39]. Since 2003, the American the disease and its treatment, dietary changes required, and
Diabetes Association (ADA) uses a marginally different exercise, with the aim of keeping both the short-term and the
range for the impaired fasting glucose of 100 – 125 mg/dl long-term blood glucose levels within adequate and
(5.6 – 6.9 mmol/l). The glycated hemoglobin is better than acceptable bounds. Additionally, given the associated higher
the fasting glucose for determining the risks of risk of cardiovascular disease, modifications of lifestyle are
cardiovascular disease and the death from any cause [40]. recommended to control blood pressure [47, 48], including
healthy eating, regular exercise, and maintaining normal
2.4. Prevention of Diabetes weight (BMI 18 to 25).
There preventive measure for type 1 diabetes is not known Weight loss can prevent progression from the prediabetes
[1]. Type 2 diabetes—which accounts for 85 to 90% of all to type 2 diabetes, result in a partial remission in those with
cases worldwide—can normally be prevented or delayed by diabetes, or decrease the risks of cardiovascular disease [49,
engaging in physical activity, eating a healthy diet, and 50]. No single dietary pattern is the best for all individuals
maintaining normal body weight [1]. Higher levels of with diabetes [51]. Healthy dietary patterns, such as
physical activity (over 90 minutes per day) reduce the risks Mediterranean diet, low-carbohydrate diet DASH diet, are
of diabetes by 28% [41]. Effective dietary changes known to usually recommended, although no evidence support one
help prevent diabetes include maintaining diet rich in fiber over the others [49, 50]. According to the ADA, reducing the
and whole grain, and choosing good fats, such as overall carbohydrate intake for people with diabetes has
polyunsaturated fats found in vegetable oils, nuts, and fish shown the most evidence for glycemic improvement, and for
[42]. Eating less red meat and other foods with saturated fat, those with type 2 diabetes who are unable to meet the
in addition to limiting sugary beverages can also help prevent glycemic target or where reducing anti-glycemic medication
diabetes. The smoking of tobacco is also associated with is a priority, very-low or low carbohydrate diets are viable
increased risk of diabetes and its related complications, thus approach [50]. For overweight individuals with diabetes type
smoking cessation can be a key preventive measure as well 2, a diet that achieves loss of weight is effective [51].
[43]. 2.5.2. Medications for Diabetes Mellitus
The relationship between type 2 and the main modifiable i. Glucose Control
risk factors (unhealthy diet, physical inactivity, tobacco use, Most medications used for diabetes treatment act by
and excess weight) is similar in all the regions of the world. lowering blood sugar level through different mechanisms.
In addition, there is increasing evidence that the fundamental There is general consensus that when those with diabetes
determinants of diabetes mellitus are a reflection of the main maintain tight control of glucose (i.e. keeping the glucose
forces driving social, cultural, and economic change: level in their blood within normal range), they experience
globalization, population aging, urbanization, and the general fewer complications like kidney and eye problems [52, 53].
health policy environment [42]. However, there is discussion as to whether this is cost-
2.5. Diabetes Management effective and appropriate for people later in life where
hypoglycemia risk may be more significant [54]. There are a
The management of diabetes focuses on keeping blood few different classes of anti-diabetic medication. Diabetes
sugar levels very close to normal, without causing a low type 1 can only be treated using insulin, typically with a
blood sugar level. This can often be accomplished with combination of NPH and regular insulin, or synthetic analogs
dietary changes, weight loss, exercise, and use of of insulin. Type 2 diabetes can also be treated with insulin at
appropriate medications (oral medications, insulin). the later stages. Some medications for diabetes type 2 are
Learning about the disease and also actively participating in available by oral, such as metformin, while others are
the treatment is very important, since complications are available by only injection such as the GLP-1 agonists.
usually less severe and far less common in individuals who Generally, metformin is recommended as first-line
have well-managed their blood sugar levels [44]. Per the treatment for diabetes type 2, as there is adequate evidence
American College of Physicians (ACP), the goal of the that it decreases mortality. Metformin works by reducing the
treatment is attaining an HbA1C level of 7 to 8% [45]. liver's production of [55]. Several other groups of
Attention is also given to other health issues that may medications, mostly given by mouth, can also decrease blood
accelerate negative effects of diabetes, including smoking, sugar levels in type 2 diabetes. They include sulfonylureas
high blood pressure, lack of regular exercise, and metabolic (agents that increase insulin release), SGLT2 inhibitors
syndrome obesity. Specialized footwear is used widely to (agents that increase excretion of glucose in the urine),
