Received: 12 November 2018 Revised: 9 May 2019 Accepted: 17 May 2019

DOI: 10.1002/dmrr.3188

REVIEW ARTICLE

The effects of popular diets on type 2 diabetes management

Brittannie Chester1 | Jeganathan Ramesh Babu1,2,3 | Michael W. Greene1,2,3 |

Thangiah Geetha1,2,3

1
Department of Nutrition, Dietetics, and
Hospitality Management, Auburn University, Summary
Auburn, Alabama Type 2 diabetes can be managed with the use of diabetes self‐management skills.
2
Boshell Metabolic Diseases and Diabetes
Diet and exercise are essential segments of the lifestyle changes necessary for diabe-
Program, Auburn University, Auburn, Alabama
3
Center for Neuroscience Initiative, Auburn
tes management. However, diet recommendations can be complicated in a world full
University, Auburn, Alabama of different diets. This review aims to evaluate the evidence on the effects of three

Correspondence
popular diets geared towards diabetes management: low‐carbohydrate and ketogenic
Thangiah Geetha, Department of Nutrition, diet, vegan diet, and the Mediterranean diet. While all three diets have been shown to
Dietetics, and Hospitality Management,
Auburn University, 101B Poultry Science
assist in improving glycaemic control and weight loss, patient adherence, acceptabil-
Building, 260 Lem Morrison Drive, Auburn, AL ity, and long‐term manageability play essential roles in the efficacy of each diet.
36849.
Email: thangge@auburn.edu
K E Y W OR D S

Funding information diabetes, diet, ketogenic, Mediterranean, vegan

AAES Award for Interdisciplinary Research
(AAES‐AIR); Hatch/Multistate Funding
Program; Alabama Agricultural Experimental
Station (AAES)

1 | I N T RO D U CT I O N self‐management education provided by a health care professional

Lifestyle modifications and self‐management skills are crucial to the
management of type 2 diabetes mellitus.1-3 One of the most significant
lifestyle changes and challenges for patients with diabetes is a change in
eating habits. The typical carbohydrate portion–controlled diet has
been prescribed for patients with diabetes for many years, but now, sev-
eral different diets are being tested in this population. According to the
Centers for Disease Control and Prevention (CDC), the number of peo-
4
ple with diabetes has more than tripled in the last couple of decades.
Current CDC data and statistics report that 30.3 million people in the
United States have diabetes; 7.2 million are believed to be living with
undiagnosed diabetes; and 84.1 million people are at increased risk for
4
developing type 2 diabetes. Thus, more than 114 million Americans
are at risk of developing the devastating complications that result from
poorly controlled diabetes. Between the direct cost of diabetes and the
reduced productivity, the total costs of diagnosed diabetes in the
5
United States in 2017 were $327 billion. Proper management of diabe-
tes is crucial for the reduction of health care costs, better quality of life,
and preventing minor and severe complications.
In order to help prevent complications, type 2 diabetes must be
carefully managed with diabetes self‐management skills. Diabetes
includes diet/nutrition education or medical nutrition therapy (MNT),
diabetes basics, blood sugar monitoring, medication management,
and exercise. Providing MNT to people with diabetes is effective in
reducing hospitalization and physician services by 9.5% and 23.5%,
respectively, which, in turn, reduces health care costs in the long
run.6 Some of the goals for MNT for individuals with diabetes are to
promote and support healthful eating patterns, achieve and maintain
body weight goals, attain individualized glycaemic, blood pressure,
and lipid goals, and delay or prevent the complications of diabetes.7
The American Diabetes Association (ADA) recommends lowering
calorie intake through a hypocaloric diet for overweight or obese
adults with type 2 diabetes to induce weight loss, which improves
blood glucose levels.7 Obesity is a major independent risk factor for
developing type 2 diabetes and other weight‐related complications
that cause significant rates of morbidity and mortality.8 More than
90% of people with type 2 diabetes are overweight or obese. Modest
weight loss, as little as 5% of total body weight, can help to improve
the haemoglobin A1c (HbA1c) levels in these patients.7 However, pro-
viding recommendations for the best diet for a patient with diabetes
to achieve optimal glycaemic control can be challenging. There are
several dietary approaches to control hyperglycaemia in type 2

