Food pattern, lifestyle and diabetes mellitus

The Six Pillars of Lifestyle Medicine in Managing Noncommunicable Diseases - The Gaps in Current Guidelines

BACKGROUND

Noncommunicable diseases (NCDs), also known as chronic diseases that are long-lasting, are considered the major cause of death and disability worldwide, and the six pillars of lifestyle medicine (nutrition, exercise, toxic control, stress management, restorative sleep, and social connection) play an important role in a holistic management of their prevention and treatment. In addition, medical guidelines are the most accepted documents with recommendations to manage NCDs.

OBJECTIVE

The present study aims to analyze the lack of lifestyle pillars concerning the major Brazilian medical guidelines for NCDs and identify evidence in the literature that could justify their inclusion in the documents.

METHOD

Brazilian guidelines were selected according to the most relevant causes of death in Brazil, given by the Mortality Information System, published by the Brazilian Ministry of Health in 2019. Journals were screened in the PUBMED library according to the disease and non-mentioned pillars of lifestyle.

RESULTS

Relevant causes of deaths in Brazil are acute myocardial infarction (AMI), diabetes mellitus (DM), and chronic obstructive pulmonary diseases (COPD). Six guidelines related to these NCDs were identified, and all address aspects of lifestyle, but only one, regarding cardiovascular prevention, highlights all six pillars. Despite this, a literature search involving over 50 articles showed that there is evidence that all the pillars can help control each of these NCDs.

CONCLUSION

Rarely are the six pillars of lifestyle contemplated in Brazilian guidelines for AMI, DM, and COPD. The literature review identified evidence of all lifestyle pillars to offer a holistic approach for the management and prevention of NCDs.

Models Predicting Postpartum Glucose Intolerance Among Women with a History of Gestational Diabetes Mellitus: a Systematic Review

PURPOSE OF REVIEW

Despite the crucial role that prediction models play in guiding early risk stratification and timely intervention to prevent type 2 diabetes after gestational diabetes mellitus (GDM), their use is not widespread in clinical practice. The purpose of this review is to examine the methodological characteristics and quality of existing prognostic models predicting postpartum glucose intolerance following GDM.

RECENT FINDINGS

A systematic review was conducted on relevant risk prediction models, resulting in 15 eligible publications from research groups in various countries. Our review found that traditional statistical models were more common than machine learning models, and only two were assessed to have a low risk of bias. Seven were internally validated, but none were externally validated. Model discrimination and calibration were done in 13 and four studies, respectively. Various predictors were identified, including body mass index, fasting glucose concentration during pregnancy, maternal age, family history of diabetes, biochemical variables, oral glucose tolerance test, use of insulin in pregnancy, postnatal fasting glucose level, genetic risk factors, hemoglobin A1c, and weight. The existing prognostic models for glucose intolerance following GDM have various methodological shortcomings, with only a few models being assessed to have low risk of bias and validated internally. Future research should prioritize the development of robust, high-quality risk prediction models that follow appropriate guidelines, in order to advance this area and improve early risk stratification and intervention for glucose intolerance and type 2 diabetes among women who have had GDM.

Dynamics of Gut Microbiota and Clinical Variables after Ketogenic and Mediterranean Diets in Drug-Naïve Patients with Type 2 Diabetes Mellitus and Obesity