reduce the risks of ulcers in at-risk diabetic feet, though acarbose (agents that decrease the absorption of sugar from
evidence for the efficiency of this remains equivocal [46]. intestines), and Thiazolidinedione (agents that make body
In some developing countries, many untrained more sensitive to insulin) [55]. When insulin is used in
traditionalists claimed that some bitter phytochemicals are diabetes type 2, a long-acting formulation is often initially
helpful in the treatment of diabetes [22]. added, while continuing oral medications. Then the doses of
insulin are increased to the glucose targets. tobacco smoking, alcohol intake, and high blood pressure
ii. Blood Pressure [63].
Since cardiovascular disease is serious complication The WHO estimates that diabetes caused 1.5 million
associated with diabetes mellitus, blood pressure levels lower deaths in 2012, making diabetes the 8th leading cause of
than 130/80 mmHg have been recommended. However, death [62]. However another 2.2 million deaths in the whole
evidence supports lower than or equal to anywhere between world were attributable to high blood glucose levels and the
140/90 mmHg – 160/100 mmHg. The only added benefit increased risks of cardiovascular diseases and other
found for blood pressure target below this range was an associated complications, such as kidney failure, which
isolated reduction in risk of stroke, and this was accompanied usually lead to premature death and are usually listed as the
by increased risks of other serious adverse events [56]. A underlying cause of death certificates rather than diabetes
review in 2016 found potential harm to treating less than 140 [62]. For example, in 2017, [2] estimated that diabetes caused
mmHg [57]. Among medications that lower blood pressure, 4 million deaths worldwide (a significant increase from the
the angiotensin-converting enzyme inhibitors (the ACEIs) WHO report in 2012), using modeling to estimate total
improve the outcomes in individuals with diabetes whereas number of deaths that may be directly or indirectly associated
the similar medications, known as angiotensin receptor with diabetes.
blockers (ARBs), do not [58]. Aspirin is also recommended Diabetes occurs all over the world but is more common
for individuals with cardiovascular problems, however the (mostly type 2 diabetes) in more developed countries.
routine use of aspirin is not found to improve the outcomes in However, the highest increase in the rates has been found in
uncomplicated diabetes mellitus. low- and middle-income countries [62], where over 80% of
iii. Surgery diabetic deaths occur [64], mainly due to poor management
Weight loss surgery in people with type 2 diabetes and and treatment of the disease. The fastest prevalence increase
obesity is usually an effective measure. Many can maintain is expected in Africa and Asia, where most individuals with
normal blood sugar level with little or no medications diabetes will most likely live in 2030 [65]. The increase in
following a surgery and long-term mortality is often rates in developing nations follows the trend of lifestyle
decreased [59]. There is, however, short-term mortality risk changes and urbanization, including less physically
of below 1% from the surgery [60]. The body mass index demanding work, increasingly sedentary lifestyles, and the
(BMI) cutoffs for when the surgery is appropriate are still global nutrition transitions, marked by the increased
unclear [59]. It is recommended, however, that this option be consumption of foods that are highly energy-dense but with
considered in individuals who are not able to get both their poor nutrient profile (often high in saturated fats and sugar,
blood sugar and body weight under control. A pancreas sometimes called the "Western-style" diet) [62, 65]. The
transplant can be occasionally considered for those with global number of diabetes cases may increase by over 48%
diabetes type 1 who have severe complications of their between 2017 and 2045 [2].
diseases, including end-stage kidney disease demanding
kidney transplantation. 2.7. Societal and Cultural Significance
iv. Support The 1989 St. Vincent Declaration [66] was the result of
In countries using a system of general practitioner, such as internationally concerted efforts to improve care accorded to
the UK, care may take place mostly outside hospitals, with the people with diabetes. Doing so is vital not only in terms
hospital-based specialists care used only in the case of of life expectancy and quality of life but also economically
difficult blood sugar control, complications, or research and productivity-related resources for the governments and
projects. In other circumstances, the specialists and general healthcare systems; expenses due to diabetes have shown to
practitioners share care in team approach. The home be major drain on health.
telehealth support may be an effective management technique Several countries established more and less fruitful
[61]. national diabetes programmes for improvement of treatment
2.6. Epidemiology of the disease [67]. People with diabetes who have symptoms
of neuropathy such as tingling or numbness in the feet or the