Diabetes Metab Res Rev. 2019;35:e3188. wileyonlinelibrary.com/journal/dmrr © 2019 John Wiley & Sons, Ltd. 1 of 10
https://doi.org/10.1002/dmrr.3188
2 of 10
diabetes patients, but carbohydrate portion control is the typical diet
taught by the ADA, registered dietitians (RDs), and diabetes self‐
management education and support (DSMES) facilities.7
The ADA recommends lowering HbA1c levels to <7%, controlling
blood pressure to <130/80 mm Hg, and controlling low‐density lipo-
protein (LDL) cholesterol to <100 mg/dL (<70 mg/dL for those with
a diagnosed cardiovascular disease [CVD]) to reduce the risk of micro-
7
vascular and cardiovascular complications. The ADA also recom-
mends a variety of eating patterns that are acceptable for the
management of type 2 diabetes and prediabetes, including Mediterra-
nean, dietary approaches to stop hypertension (DASH), and plant‐
based diets.7 Reducing calories and monitoring carbohydrate intake
9,10
are the leading MNT concepts for type 2 diabetes. Since weight
loss is an excellent treatment for overweight or obese people with
type 2 diabetes, a wide range of diets are now recommended for man-
aging diabetes, but the safety and long‐term efficacy are in question.
The present review aims to compare the effectiveness of three popu-
lar diets on glycaemic control and weight loss in patients with type 2
diabetes mellitus: low‐carbohydrate and ketogenic diet, the Mediterra-
nean diet, and the vegan diet.
2 | L O W‐ C A R B O H Y D R A T E A N D
K E T O G E N I C D I E T TO M A N A G E TY P E 2
DIABETES
Most recently, there has been a renewed interest in the impact of
the low‐carbohydrate and ketogenic diets for weight loss, the treat-
ment of diabetes, and even improved performance in endurance and
strengthening athletes. This remains a controversial diet among
health care professionals because of the strict restriction of carbohy-
drates. Since dietary carbohydrate is the primary macronutrient that
raises blood glucose levels, dietary carbohydrate portion control reli-
ably reduces high blood glucose.11 However, among patients with
diabetes, extreme carbohydrate restriction may increase the risk of
hypoglycaemia, especially in patients treated with insulin and insulin
11
secretagogues (sulfonylureas and incretin‐based therapies). Conse-
quently, modification in drug dosage is recommended before initiat-
ing such a diet depending on glycaemic control and class of diabetes
11
medication therapy. According to the Lifestyle management sec-
tion of the 2018 ADA standards,7 the exact amount of carbohydrate
consumption recommended for each diabetes patient is uncertain,
because of individualized calorie needs; however, tracking the carbo-
hydrate consumption and blood glucose level is essential. Typically,
the ADA recommends about 45% of a person's calories should come
from carbohydrates, which is about 30 to 60 g of carbohydrates per
meal and about 15 to 30 g of carbohydrates for snacks.12
Gomez‐Arbelaez et al used a short‐term very‐low‐calorie keto-
genic diet for weight loss.13 This short‐term diet ranged from 600
to 800 calories per day and 50 g of carbohydrates from vegetables
in the ketogenic phases of the very‐low‐calorie ketogenic diet. When
the ketogenic phases of the diet ended, the progress to maintenance
was started, and the calories were increased individually on the basis
CHESTER ET AL.
of weight loss to 800 to 1500 calories per day for the low‐calorie
ketogenic diet with an increasing variety of foods and 1500 to 2000
calories per day in the maintenance phase where the carbohydrates,
protein, and fat intake were balanced. Most research involving low‐
carbohydrate ketogenic diets refrain from using specific calorie ranges
because of individualized calorie needs, which are based on metabolic
rates and changes in hunger and satiety due to the carbohydrate
limits for the low‐calorie ketogenic diet.14 Ad libitum low‐calorie keto-
genic diet has been used because there are typically recommended
and restricted foods, and this type of high‐protein, low‐carbohydrate
diet reduces hunger and lowers food intake significantly more than
high‐protein, medium‐carbohydrate nonketogenic diets.14
According to the 2018 ADA standards of care, to promote weight
loss in obese and overweight patients with type 2 diabetes, the diet
and calorie needs should be individualized, and behavioural strategies
should be provided to achieve a 500 to 750 kcal/d energy deficit.
Diets with similar caloric restriction but differing in protein, carbohy-
drate, and fat content are equally effective in achieving weight loss.7
The 2018 ADA standards of care also mention that meal replacements
or food substitutes can be used to achieve weight loss of more than
5% using short‐term (3‐mo) interventions that use very‐low‐calorie
diets (<800 kcal/d), and total meal replacements can be prescribed
for patients assessed and approved by trained practitioners in medical
care settings with close medical monitoring.7 Hemmingsson et al eval-
uated the effectiveness of three different low‐calorie diets on weight
loss for 3 months, which was followed by the same maintenance pro-
gramme for the remaining 9 months.15 The very‐low‐calorie diet
consisted of 500 calories of liquid‐food substitutes per day then grad-
ually reintroducing food after 6 to 10 weeks; the low‐calorie diet
consisted of 1200 to 1500 calories of liquid‐food substitute and food
combination per day, and the last low‐calorie diet consisted of a 1500
to 1800 calorie‐restricted normal‐food diet. The very‐low‐calorie diet
showed lower dropout rates and more significant weight loss than the
other diets after the year‐long study.15
The benefits of very‐low‐carbohydrate or ketogenic diets (less than
50‐g carbohydrate per day) are shown in few studies15,16 but are only
suitable for 3 to 4 months depending upon the individuals.7 The keto-
genic diet is high in fat and low in carbohydrates, which simulate the
metabolic effects of starvation by forcing the body to use primarily fat
as a fuel source. The ketogenic diet mimics starvation, allowing the body
to go into a metabolic state of ketosis.17 Ketosis is a metabolic state
where most of the body's energy supply comes from ketone bodies in
the blood, instead of a state of glycolysis where blood glucose provides
most of the energy. Carbohydrate restriction induces the pancreas to
signal fat cells to release fatty acids, which get taken up by the liver
and converted into ketones and released into blood.17 Whether the
patients are in an actual state of ketosis requires testing of the breath,
urine, or blood. It is reported that most patients with diabetes receive
44% to 46% of total calories from their carbohydrate intake, so modify-
ing eating patterns too drastically is often unsuccessful for long term.18
According to the Academy of Nutrition and Dietetics, macronutrient
amounts should be individualized for patients with type 2 diabetes,
and there is limited research regarding the significant effects on HbA1c
CHESTER ET AL.