Type 2 diabetes mellitus (T2DM), the most common form of diabetes, is a progressive chronic metabolic disease that has increasingly spread worldwide, enhancing the mortality rate, particularly from cardiovascular diseases (CVD). Lifestyle improvement through diet and physical activity is, together with drug treatment, the cornerstone of T2DM management. The Mediterranean diet (MD), which favors a prevalence of unprocessed vegetable foods and a reduction in red meats and industrial foods, without excluding any food category, is usually recommended. Recently, scientific societies have promoted a very low-calorie ketogenic diet (VLCKD), a multiphasic protocol that limits carbohydrates and then gradually re-introduces them, with a favorable outcome on body weight and metabolic parameters. Indeed, gut microbiota (GM) modifications have been linked to overweight/obesity and metabolic alterations typical of T2DM. Diet is known to affect GM largely, but only a few studies have investigated the effects of VLCKD on GM, especially in T2DM. In this study, we have compared anthropometric, biochemical, lifestyle parameters, the quality of life, and the GM of eleven patients with recently diagnosed T2DM and overweight or obesity, randomly assigned to two groups of six and five patients who followed the VLCKD (KETO) or hypocaloric MD (MEDI) respectively; parameters were recorded at baseline (T0) and after two (T2) and three months (T3). The results showed that VLCKD had more significant beneficial effects than MD on anthropometric parameters, while biochemical improvements did not statistically differ. As for the GM, despite the lack of significant results regarding the alpha and beta diversity, and the Firmicutes/Bacteroidota ratio between the two groups, in the KETO group, a significant increase in beneficial microbial taxa such as Verrucomicrobiota phylum with its members Verrucomicrobiae, Verrucomicrobiales, Akkermansiaceae, and Akkermansia, Christensenellaceae family, Eubacterium spp., and a reduction in microbial taxa previously associated with obesity (Firmicutes and Actinobacteriota) or other diseases (Alistipes) was observed both at T2 and T3. With regards to the MEDI group, variations were limited to a significant increase in Actinobacteroidota phylum at T2 and T3 and Firmicutes phylum at T3. Moreover, a metagenomic alteration linked to some metabolic pathways was found exclusively in the KETO group. In conclusion, both dietary approaches allowed patients to improve their state of health, but VLCKD has shown better results on body composition as well as on GM profile.

Behaviour change interventions to promote health and well-being among older migrants: A systematic review

Background

Whether behaviour change interventions are effective for the maintenance of older migrants’ health and well-being is uncertain. A systematic review was conducted to assess evidence for the capacity of behaviour change techniques (BCTs) to promote the health and well-being of older migrants.

Methods

Electronic databases (Cochrane CENTRAL, Embase, Ovid MEDLINE and Web of Science) were searched systematically to identify relevant randomised controlled trials, pre–post studies and quasi-experimental studies published before March 2021. Additional articles were identified through citation tracking. Studies examining BCTs used to promote the health and/or well-being of older migrants were eligible. Two independent reviewers used the Behaviour Change Technique Taxonomy version 1 to extract data on BCTs. Data on intervention functions (IFs) and cultural adaption strategies were also extracted. Intervention contents (BCTs, IFs, culture adaption strategies) were compared across effective and ineffective interventions according to health and well-being outcome clusters (anthropometrics, health behaviour, physical functioning, mental health and cognitive functioning, social functioning and generic health and well-being).

Results

Forty-three studies (23 randomised controlled trials, 13 pre–post studies and 7 quasi-experimental studies) reporting on 39 interventions met the inclusion criteria. Thirteen BCTs were identified as promising for at least one outcome cluster: goal-setting (behaviour), problem-solving, behavioural contract, self-monitoring of behaviour, social support (unspecified), instruction on how to perform the behaviour, information about health consequences, information about social and environmental consequences, demonstration of the behaviour, social comparison, behavioural practice/rehearsal, generalisation of a target behaviour and addition of objects to the environment. Three BCTs (instruction on how to perform the behaviour, demonstration of the behaviour, and social comparison) and two IFs (modelling and training) were identified as promising for all outcome clusters.

Conclusions

Thirteen distinct BCTs are promising for use in future interventions to optimise health and well-being among older migrants. Future research should focus on the effectiveness of these BCTs (combinations) in various contexts and among different subgroups of older migrants, as well as the mechanisms through which they act. Given the scarcity of interventions in which cultural adaption has been taken into account, future behavioural change interventions should consider cultural appropriateness for various older migrant (sub)groups.

Trial registration

PROSPERO CRD42018112859.