In 2017, a record of 425 million individuals had diabetes hands are two times as likely to be unemployed as people
in the whole world, up from an estimated 382 million in 2013 without the symptoms. In 2010, the diabetes-related
and from about 108 million in 1980 [62]. Accounting for emergency room (ER) rates of visit in the US were higher
shifting age structure of global population, diabetes among individuals from the lowest income communities (i.e.
prevalence is 8.8% among adults, nearly the double rate of 526 per 10,000 population) than from highest income
4.7% in 1980 [62]. Type 2 makes up around 90% of the communities (i.e. 236 per 10,000 population). Around 9.4%
cases. A number of data indicate rates are approximately of diabetes-related emergency room visits were for the
equal in men and women, but male excess in diabetes is uninsured [68].
found in many populations with higher incidence of type 2
diabetes, likely due to sex-related differences in the insulin 2.8. Other Animals
sensitivity, the consequences of obesity and the regional body In other animals, diabetes is most often encountered in cats
fat depositions, and other contributing factors such as
and dogs. Middle-aged animals are most usually affected. adequate calories [71]. A healthy diet is essential for
Female dogs are two times as likely to be affected as the males, nutrition and good health. It protects an individual against
whereas according to some sources, the male cats are also more numerous chronic noncommunicable diseases, such as
susceptible than females. In both species, all the breeds may be diabetes (especially type 2), heart disease, and cancer [72].
affected, but a number of small dog breeds are most likely to Eating a variety of diets and consuming less salt, saturated
develop diabetes, such as the Miniature Poodles. The feline and industrially-produced trans-fats, and sugars are essential
diabetes is strikingly related to human diabetes type 2. The for a healthy diet.
Burmese breed, together with the Russian Blue, Norwegian A healthy diet may contain whole grains, fruits, and
Forest, and Abyssinian cat breeds, indicated an increased risk of vegetables, and includes little or no processed foods and
diabetes, while several breeds showed lower risks. There is a sweetened beverages. Requirements for a healthy diet may be
connection between overweight and an increased feline diabetes met from a variety of animal-based and plant-based foods,
risks. The symptoms may relate to polyuria and fluid loss, but though a non-animal source of the vitamin B12 is required
the course may also be insidious (producing harm in a stealthy, for those following a vegan diet [73]. Various nutrition
usually, gradual manner). Diabetic animals are more susceptible guides are published by the governmental, medical, and
to infections. The long-term complications acknowledged in nutritional institutions to educate people on what to be eating
humans are much infrequent in animals. The principles of to be healthy. The nutrition facts labels are also compulsory
treatment (oral antidiabetics, subcutaneous insulin, weight loss) in many countries to allow the consumers to choose foods
and management of emergencies (for example, ketoacidosis) are based on components relevant to health, rather than just
similar to those treatments in humans. merely satisfying their appetite.
The World Health Organization makes the following 5
2.9. Research Development recommendations with respect to both individuals and
Inhalable insulin has been developed [69]. The original populations: [72]
products were withdrawn because of side effects [69]. In 1. Eat 400 g of fruits and vegetable or above per day
June 2014, Afrezza, under development by pharmaceuticals (cassava, potatoes, sweet potatoes, and other starchy
company MannKind Corporation, was permitted by the US root crops do not count). A healthy diet also contains
FDA for general sale. An advantage to inhaled insulin is legumes (for example, beans, lentils), whole grains and
more convenient and easy to use. The transdermal insulin in nuts.
form of cream has been developed and many trials are being 2. Limit intake of fats. Less than 30% of total calories
conducted on individuals with type 2 diabetes [70]. should come from fat. Prefer unsaturated fats to
saturated fats. Shun trans fats.
2.10. Diets and Nutrition for Diabetes and Its 3. Limit the intake of the simple sugars to below 10% of
Prevention calorie (below 25 grams or below 5% of calories per
day may even be better).
Maintaining a healthy diet, low-fat diet, low-calorie diet, 4. Limit sodium and salt from all sources and make sure
paleolithic diet, very low carbohydrate diet, raw foodism, that salt is iodized. Below 5 g of salt per day have
and/or ketogenic diet can help prevent or manage diabetes. been shown to reduce the risks of cardiovascular
2.10.1. Healthy Diet diseases.
A healthy diet is any diet that helps to improve or maintain 5. Maintain healthy weight by consuming approximately
overall health. Healthy diet provides the body with the the same number of calories the body is using.
essential nutrition: fluid, micronutrients, macronutrients, and
Table 3. The three healthy patterns.
Food group/subgroup (units) U.S. style Med-style Vegetarian