or insulin between differing amounts of carbohydrates (39% to 57% of
energy) and fat (27% to 40% of energy).19
Current recommendations of the Dietary Guidelines Advisory
Committee state that diets with less than 45% of calories from car-
bohydrates are not more successful than other diets for long‐term
weight loss (12 mo).20 A systematic review by Anton et al21 found
this to be false among the studies they reviewed. They found that
studies with diets consisting of less than 45% of calories from carbo-
hydrates, like Atkins and Palaeolithic, substantially produced short‐
term and long‐term weight loss. Many early studies concluded that
carbohydrates are a necessary nutrient for optimum human health
and function. On the other hand, it was alternatively believed that
fat was a more reliable fuel source because it was one of the pri-
mary fuel sources for existence in the lives of hunters and gath-
erers.22 However, there was no single hunter‐gather diet as
geographic location, seasonality, and resource availability impacted
the contribution of carbohydrate, fat, and protein in the diet.22
Before the development of agriculture, dietary carbohydrates were
not as readily available, so people depended more on fat and protein
for nutritional energy. Thus, some populations survived on a low‐
carbohydrate diet.
Not only has the ketogenic diet been studied as a treatment for
obesity and diabetes but also seizures, epilepsy, and many other dis-
23
eases. According to Dr John Freeman, one of the nation's leading
advocates for the ketogenic diet, the diet has reemerged and its
effectiveness for other neurological disorders, including brain
tumours, autism, and even Alzheimer disease, is being explored as
well.23 The classic ketogenic diet for epilepsy or seizures is typically
a 4:1:1 ratio for fat, protein, and carbs, where 90% of the diet comes
from fat. In diabetes and other disorders, the ketogenic diet is
defined as less than 20 g of carbohydrates per day, where typically
71% of the calories come from fat, 25% from protein, and 4% from
carbohydrates.23
Losing weight is a very reliable treatment/management for type 2
diabetes, so most diets focus on weight loss. Most traditional diabetes
diets involve instructing patients to lower their fat consumption and
eat 500 fewer kilocalories per day than their calculated energy mainte-
nance needs to reduce weight.7 Therefore, it is easy to disregard the
ketogenic diet as a treatment for type 2 diabetes, because many people
with type 2 diabetes are overweight, and a high‐fat diet can seem con-
tradictory. However, the goal of the ketogenic diet is to have the body
use fat for energy instead of carbohydrates or glucose. For this reason,
a person on the ketogenic diet gets most of their calories from eating fat,
with very little of the diet coming from carbohydrates. The drastic
weight loss seen in many diets brings up the question of fat vs muscle
loss excluded individuals with diabetes but reveals a clear conclusion
of muscle preservation during rapid weight loss in Gomez‐Arbelaez
13
et al. The participants were weighed four times: once before ketosis,
during the maximum level of ketosis, during normal diet with reduced
ketones, and after they were out of ketosis. Before ketosis, there was
an average body weight of 95.9 ± 16.3 kg; at the time of maximum level
of ketosis, there was an average body weight of 84.2 ± 18.0 kg; as
patients began the return to a regular diet after 80 days, there was an
3 of 10
average body weight of 76.6 ± 11.1 kg; and lastly, after ketosis, there
was an average body weight of 75.1 ± 11.8 kg. All weights were statis-
tically different from baseline levels.13
Digestible carbohydrates are broken down into glucose, which is
mainly transported and used as energy or stored as glycogen in the
liver and muscle tissue. When deprived of dietary carbohydrates (usu-
ally below 50 g/d), the liver becomes the sole provider of glucose to
feed the organs, especially the brain, accounting for approximately
20% of total energy expenditure.17 The brain cannot directly use fat
for energy, but once liver glycogen is depleted, the ketone bodies that
the liver derives primarily from fatty acids in the diet or body fat and
also ketogenic amino acids serve as a backup system. Meanwhile,
the blood glucose remains physiologically normal because of glucose
derived from glucogenic amino acids and indirectly from the break-
down of fatty acids.
The ketogenic diet may reduce the need for insulin. Because of this
possible effect, the ketogenic diet has the potential to decrease blood
glucose levels. Managing carbohydrate intake is often recommended
for people with type 2 diabetes because carbohydrates turn to glucose
and, in large quantities, can cause a spike in blood sugar level. By
switching most calories from carbohydrates to fat, some people expe-
rience reduced blood sugar. The Atkins diet is one of the most popular
low‐carbohydrate diets that is often associated with the ketogenic
diet. However, the two diets are very different. According to Anton
et al,21 the Atkins diet showed the most evidence in producing clini-
cally meaningful short‐term (≤6 mo) and long‐term (≥1 y) weight loss
when compared with other popular diets. While cutting excess carbs is
a good step and aids in weight loss, it is unclear if this diet alone can
be considered a treatment for diabetes. During the first 2 weeks, less
than 20 g of carbohydrates are consumed daily, with a gradual
increase to 50 g daily.
While the ketogenic diet may have positive aspects, there are also
potentially dangerous effects for patients with diabetes. Changing the
body's primary energy source from carbohydrates to fat causes an
increase in ketones in the blood or dietary ketosis.23 When there are
too many ketones in the body, a patient may be at risk of developing
diabetic ketoacidosis (DKA). DKA is most prevalent in type 1 diabetes
when blood glucose levels are too high and a large number of ketones
are produced, which alters the pH level in the blood and can arise from
a lack of insulin.24 In dietary ketosis, the pH remains in normal levels
and has positive effects on insulin and glucagon. Many individuals
are also concerned about fat intake's effect on cholesterol and lipid
levels. Several studies conclude that the low‐carbohydrate ketogenic
diet improves blood glucose, lipid, and cholesterol levels in humans
but shows different results in rodents.24-27 Low‐carbohydrate keto-
genic diets show lipid accumulation, hepatic steatosis, and nonalco-
holic fatty liver disease in rodents.24-27 However, further research is
needed to evaluate the long‐term effects of this diet in humans.
Without the proper amount of carbohydrates, the body will create
glucose from noncarbohydrate precursors or gluconeogenesis. The
adherence to such a restrictive carbohydrate diet is also a concern,
plus the long‐term effects of this diet such as the stimulation of the
development of nonalcoholic fatty liver disease and systemic glucose
4 of 10 CHESTER ET AL.