Using event-related potentials to study food-related cognition: An overview of methods and perspectives for future research

Electroencephalography (EEG), and the measure of event-related potentials (ERPs) in particular, are useful methods to study the cognitive and cerebral mechanisms underlying the perception and processing of food cues. Further research on these aspects is necessary to better understand how cognitive functioning may influence food choices in different populations (e.g. obese individuals, individuals with eating disorders). To help researchers in designing future studies, this article provides an overview of the methods used in the current literature on ERPs and food-related cognition. Several methodological aspects are explored to outline interesting perspectives for future research, including discussions on the main experimental tasks used, the cognitive functions assessed (e.g. inhibitory control, attentional processing), the characteristics of the participants recruited (e.g. weight status, eating behaviors), and the stimuli selected (e.g. food pictures, odors). The issues generated by some of these methodological choices are discussed, and a few guidelines are provided.

The effect of COVID-19 pandemic on lifestyle-related behaviours in Turkey: A web-based cross-sectional study

Background

The COVID‐19 pandemic and restrictions imposed to eradicate it have affected healthy lifestyle‐related behaviours.

Aim

The aim of this study was to determine the effect of COVID‐19 on lifestyle‐related behaviours.

Methods

This cross‐sectional web‐based survey research was performed with a convenience sample of 1020 adults residing in Turkey. Data were collected with self‐report data collection tools on 8–28 April 2021: a sociodemographic characteristics form and the impact of COVID‐19 on lifestyle‐related behaviours questionnaire.

Results

Eating behaviours, physical activity and sleep patterns of the participants were negatively affected during COVID‐19 pandemic (p < 0.001). More than half of the participants experienced weight gain during the pandemic. Also, stress levels and smoking increased (p < 0.01). The participants reported having changes in their lifestyles most frequently due to the fear of COVID‐19 infection, stress, decreased motivation, closure of the facilities for social and sports activities and increased food prices. Predictors of lifestyle‐related behaviours were found to be education (β = .189), income (β = −.101), residing in a village (β = .113) and the presence of a chronic disease (β = .075) (p < 0.001).

Conclusions

During the pandemic, COVID‐19‐related restrictions should be applied whilst taking account of both social distancing measures and maintenance of healthy lifestyle‐related behaviours. Nurses should offer counselling for maintenance of healthy lifestyle‐related behaviours.

What is already known about this topic?

Studies performed at the beginning and during the course of COVID‐19 pandemic in different countries have shown that lifestyle‐related behaviours are negatively affected.

Few studies have used a valid and reliable tool to determine the effect of COVID‐19 on lifestyle‐related behaviours.

The effect of COVID‐19 on lifestyle‐related behaviours has not been examined from a nursing perspective.

What this paper adds?

In the present study, which was performed at a time when night curfews and weekend shutdowns were imposed in Turkey, lifestyles of the participants were found to be negatively affected.

More than half of the participants gained weight and had increased stress and smoking and a decreased sleep quality.

The negative effect on lifestyle‐related behaviours was more severe in participants with low education and income levels, living in a village and suffering from a chronic disease.

The implications of this paper:

Restrictions introduced during the pandemic should both take account of social distancing measures and allow healthy lifestyle‐related behaviours.

Nurses playing a role in first line health care services should offer education and counselling for maintenance of healthy lifestyle‐related behaviours by utilizing information and communication technology (e.g., video calls).