Fruits (cup equivalent, eq) 2 2.5 2
Vegetables (cup eq) 2.5 2.5 2.5
Dark green 1.5 per week 1.5 per week 1.5 per week
Red/orange 5.5 per week 5.5 per week 5.5 per week
Starchy 5 per week 5 per week 5 per week
Legumes 1.5 per week 1.5 per week 3 per week
Others 4 per week 4 per week 4 per week
Grains (oz eq) 6 6 6.5
Whole 3 3 3.5
Refined 3 3 3
Dairy (cup eq) 3 2 3
Protein Foods (oz eq) 5.5 6.5 3.5
Meat (red and processed) 12.5 per week 12.5 per week --
Poultry 10.5 per week 10.5 per week --
Seafood 8 per week 15 per week --
Eggs 3 per week 3 per week 3 per week
Nuts/seeds 4 per week 4 per week 7 per week
Food group/subgroup (units) U.S. style Med-style Vegetarian

Processed soy (including tofu) 0.5 per week 0.5 per week 8 per week
Oils (g) 27 27 27
Solid fats limit (g) 18 17 21
Added sugars limit (g) 30 29 36
Source: [74]
1) vegetables, nuts, roots, meat, organ meats, and fruits;

2.10.2. Low-fat Diet 2) vegetables (including root vegetables), nuts, fish, meat,
A low-fat diet is a diet that restricts fats, and often eggs, and fruit (including fruit oils, e.g., coconut oil,
cholesterol and saturated fat as well. Low-fat foods are palm oil, and olive oil), and it excluded dairy, legumes,
intended to reduce occurrence of conditions such as heart extra sugar, grain-based foods, and nutritional products
diseases and obesity, which increases the risks of diabetes of industry (such as refined carbohydrates and refined
and can worsen diabetes in already diabetic patients. For fats); and
weight loss, low-fat diets perform similarly to low- 3) avoids processed foods, and lay emphasis on eating
carbohydrate diets, since macronutrients compositions do not vegetables, nuts and seeds, fruits, eggs, and lean meats
determine weight loss success [75]. Fat provides 9 calories/g [83].
while carbohydrates and protein each provide 4 calories/g. As of 2016 there are limited information on the metabolic
The Institute of Medicine recommends restricting fat intake effects on the humans eating a paleolithic diet, but data are
to 35% or less of total calories to control the intake of based on the clinical trials which have not been enough to
saturated fat [76]. Although low fats may affect the have a sufficient statistical significance to allow the call for
functional properties of foods [77, 78], restricting fats intake generalizations [81, 83]. These preliminary trials have
within the recommended limit is required for healthy living indicated that participants consuming a paleolithic nutrition
and managing diabetes. pattern had better metabolic and cardiovascular health than
According to the National Academies Press, high-fat diet individuals eating a standard diet [81, 84], though the
often contain unacceptably high amounts of saturated fats, evidence is sufficient enough to recommend the paleolithic
even if saturated fats from tropical oils and animal products diet for treatment of metabolic syndrome [84], but it may
are avoided. This is due to all fats contain some levels of also be used to reduce the risks of diabetes and other
saturated fatty acids. For instance, if an individual chose fats nutritional diseases. As of 2014 there was lack of evidence
with 20% saturated fatty acids, the setting of fat intake at that paleolithic diet is effective in treatment of inflammatory
35% of the total calories mean that 7% of the calories would bowel disease [85].
come from the saturated fat. For this reason, Institute of
Medicine and many nutritional institutions recommend 2.10.4. Low-carbohydrate Diets
consuming no more than 35% of the calories from fat [79]. (Carbohydrate-Restricted Diets)
Low-fat diets have been promoted to prevent heart disease Low-carbohydrate diets, also known as carbohydrate-
and obesity. Lowering fat intake from 35 to 40% of total restricted diets (CRDs) are the diets that restrict consumption
calories to 15 to 20% of total calories has shown to reduce of carbohydrate relative to the average diet. Diets high in
total and LDL cholesterol by 10 – 20%; however, most of carbohydrates (e.g., pasta, sugar, bread) are limited, and
this reduction is due to a decrease in saturated fat intake [80]. replaced with the foods containing higher percentage of
protein (e.g., meat, shellfish, eggs, cheese, poultry, fish, nuts,
2.10.3. Paleolithic Diet and seeds) and fat, as well as low carbohydrate foods, such as
The Paleolithic diet, caveman diet, stone-age diet, or Paleo chard, collards, spinach, kale, and other fibrous vegetables.
diet is a modern fad diet requiring sole or predominant However, there is a lack of general standardization of how
consumption of foods acknowledged to have been available much carbohydrates low-carbohydrate diets must have,