intolerance found in mice.25 Nevertheless, the ketogenic diet provides
impressive results for weight loss, which aids in decreasing insulin
resistance and reducing blood glucose levels.26 The low‐carbohydrate
ketogenic diet also improves blood insulin levels and, according to
Hussain et al,28 is safe to use for a more extended period in obese dia-
betic subjects. Furthermore, very‐low‐carbohydrate, ketogenic diets
have not found to have an adverse effect on glucose metabolism or
23,24
insulin resistance in humans. The ketogenic diet may offer hope
to people with type 2 diabetes who have difficulty controlling their
symptoms. Not only do many people feel better with fewer diabetic
symptoms but they may also be less dependent on medications.23,24
In 2008, researchers conducted a 24‐week study to determine the
effects of a low‐carbohydrate, ketogenic diet (LCKD) on people with
type 2 diabetes and obesity.29 The participants were advised by a die-
titian to limit their dietary carbohydrate intake to less than 20 g/d,
without changing the total caloric intake. The participants were
allowed to eat unlimited amounts of animal foods (meat, chicken,
turkey, other fowl, fish, and shellfish) and eggs but restricted amounts
of hard cheese (4 ounces per day), fresh cheese (2 ounces per day),
salad (2 cupfuls per day), and nonstarchy vegetables (1 cupful per
day). At the end of the study, participants who followed the ketogenic
diet had greater improvements in glycaemic control (HbA1c), body
weight, and medication reduction compared with those who followed
a low‐glycaemic index diet (Table 1). More than 50% of the
participants were dropped out from the study because of the refusal
to stick to the assigned diet, unsatisfied with the diet, lost to follow‐
up, too busy, relocation, and for few, no reason was mentioned.29 In
a pilot feasibility study, Saslow et al16 found the ketogenic diet
outperformed a regular low‐fat diabetes diet over 32 weeks online
intervention. Participants in the very‐low‐carbohydrate ketogenic diet
improved their glycaemic control and lost more weight after the diet
intervention.16