The relationship between acute stress and neurophysiological and behavioral measures of food-related inhibitory control: An event-related potential (ERP) study

Stress influences many health-related behaviors including diet and nutrition intake, often resulting in increased calorie intake, fewer healthy eating behaviors, and poorer nutrition. Food intake is modulated by inhibitory control and has important implications for our physical, mental, and emotional health. Yet, little is known about the relationship between stress and food-related inhibitory control. We tested the influence of a short-term experimental stressor on behavioral and event-related potential (ERP; N2 and P3 components) measures of food-related inhibitory control. Ninety-seven healthy participants were randomly assigned to complete the Trier Social Stress Test (TSST) (n = 48, 27 females [52.9%]) or a neutral control condition (n = 49, 35 females [70%]) immediately followed by food-specific go/no-go and neutral go/no-go tasks while electroencephalogram (EEG) data were recorded. Stress levels were successfully manipulated, with heightened self-report and physiological measures (heart rate and systolic blood pressure) of the stress response in individuals who completed the TSST compared to control. As expected, the high calorie food-specific go/no-go task elicited larger N2 amplitude than the neutral task. N2 component amplitude was also significantly larger following the TSST relative to the control task. There were no significant between-group or task differences for P3 amplitude or behavioral measures. Findings suggest heightened N2 amplitude following psychological stress that is not specific to food or inhibition processes and may reflect heightened arousal following stress. Future research in individuals with overweight/obesity or experiencing chronic stress will further clarify the role of stress in food-related inhibitory control.

Reenvisioning Traditional to Regenerative Therapeutic Advances in Managing Nonalcoholic Fatty Liver Disease in Diabetes Mellitus

Reports indicate the increasing prevalence of liver disorders in diabetes mellitus (DM) patients. Clinically, it has also been revealed that the existence of nonalcoholic fatty liver disease (NAFLD) enhances the incidence of type 2 diabetes mellitus (T2DM), while T2DM exacerbates NAFLD to extremely severe forms of steatohepatitis, cirrhosis, and hepatocellular carcinoma. This implies the coexistence and bidirectional nature of NAFLD and T2DM, which function synergistically to drive adverse consequences in clinical practice. For treatment of such comorbid state, though the existing practices such as lifestyle management, traditional Chinese medicines (TCM), and pharmaceuticals have offered somewhat relief, the debate continues about the optimal therapeutic impacts. Recent developments in the field of tissue engineering have led to a renewed interest in novel biomaterial alternatives such as stem cells. This might be attributable to their differentiation potential towards hepatic and pancreatic lineage. These cellular therapies could be further complemented by platelet-derived biomaterials, TCM formulations, or any specific drug. Based on these abovementioned approaches, we aimed to comprehensively analyze various preclinical and clinical studies from traditional to regenerative therapeutic approaches in managing concomitant NAFLD and T2DM.

Metabolic and Molecular Subacute Effects of a Single Moderate-Intensity Exercise Bout, Performed in the Fasted State, in Obese Male Rats

Introduction and objectives: Obesity represents a major global public health problem. Its etiology is multifactorial and includes poor dietary habits, such as hypercaloric and hyperlipidic diets (HFDs), physical inactivity, and genetic factors. Regular exercise is, per se, a tool for the treatment and prevention of obesity, and recent studies suggest that the beneficial effects of exercise can be potentiated by the fasting state, thus potentially promoting additional effects. Despite the significant number of studies showing results that corroborate such hypothesis, very few have evaluated the effects of fasted-state exercise in overweight/obese populations. Therefore, the aim of this study was to evaluate the subacute effects (12 h after conclusion) of a single moderate-intensity exercise bout, performed in either a fed or an 8 h fasted state, on serum profile, substrate-content and heat shock pathway–related muscle protein immunocontent in obese male rats. Methods: Male Wistar rats received a modified high-fat diet for 12 weeks to induce obesity and insulin resistance. The animals were allocated to four groups: fed rest (FER), fed exercise (FEE), fasted rest (FAR) and fasted exercise (FAE). The exercise protocol was a 30 min session on a treadmill, with an intensity of 60% of VO₂max. The duration of the fasting period was 8 h prior to the exercise session. After a 12 h recovery, the animals were killed and metabolic parameters of blood, liver, heart, gastrocnemius and soleus muscles were evaluated, as well as SIRT1 and HSP70 immunocontent in the muscles. Results: HFD induced obesity and insulin resistance. Soleus glycogen concentration decreased in the fasted groups and hepatic glycogen decreased in the fed exercise group. The combination of exercise and fasting promoted a decreased concentration of serum total cholesterol and triglycerides. In the heart, combination fasting plus exercise was able to decrease triglycerides to control levels. In the soleus muscle, both fasting and fasting plus exercise were able to decrease triglyceride concentrations. In addition, heat shock protein 70 and sirtuin 1 immunocontent increased after exercise in the gastrocnemius and soleus muscles. Conclusions: An acute bout of moderate intensity aerobic exercise, when realized in fasting, may induce, in obese rats with metabolic dysfunctions, beneficial adaptations to their health, such as better biochemical and molecular adaptations that last for at least 12 h. Considering the fact that overweight/obese populations present an increased risk of cardiovascular events/diseases, significant reductions in such plasma markers of lipid metabolism are an important achievement for these populations.