to human during the Paleolithic era [81]. The digestive which has complicated research [86]. A low-carbohydrate
abilities of the anatomically modern humans, however, are, to diet reduces body exposure to high glucose levels, leads to
a large extent, different from those of the pre-Homo sapiens weight loss, decrease the risk of obesity, and prevent or
humans, and has been used to criticize the core premise of control diabetes, and other related metabolic imbalance. A
the diet [82]. While there is wide variation in the way the definition, from American Academy of Family Physicians,
paleolithic diet is interpreted [83], the diet typically includes identifies low-carbohydrate diets as having below 20%
fruits, nuts, vegetables, meat, and roots, and typically carbohydrate content [87].
excludes foods such as sugar, processed oils, alcohol, salt, There is no enough evidence that eating low-carbohydrate
etc. The diet is based on avoiding processed food and the provides any particular health benefits, apart from weight
foods humans began eating after Neolithic Revolution when loss where low-carbohydrate diets also achieve similar
humans transitioned from the hunter-gatherer lifestyles to outcomes to other diets, since weight loss is determined
settled agriculture [81]. mainly by calorie restriction and adherence [88].
The scientific literatures commonly use the term "Paleo Nevertheless, a loss of weight is required in obese people to
nutrition pattern", which is variously described as: reduce the risks of diabetes, maintain healthy lifestyle, and
reduce the risk of cardiovascular diseases. Consequently, it is with diabetes has shown the most evidence for glycemia
scientific and logically conclusive to say that, for those with improvement and may be applied in a range of eating
obesity and overweight, maintaining and adhering to low- patterns that meet individual requirements and preferences,
carbohydrate diets is essential for reducing the risk of and for people with type 2 diabetes who cannot meet the
diseases such as diabetes, cardiovascular disease, etc. An glycemic target or where reducing anti-glycemic medication
extreme form of a low-carbohydrate diet –ketogenic diet – is is a priority, low or very-low-carbohydrate diets are viable
made as medical diet for treating epilepsy [85, 89]. Through approach.
celebrity endorsement it has come to be popular weight-loss
fad food, but there is no evidence of distinctive benefits for 2.10.5. Very-low-calorie Diet
this purpose, and it can have a few initial side effects [89]. A very-low-calorie diet (VLCD), also called
The British Dietetic Association (BDA) named it among the semistarvation diet or crash diet [96], is type of fad diet with
top 5 worst celeb foods to avoid in 2018 [89]. extremely or very low daily food energy consumption.
There is little evidence for effectiveness of low- VLCD is defined as a diet containing 800 kilocalories (3,300
carbohydrate diet for individuals with type 1 diabetes [86]. kJ) or less per day [97, 98]. Modern medically supervised
For some people, it may be feasible to adhere to a low- very-low-calorie diets (VLCDs) use total meal replacement,
carbohydrate regime in combination with carefully-managed with regulated formulation in Europe and Canada which have
insulin dosing, it can be hard to strictly maintain and there the recommended daily requirements for fatty acids, protein,
are some concerns about the potential adverse health effect vitamins, minerals, trace elements, and electrolyte balance.
caused by the diet [86]. In general, individuals with type 1 Carbohydrates can be completely absent, or partly substituted
diabetes are advised to maintain an individualized eating plan for the protein; this choice has significant metabolic effects.
[86]. Medically supervised very-low-calorie diets have specific
The proportion of carbohydrates of all types in a diet is not therapeutic application for rapid loss of weight, such as
directly linked to the risks of diabetes type 2, although there before a bariatric surgery or in morbid obesity, using
is some evidence linking diets containing some high- formulated, nutritionally complete liquid foods containing
carbohydrate products, such as white rice or sugar-sweetened not more than 800 kilocalories per day for maximum of 12
drinks, are associated with increased risks of type 2 diabetes. weeks [97]. Unmonitored very-low-calorie diets with
Some evidence indicates that eating fewer carbohydrate insufficient macronutrient and mineral intakes have the
foods can reduce biomarkers of diabetes type 2 [90, 91]. potential to cause electrolyte imbalance and unexpected