TABLE 1 Effects of low‐carbohydrate diet on diabetes

References Design and Methods Results

16
Saslow et al Thirty‐four participants were randomized at the University of
California, San Francisco (UCSF) to the moderate
carbohydrate calorie restricted (MCCR) (n = 18) or low‐
carbohydrate ketogenic (n = 16). They compared a
conventional diabetic diet (MCCR) (45% to 50% of their
calories from carbohydrates), calorie‐restricted
recommendations to a very‐low‐carbohydrate, ketogenic
diet (≤50‐g carbohydrates per day not including fibre) in
persons with HbA1c > 6.0%. The primary outcome measure
was change in glycated haemoglobin (HbA1c) from baseline
to 3 mo. Key secondary outcomes were changes in lipids,
insulin resistance as estimated by homeostatic model
assessment (HOMA), and weight.
Westman et al29 In the low‐carbohydrate ketogenic diet (LCKD) group, a
registered dietitian (RD) instructed participants to restrict
intake of dietary carbohydrate to fewer than 20 g/d,
without explicitly restricting caloric intake.
In the low‐glycaemic index, reduced‐calorie group (LGID), the
RD instructed participants to follow a low‐glycaemic index,
reduced‐calorie diet with approximately 55% of daily
caloric intake from carbohydrate.
Al‐Khalifa et al30 Adult rats were divided into three groups: normal diet, LCKD,
and high‐carbohydrate diet. Each group was subdivided
into normal, sham, and diabetic groups. Specific diets were
given to each group of animals for a period of 8 wk. The
rats were monitored daily for food and water intake, and
weight, urine output, and blood glucose levels were
monitored weekly.
Nielsen and Joensson31 Retrospective follow‐up after 44 mo observation time of
previously studied subjects on body weight and glycaemic
control in a low‐carbohydrate diet (20% carbohydrate).
Obese participants with type 2 diabetes were divided into
two groups of participants observed closely over 6 mo
(low‐carbohydrate intervention group, n = 16; controls,
n = 15) and reported maintenance of these gains after 22
and 44 mo, without close follow‐up.
Both groups had significant weight loss. However, the mean
weight loss was larger in the low‐carbohydrate ketogenic
LCKD group (MCCR: −2.6 kg and −2.8% of body weight;
low‐carbohydrate ketogenic group LCKD: −5.5 kg and
−5.5% of body weight), but the difference was not
statistically significant at P = 0.09. Within the MCCR
group, HbA1c change was not significant (−0.2%,
P = 0.19); the between‐group difference of change in
HbA1c (−0.4%) favoured the LCKD low‐carbohydrate
ketogenic group (95% CI, −0.8% to −0.02%, P = 0.04).
Both interventions led to improvements in haemoglobin A1c,
fasting glucose, fasting insulin, and weight loss. The LCKD
group had greater improvements in haemoglobin A1c
(−1.5% vs −0.5%, P = 0.03), body weight (−11.1 vs
−6.9 kg, P = 0.008), and high‐density lipoprotein
cholesterol (+5.6 vs 0 mg/dL, P < 0.001) compared with
the LGID group. Diabetes medications were reduced or
eliminated in 95.2% of LCKD vs 62% of LGID participants
(P < 0.01).
The results showed that LCKD was effective in bringing
blood glucose level close to normal (P < 0.01). Food and
water intake and urine output were increased in all
groups except the LCKD group (P < 0.01). The body
weight was significantly reduced in all diabetic animals
except in the LCKD group (P < 0.01).
The mean body weight at the start of the initial study was
100.6 ± 14.7 kg. At 6 mo, it was 89.2 ± 14.3 kg, from 6 to
22 mo, mean body weight had increased to an average of
92.0 ± 14.0 kg, and at 44 mo, average weight has
increased to 93.1 ± 14.5 kg. Of the 16 intervention
participants, five retained or reduced body weight since
the 22 mo point and all but one had lower weight at
44 mo than at the start. The initial mean HbA1c was
8.0% ± 1.5%. After 6, 12, 22, and 44 mo, HbA1c was
6.1% ± 1.0%, 7.0% ± 1.3%, 6.9% ± 1.1%, and 6.8% ± 1.3%,
respectively.
CHESTER ET AL.
In Yancy et al,32 Durham Veterans Affairs Medical Center (VAMC)
outpatient clinics conducted a study evaluating the low‐carbohydrate,
ketogenic diet (LCKD) as the treatment for type 2 diabetes. The LCKD
may be effective for improving glycaemia and reducing medications in
patients with type 2 diabetes. Twenty‐one patients were provided
with LCKD counselling (20 g/d). When a participant neared half the
weight loss goal or experienced cravings, he or she was advised to
increase carbohydrate intake by approximately 5 g/d each week as
long as weight loss continued. Median fasting glucose values
decreased by 12.5 mg/dL from baseline to week 16; the mean body
weight decreased significantly from 131.4 ± 18.3 to 122.7 ± 18.9 kg;
body mass index (BMI) decreased from 42.2 ± 5.8 to 39.4 ± 6.0 kg/
m2; and waist circumference decreased from 130.0 ± 10.5 to
123.3 ± 11.3 cm. The percent change in body weight was −6.6%.
The mean fasting glucose decreased by 17% from
9.08 ± 4.09 mmol/L at baseline to 7.57 ± 2.63 mmol/L at week 16.
The primary outcome, HbA1c, decreased from 7.5% ± 1.4% at baseline
to 6.3% ± 1.0% at week 16 (P < 0.001). Only 21 of the 28 participants
completed the 16 weeks of follow‐up. The dropouts were due to par-
ticipants who were unable to adhere to study meetings and unable to
adhere to the diet, but no participant reported terminating as a result
of adverse effects associated with the diet. Diabetes medications were
discontinued in seven participants, reduced in 10, and unchanged in
32
four participants.
3 VEGAN DIET TO MANAGE TYPE 2
| stable (n = 17 out of 49 vegan and n = 12 out of 50 for ADA), A1c
DIABETES
Diabetes prevalence is relatively low among individuals following
plant‐based and vegetarian diets, and clinical trials using such diets
have shown improvements in glycaemic control and cardiovascular
health.33 The vegan diet consists of a diet without meat, or animal
products, which includes no added animal fats when cooking as well.
A low‐fat plant‐based diet influences nutrient intake and body compo-
sition in several ways that may, in turn, affect insulin sensitivity. First,
because such diets are low in fat and high in fibre, they typically cause
associated reductions in dietary energy density and energy intake,
which are not adequately compensated for by increased food intake.33
Carbohydrate intake typically increases, because of the elimination of
meat, which is usually replaced by high‐carbohydrate foods.
The first major randomized clinical trial on diabetic patients treated
purely with a plant‐based (vegan) diet, compared it with a regular diet
based on the 2003 ADA guidelines. 34
A total of 99 participants, 27 to
82 years of age, were counselled on both diets and followed for
22 weeks. Barnard et al investigated the qualitative and quantitative
changes in individuals with type 2 diabetes following a low‐fat vegan
34,35
diet compared with a regular diabetes diet. The conventional diabe-
tes diet group followed the ADA diet using the guidelines of the 2003
ADA guidelines of 15% to 20% protein, <7% saturated fat, 60% to
70% carbohydrate and monounsaturated fats, and cholesterol
<200 mg/d. The calorie intake was calculated on the basis of individual
weight and lipid levels, and participants with a BMI > 25 kg/m2 were
5 of 10
prescribed energy intake deficits of 500 to 1000 kcal. After the
22 weeks, the calorie intake reduced from 1846 ± 597 to
1391 ± 382 kcal/d, P < 0.0001. The vegan diet group followed a diet
where 10% of the calories came from fat, 15% from protein, and 75%
from carbohydrates, but portion sizes, energy intake, and carbohydrate
intake were unrestricted. Participants were instructed to follow a vegan
diet, which avoids all animal products and added fats and favours low‐
glycaemic index foods, such as beans and green vegetables. After
22 weeks, the vegan diet group reduced their calories from
1759 ± 468 to 1425 ± 427 kcal/d, P < 0.0001. Carbohydrate intake
increased in the vegan group from 205 ± 69 to 251 ± 70 g/d
(P < 0.0001) but fell in the ADA group from 213 ± 70 to 165 ± 51 g/d
(P < 0.0001 [between‐group P < 0.001]).34
The vegan group lost significantly more weight and decreased their
HbA1c significantly more than the ADA diet group. Body weight fell
5.8 kg in the vegan group (P < 0.0001) and 4.3 kg in the ADA group
(P < 0.0001) (between‐group P < 0.082). HbA1c fell 0.96 percentage
points (P < 0.0001) in the vegan group and 0.56 percentage points
(P < 0.0009) in the ADA group.34 Among participants whose diabetes
medications remained unchanged throughout, A1c fell 1.23 points in
the vegan group and 0.38 points in the ADA group (P < 0.01).
Subanalyses were conducted to assess the effects of medication
changes and dietary adherence. For those who met dietary adherence
criteria (n = 33 out of 49 for vegan and 22 out of 50 for ADA), the A1c
changes were −1.20% for the vegan group and −0.88% for the ADA
group P < 0.31. For those who were both adherent and medication
changes were −1.48% for the vegan group and −0.81% for the ADA
diet group. While both groups showed improvements, the vegan diet
group saw greater improvements in glycaemic control than the ADA
guidelines diet.35 Another study by Lee et al showed that the vegan
diet had better improvements in HbA1c levels than the regular diabe-
tes diet (Table 2).36
A common concern for most health professionals when
recommending a vegan diet is the patients' adherence, awareness,
and approval of a strict diet of no meat or meat products. A cross‐
sectional study of 98 patients and 25 health care providers in the
Regional Diabetes Education Centre in ON, Canada, assessed
the awareness, barriers, and promoters of plant‐based diet use for
the management of type 2 diabetes.36 On the basis of questionnaire
responses, 9% of respondents currently followed a plant‐based diet,
but 66% indicated the willingness to develop one for 3 weeks.
Although they were given the appropriate support, almost half of par-
ticipants cited concerns regarding “family eating habits” (48%), a lack
of “meal planning skills” (45%), and a “preference to eat meat” (45%)
as primary deterrents to following a plant‐based diet.36 Katcher
et al39 also indicate in a workplace study that a vegan diet is well
accepted with over 95% adherence rate and subjects report increased
energy level, better digestion, better sleep, and increased satisfaction
when compared with the control group.39
A large cohort study showed that people who follow a range of
plant‐based diets have a significantly lower prevalence of type 2 dia-
betes and that those with greater adherence to plant‐based foods,
6 of 10 CHESTER ET AL.