Prevalence and Risk Factors of Hypertension, Diabetes, and Dyslipidemia among Adults in Northwest China

Objective

To understand the prevalence and its risk factors of hypertension, diabetes mellitus, and dyslipidemia among adults aged over 18 years in Northwest China and provide data for the prevention and control of chronic diseases in Northwest China.

Methods

Three waves of survey on chronic diseases and nutrition monitoring with multistage stratified cluster random sampling were conducted in 10 counties of Northwest China in 2013, 2015, and 2018, respectively. Personal information, socioeconomic status (SES), and behavioral risk factors (cigarettes smoking, alcohol consumption, diets, and physical activity) were collected by face-to-face interview. Height, weight, and blood pressure were measured, and blood glucose and serum lipid were tested. Prevalence of hypertension, diabetes, and dyslipidemia of the three waves was estimated, and multivariate logistic regression was used to analyze their risk factors.

Results

The prevalence of hypertension, diabetes, and dyslipidemia was 41.59%, 11.16%, and 32.48%, respectively. Their standardized prevalence was 29.31%, 7.94%, and 31.54%. Univariate analysis showed that the prevalence of hypertension, diabetes, and dyslipidemia was significantly different among educational levels, marital status, occupation, smoking, drinking, central obesity, and BMI classification (P < 0.05). Multivariate logistic regression analysis showed that factors like male gender, central obesity, overweight, and obesity were associated with hypertension, diabetes, and dyslipidemia (P < 0.05). High BMI index is one of the risk factors of the three diseases. The odds ratio (OR) of general overweight associated with hypertension, diabetes, and dyslipidemia was 1.663, 1.206, and 1.579 compared to normal body weight, respectively. And that was 3.094, 1.565, and 2.285 for obesity. Age was one of the risk factors for hypertension and diabetes (P < 0.05). Age groups of 45–59 years and 60 years and above were more associated with hypertension than of 18–44 age group (OR_{45-59 group} = 2.777, OR_{60 years and above} = 6.948), similar to their association with diabetes (OR_{45-59 group} = 2.357, OR_{60 years and above} = 3.521). Daily smoking is associated with diabetes and dyslipidemia (OR _{for diabetes} = 1.217, OR _{for dyslipidemia} = 1.287) and alcohol drinking associated with hypertension and dyslipidemia (OR _{for hypertension} = 1.014, OR _{fordyslipidemia} = 1.034). Hypertension, diabetes, and dyslipidemia were also associated with each other (P < 0.05). The number of participants with hypertension, diabetes, and dyslipidemia accounted for 2.33% of all the participants, 15.60% for participants with hypertension and dyslipidemia, 4.58% for hypertension and diabetes, and 3.57% for diabetes and dyslipidemia, respectively.

Conclusion

Factors like male, smoking, drinking, central obesity, overweight, and obesity were associated with hypertension, diabetes, and dyslipidemia in northwest China. Interventions on these risk factors and coexistence of the three diseases may help improve public health in this area.