A 2018 report on diabetes type 2 by the European death via ventricular tachycardia either upon refeeding or by
Association for Study of Diabetes (EASD) and the American starvation [99].
Diabetes Association (ADA) found that low-carbohydrate 2.10.6. Raw Foodism
diets may not be as good as Mediterranean diets for Raw foodism, also called rawism or following raw food
improving glycemic control, and also that although having diet, is dietary practice of consuming only or mostly foods
healthy body weight is vital, there is no single ratio of intake that are unprocessed and uncooked. Depending on the
of carbohydrate, proteins, and fat that is optimal for every philosophy, or the type of lifestyle and the results desired,
individual with type 2 diabetes [92]. There is no sufficient raw food diets can include a selection of vegetables, nuts,
evidence that diets with low-carbohydrate are better than fruits, seeds, eggs, meat, fish, and dairy products [100].
conventional healthy diets, wherein carbohydrates typically Also, the diet may include simply processed food, such as
account for over 40% of calories consumed [93]. Low- cheese, numerous types of sprouted seeds, and fermented
carbohydrate dieting has no effects on the kidney function of foods such as sauerkraut, yogurts, kefir, or kombucha, but
individuals who have type 2 diabetes [94]. normally not foods that have been homogenized,
Limiting carbohydrate consumption commonly results in pasteurized, or produced with synthetic pesticides, solvents,
improved glucose control, though without long-term weight food additives, and fertilizers. Raw food diets are diets
loss [90], but there may be immediate (2 to 10 weeks) entirely or mostly composed of food that is uncooked or
noticeable weight loss, depending on the amounts of other cooked at low temperatures. When uncooked, many starch
energy-giving nutrients, especially fats. Low-carbohydrate molecules are more likely resistant to digestion in the body,
diet can be useful to help individuals with type 2 diabetes thereby reducing the glucose levels. Cooking improves the
lose weight, although no single approach is proven to be digestibility of nutrients [77]. The medical authorities have
consistently superior [95]. According to the American defined raw foodism as a fad diet. The raw food diets,
Diabetes Association, people with diabetes should be precisely raw veganism, fail to provide the essential
developing a healthy eating pattern rather than focusing on minerals and nutrients such as iron, calcium, and protein.
individual micronutrients, macronutrients, or single foods. Claims held by the raw food proponents are
ADA recommended that the carbohydrate in a diet should pseudoscientific [101].
come from legumes, vegetables, fruits, dairy (yogurt and
milk), and whole grains, while sugary drinks and highly- 2.10.7. Ketogenic Diet
refined foods should be avoided [95]. The ADA also stated The ketogenic diet is high-fat, adequate-protein, and low-
that reducing the overall intake of carbohydrate for people carbohydrate diet that is used primarily in medicine to treat
difficult-to-control (i.e. refractory) epilepsy in children. The blood sugar level. Prevention and treatment of diabetes involve
ketogenic diet compels the body to burn fats instead of maintaining healthy diet, normal body weight, regular physical
carbohydrates. The carbohydrates contained in food are exercise, and avoiding use of tobacco. Maintaining a healthy diet,
normally converted into glucose, which is transported around low-fat diet, low-calorie diet, paleolithic diet, very low
the body and is mainly important in fueling the brain carbohydrate diet, raw foodism, and/or ketogenic diet can help
function. However, if little or no carbohydrate remains in the prevent or manage diabetes.
diets, the liver converts fat into ketone bodies and fatty acids.
The ketone bodies pass into brain and replace glucose as
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Article · February 2020

Chinaza Godswill Awuchi Chinelo Kate Echeta

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Diabetes and the Nutrition and Diets for Its

stroke, foot ulcers, damage to the eyes, and chronic kidney

condition where cells fail to properly respond to insulin. As dermadromes [12].

Table 1. Comparison of type 1 and 2 diabetes.

Feature Type 1 diabetes Type 2 diabetes

d. Pancreatectomy and muscle cells [3].

Condition 2-hour glucose Fasting glucose HbA1c

Food group/subgroup (units) U.S. style Med-style Vegetarian

Food group/subgroup (units) U.S. style Med-style Vegetarian

1) vegetables, nuts, roots, meat, organ meats, and fruits;

[71] Lean, Michael J. E. (2015). P

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