TABLE 2 Effects of vegan diet on diabetes

References Design and Methods Results

36
Lee et al A randomized controlled trial conducted in Korea compared a brown Haemoglobin A1c levels decreased by 0.5 points in the vegan group
rice–based vegan diet with a conventional diabetic diet in patients compared with 0.2 points in the conventional group (0.017).
ages 30‐70 y with type 2 diabetes. Participants assigned to the
vegan diet were asked to eat brown rice, favour low‐glycaemic
index foods (eg, legumes, legumes‐based foods, green vegetables,
and seaweed), and avoid polished/white rice, processed food
made of rice flour or wheat flour, and all animal food products.
Portions, calories, and frequency of meals were not restricted.
McMacken One of the first major randomized clinical trials on diabetic patients By the end of the trial, 43% (21 of 49) of the vegan group and 26%
and treated purely with a plant‐based (vegan) diet, comparing it with a (13 of 50) of the ADA group participants reduced their diabetes
Shah37 conventional diet based on the 2003 American Diabetes medications. Excluding those who changed medications,
Association (ADA) guidelines. A total of 99 individuals, ages 27‐ haemoglobin A1c fell 1.23 points in the vegan group compared
82 y, were randomized to counselling on a low‐fat vegan diet or with 0.38 points in the ADA group (0.01). Body weight decreased
the ADA diet and followed up for 22 wk. The recommended vegan 6.5 kg in the vegan group and 3.1 kg in the ADA group
diet comprised approximately 10% of energy from fat, 15% from (P < 0.001). Among those who did not change lipid‐lowering
protein, and 75% from carbohydrates and consisted of vegetables, medications, LDL cholesterol fell 21.2% in the vegan group and
fruits, grains, and legumes. Participants in the vegan group were 10.7% in the ADA group (0.02).
asked to avoid animal products and added fats and to favour low‐
glycaemic index foods, such as beans and green vegetables.
Yokoyama Six intervention groups using lacto‐ovo vegetarian or vegan diets In the pooled analysis, consumption of vegetarian diets was
et al38 with a total of 255 participants (17 lacto‐ovo vegetarian and 238 associated with a significant mean reduction in HbA1c (−0.39
vegan) with type 2 diabetes. The pooled effects of vegetarian diets percentage point; 95% CI, −0.62 to −0.15; 0.001; I2 = 3.0; 0.389),
on HbA1c and fasting blood glucose levels were analysed. compared with omnivorous diets.

such as a low‐fat vegan diet, experience the significant benefit.40 Tuso
et al define a plant‐based diet as a regimen that encourages whole,
plant‐based foods and discourages meats, dairy products, and eggs
41
as well as all refined and processed foods. The vegan diet is reported
to have the ability to reverse noncommunicable diseases and increase
41 42
longevity. Barnard et al tested the hypothesis that a vegan inter-
vention would improve glycaemic control, body weight, plasma lipid
concentrations, blood pressure, and indices of renal function during
a 20‐week intervention and do so more effectively than an interven-
tion using a portion‐controlled eating plan. Individuals with type 2 dia-
betes were recruited and treated in a single endocrinology practice in
Washington, DC. Participants (19 vegans and 21 portioned controlled)
attended weekly after‐hours classes in the office waiting room. The
vegan diet plan excluded animal products and added oils and favoured
low‐glycaemic index foods. Both a low‐fat vegan diet and a portion‐
controlled diet based on ADA guidelines improved glycaemic and lipid
control in type 2 diabetic patients.
The significant improvements within the groups were body weight
decreased by 6.3 kg in the vegan group and 4.4 kg in the portion‐
controlled group (P < 0.001 for within both groups), BMI decreased
by 2.3 kg/m2 in the vegan group and 1.5 kg/m2 in the portion‐
controlled group (P < 0.001 for both), and median HbA1c values fell
0.40 percentage points in the vegan group (P < 0.05) and portion‐
controlled groups (P ≤ 0.01). However, when the vegan group results
and portion‐controlled groups were compared, these improvements
were not significant (0.10 for body weight, 0.075 for BMI, and 0.68
for HbA1c). Medications for glycaemic control were reduced in four
participants, mixed (medication changes in opposite directions) in
two, and unable to assess in two participants of the vegan groups.
Median fasting glucose values decreased by 16.0 mg/dL in the vegan
group compared with 12.5 mg/dL to participants in the portion‐
controlled group. However, there was no significant difference
between the low‐fat vegan and a portion‐controlled eating plan.41
The portion‐controlled plan included energy intake limits for weight
loss and provided guidance on portion sizes. The medications in the
vegan group were reduced in four participants, mixed in two, and
the use of medication was not assessed accurately in two participants.
The medications were increased in three participants, reduced in six,
and mixed in four participants of the portion‐controlled group. Five
participants dropped out of the study, two vegan group participants
and three portion‐controlled group participants, because of participant
location changes for one, one withdrew for unknown reasons, and
three were lost to follow‐up.42
Data from the Adventist Health Study 2 were used by Tonstad
et al40 to a group over 40 000 Seventh‐day Adventist participants into
vegan, lacto‐ovo vegetarian, pesco vegetarian, semivegetarian, or non-
vegetarian reference groups. A follow‐up questionnaire after 2 years
elicited information on the development of diabetes. Cases of diabetes
developed in 0.54% of vegans, 1.08% of lacto‐ovo vegetarians, 1.29%
of pesco vegetarians, 0.92% of semivegetarians, and 2.12% of nonveg-
etarians, which were associated with a substantial and independent
reduction in diabetes incidence. When considering a vegetarian diet
(no meat, but including some animal products) vs a vegan diet (no meat
or animal products), it is worth noting that the nonvegans in this cohort
ate meat and poultry relatively infrequently (once a week or more for
nonvegetarians; less than once a week for semivegetarians). This
CHESTER ET AL. 7 of 10

suggests that even small increases in red meat and poultry consumption
disproportionately increase the risk of type 2 diabetes.
4 | MEDITERRANEAN DIET TO MANAGE
T Y P E 2 D I A B E T ES
The term “Mediterranean diet” mainly refers to a primarily plant‐based
dietary pattern. The Mediterranean diet is a diet traditionally followed
in Greece, Crete, southern France, and parts of Italy that emphasize
fruits and vegetables, nuts, grains, olive oil, grilled or steamed chicken
43
and seafood, and a glass or two of red wine. The Mediterranean diet
differs from the traditional American diet being lower in red meat and
butter. There is not only one Mediterranean diet due to the variations
from one Mediterranean country or region to another. However, the
shared features of what is usually spoken of as the Mediterranean‐style
diet are high consumption of nutrient dense foods like fruits, vegetables,
whole grains, legumes, nuts, and seeds with olive oil being the crucial
monounsaturated fat source. The diet is rich in foods high in omega‐3
fatty acids, like fatty fish and walnuts, limited in red meat and animal
44
products and wine is drunk in moderate (or small) amounts.
In the last decades, nutritional science and recommendations have
shifted from a specific nutrient amount or energy or calorie range to a
broader view of overall nutritious lifestyle that emphasizes quality and
dietary patterns that promote metabolic health.45 Instead of focusing
on the amounts of single nutrients, the focus is on the interactions of
the bioactive nonnutrients present in food (ie, fibre, antioxidants, and
minerals).45 As a result, the relationship between nutrition and health
is viewed holistically and within the context of the whole diet. The Med-
iterranean dietary pattern is an example for this new approach to nutri-
tion as it is a vital source of vitamins, minerals, antioxidants, mono‐ and
poly‐unsaturated fatty acids, and fibre—all of which provide a wide
range of health benefits.45 The Mediterranean diet is characterized by
the consumption of plant‐based foods like whole grains, legumes, fruits,
vegetables, nuts, and olive oil; and fish, wine in moderation, and a mod-
erate intake of meat, dairy products, processed foods, and sweets.44
According to 2015 to 2020 Dietary Guidelines, the Mediterranean diet
and all other diets should be individualized, and the calorie needs can
range from 1600 to 3200 calories in order to meet the nutritional needs
of children 9 years and older and adults.46
There is abundant evidence of its health benefits and a great
potential for long‐term adherence and sustainability, which is an
important factor in any diet for individuals with diabetes. Vitale et al
conducted a study of 2568 participants at 57 diabetes clinics and
found that the Mediterranean dietary lifestyle was a suitable model
for type 2 diabetes management.47 There are many health benefits
for people with diabetes when choosing a Mediterranean diet. Some
of the benefits include the reduction in overall mortality and mortality
of CVD and improvement in glycaemic control and cardiovascular risk
in people with diabetes. Furthermore, people who follow a Mediterra-
nean diet have also been found to have an 83% lower risk of diabe-
tes.44 One systematic review of all meta‐analyses and randomized

TABLE 3 Effects of the Mediterranean diet on diabetes

References Design and Methods Results

Esposito Four‐year randomized controlled clinical trial with 215 overweight At the end of the intervention, 44% of participants in the low‐
et al49 adults with newly diagnosed T2DM who were not receiving carbohydrate Mediterranean diet group and 70% in the low‐fat
antihyperglycaemic drug therapy and had HbA1c levels <11% were diet group required additional treatment (P < 0.001).
assigned to either a low‐carbohydrate Mediterranean diet (LCMD) Improvements were greater in the low‐carbohydrate
or a low‐fat diet (LFD) on the basis of the 2000 AHA guidelines. Mediterranean diet group for glucose and haemoglobin A1c levels,
Daily intake was restricted to 1500 kcal a day for women and with the greatest number of participants who met ADA goals for
1800 kcal a day for men, with 50% of calories from carbohydrates haemoglobin A1c in low‐carbohydrate Mediterranean diet group.
and 30% from fat. The LCMD was rich in vegetables and whole
grains and low in red meat, which was replaced with poultry and
fish. The main source of added fat was olive oil (30‐50 g/d).
Toobert Six‐month randomized controlled clinical trial: 279 postmenopausal Participants allocated to the MLP group exhibited lower HbA1c
et al50 women with T2DM were assigned to either a comprehensive levels, compared with the control group (P < 0.001). However, the
lifestyle self‐management programme that also included a relative role of the MD in the context of the programme that also
Mediterranean low‐saturated fat diet (Mediterranean lifestyle included exercise, group support, smoking cessation, and stress
programme—MLP) or usual care. Participants' macronutrient intake management training is unclear.
was individualized. The MD recommended increased amounts of
bread, vegetables, legumes, and fish; less red meat, substituting
poultry; no day without fruit; and avoidance of butter and cream,
substituting olive and canola oils or margarines.
Elhayany Twelve‐month randomized controlled clinical trial: 259 overweight Glucose, HOMA‐IR, and HbA1c decreased while insulin levels
et al51 adults with T2DM were assigned to one of three diets (a low‐ increased in all three groups. Changes in glucose, insulin, and
carbohydrate Mediterranean diet [LCMD], a traditional HOMA‐IR levels were similar among groups. The reduction in
Mediterranean diet [TMD], or a low‐fat diet [LFD]) on the basis of HbA1c levels was significantly greater for patients allocated to the
the 2003 ADA guidelines. LCMD: 35% and 45% of EI from LCMD and TMD groups, compared with patients on the LFD
carbohydrates and fat, respectively. TMD: 50% and 30% of EI from (0.021).
carbohydrates and fat, respectively. Daily energy, protein, fibre,
sodium, potassium, calcium, and magnesium intakes were similar in
both diets.
8 of 10
controlled trials (RCTs) reported a substantially lower risk of type 2
diabetes in healthy people or at‐risk patients with the highest adher-
ence to a Mediterranean diet.46 Five RCTs have evaluated the effects
of a Mediterranean diet, as compared with other commonly used
diets, on glycaemic control in subjects with type 2 diabetes. Improve-
ment of HbA1c levels was higher with a Mediterranean diet and
ranged from 0.1% to 0.6% for HbA1c. No trial reported worsening of
48
glycaemic control with a Mediterranean diet.
Katherine Esposito et al49 found that adherence to
Mediterranean‐type diet decreased A1c levels and postprandial glu-
cose levels measured independently by subjects in their natural envi-
ronment in Southern Italy (Table 3). In addition, participants with the
highest adherence to the Mediterranean diet had lower BMI, waist‐
to‐hip ratios, and the prevalence of metabolic syndrome. In a meta‐
analysis of 17 studies,52 the Mediterranean‐type diet was found to
improve fasting glucose and A1c levels for those with type 2 diabetes.
In a study conducted in Israel, the Mediterranean diet lowered fasting
glucose levels in those with diabetes more than low‐fat and low‐
carbohydrate diets, which could be related to the positive effect on
insulin sensitivity that results from replacing saturated and trans fats
with unsaturated fats.52 The overall rate of adherence for the entire
study was 95.4% at 12 months and 84.6% at 24 months. Among the
different diet groups, the 24‐month adherence rates were 90.4% in
the low‐fat group, 85.3% in the Mediterranean diet group, and
78.0% in the low‐carbohydrate group (0.04 for the comparison among
diet groups). The various reasons for dropout included personal rea-
sons and lack of motivation.46
Salas‐Salvadó et al investigated the protective benefits of a Medi-
terranean diet supplemented with extra virgin olive oil (EVOO), a Med-
iterranean diet supplemented with mixed nuts, and control diet
groups.53 The participants were adults at cardiovascular risk but with-
out diabetes. They were randomly assigned to one of the three diets,
and during follow‐up, 80, 92, and 101 new‐onset cases of diabetes
occurred in the Mediterranean diet supplemented with EVOO, Medi-
terranean diet supplemented with mixed nuts, and control diet groups,
respectively, corresponding to rates of 16.0, 18.7, and 23.6 cases per
1000 person.53 No energy/calorie restrictions were implemented,
and no intervention to increase physical activity or lose weight was
included. Salas‐Salvadó et al discusses that the phenols, minerals,
fibre, and vegetable protein in the Mediterranean diet improve
glycaemic control.53 When comparing three versions of the Mediterra-
nean diet, the highest diet level was characterized by lower energy
content, a lower intake of proteins from animal food sources, satu-
rated fat and cholesterol, added sugars, a higher intake of fibre, and
a lower glycaemic index and glycaemic load. This version resulted in
lower HbA1c levels (7.63% ± 0.48% vs 7.69% ± 0.52%, P = 0.038)
and lower BMI (30.0 ± 4.2 vs 30.6 ± 4.5 kg/m2, P = 0.020).47
5 | C O N CL U S I O N
In this review, the different diets studied were low‐carbohydrate and
ketogenic diet, vegan diet, and the Mediterranean diet based upon
CHESTER ET AL.
the glycaemic control and weight loss. When compared with all Med-
iterranean diet led to most significant improvement in glycaemic index
compared with the control diet.54 Similarly, the greater weight loss
was observed with the Mediterranean diet. However, an improvement
was also observed with low‐carbohydrate, low‐glycaemic index, and
high‐protein diets. High‐density lipoprotein (HDL) level was increased
with all diets excluding the high‐protein diet, but triglycerides were
significantly reduced only with the Mediterranean diet. The low‐
a carbohydrate diets typically did not have calorie limits, which could
assist with better adherence to the diet.54 Further research must be
done to investigate the effects and manageability of these diets long
term.
Type 2 diabetes is a complex condition where patient adherence
is crucial. While all three diets show improvement in glycaemic con-
trol and weight loss, the Mediterranean diet is a moderate diet that
includes all food groups and is more comfortable for most patients
to maintain long term. The vegan diet is very restrictive, and while
producing impressive results, the vegan diet may be difficult for peo-
ple to maintain because all meat and animal products are avoided.
Some patients, especially in low‐income families, fear the financial
burden of a vegan diet, along with the dissatisfaction of missing
the foods that they enjoy. The Mediterranean diet emphasizes a
more plant‐based diet while not eliminating any food groups.
Patients with type 2 diabetes will spend a lifetime managing this
condition and need diet plans that can be sustained long term.
Because the Mediterranean diet is a balanced diet and has a likely
hood of patient adherence, it is a more successful and realistic diet
for patients with type 2 diabetes.
ACKNOWLEDGEMENTS
This work was supported by the Alabama Agricultural Experimental
Station (AAES) Hatch/Multistate Funding Program, and AAES Award
for Interdisciplinary Research (AAES‐AIR) to J.R.B. and T.G.
CONFLIC T OF INT E RE ST
There are no conflicts of interest.
ET HIC S ST AT EME NT
This review article cites the peer‐reviewed manuscripts of other
groups. This review does not include a study design with the direct
ethical statements of the human or animal study designs.
AUTHORS C ONTRIBU TION
B.C. and T.G. conceptualized the questions and developed protocol for
the review article. B.C. wrote the manuscript. M.W.G., J.R.B., and T.G.
critically reviewed and edited the manuscript. All authors have read
and given final approval of the article to be published.
ORCID
Thangiah Geetha https://orcid.org/0000-0001-6358-0012
CHESTER ET AL.
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How to cite this article: Chester B, Babu JR, Greene MW,
Geetha T. The effects of popular diets on type 2 diabetes
management. Diabetes Metab Res Rev. 2019;35:e3188.
https://doi.org/10.1002/dmrr.3188