Do Food Odors Differently Influence Cerebral Activity Depending on Weight Status? An Electroencephalography Study of Implicit Olfactory Priming Effects on the Processing of Food Pictures

Attentional automatic processes and cerebral activity may differ between individuals with different weight statuses in the presence of food stimuli (e.g. odors, pictures). In the present study, we used an implicit olfactory priming paradigm to test the influence of non-attentively perceived food odors on the cerebral activity underlying the processing of food pictures, in normal-weight, overweight, and obese adults. A pear odor and a pound cake odor were used as primes, respectively priming sweet low-energy-density foods and high-energy-density foods. Event-related potentials were recorded while the participants passively watched pictures of sweet low and high-energy-density foods, under the two priming conditions plus an odorless control condition. The amplitude and latency of several peaks were measured (P100, N100, P200, N400). As a major result, we found that weight status influences the cerebral activity underlying the processing of food cues outside of consciousness, as early as the first detectable P100 peak.

A short questionnaire to assess changes in lifestyle-related behaviour during COVID 19 pandemic

BACKGROUND AND AIMS

The lasting impact of COVID 19 pandemic and associated restrictions are bound to be significant on lifestyle-related behaviour including diet, physical activity and sleep which is one of the important components in the management of diabetes mellitus and metabolic syndrome. This study was conducted to develop and validate a questionnaire to assess changes in individual's lifestyle-related behaviour during COVID 19 pandemic.

MATERIALS AND METHODS

The questionnaire was developed through a standardised methodology including literature review, focus group discussion, expert evaluation, pre-testing and validation. The face validity and content validity of the questionnaire were analysed. A cross-sectional survey was carried out on 103 participants to validate the questionnaire that used a 5-point Likert scale for the response option. Exploratory factor analysis was performed to establish construct validity. Cronbach's alpha was calculated to test the internal consistency of the whole questionnaire.

RESULTS

A questionnaire with 20 items to assess the lifestyle-related behaviour of people was developed. The questionnaire shows a satisfactory validity and a good internal consistency with the Cronbach's alpha value of 0.72.

CONCLUSION

The developed tool is valid and reliable to assess the changes in lifestyle-related behaviour of individuals during COVID 19 pandemic.

Lifestyle choices of Brazilian college students

Background

Lifestyle choices reflect the beliefs that individuals attribute to aspects of life. This construct can be assessed with the Individual Lifestyle Profile (PEVI) questionnaire, which measures elements of Nutrition, Physical Activity, Preventive Behaviors, Social Relationships and Stress Management.

Objective

The objective of this study was to estimate the psychometric properties of the PEVI applied to a sample of Brazilian university students, identifying the prevalence of each lifestyle component according to participants’ age, sex, weight status, course area/field and economic stratum and to estimate the contribution of these characteristics on physical and psychological lifestyle.

Methods

The PEVI data was analyzed by confirmatory factor analysis, using the indexes chi-square per degrees of freedom ratio (χ²/df), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI) and Root Mean Square Error of Approximation (RMSEA). First-order and second-order models (physical and psychological lifestyle) were tested. Prevalences of lifestyle components were calculated and compared by participants’ age, sex, weight status, course area/field and economic stratum. A hypothetical causal structural model was elaborated to investigate the impact of sample characteristics on physical and psychological lifestyles. This model was evaluated considering the global fit to the data (χ²/df, CFI, TLI and RMSEA) and the hypothetical causal trajectories (β) (α = 5%).

Results

A sample of 1,303 students was used. The mean age was 20.9 (standard deviation = 2.8) years, 66.8% of participants were females, 63.4% had weights in the normal range and 73.7% were students of the social and exact sciences. The PEVI data showed an adequate fit for both the first- (χ²/df = 2.03, CFI = 0.98; TLI = 0.97; RMSEA = 0.04) and second-order (χ²/df = 2.25; CFI = 0.97; TLI = 0.97; RMSEA = 0.04) models. There was a higher prevalence of unfavorable physical and psychological lifestyle choices among females, among underweight and obese individuals, in older students and in those with lower economic strata. Moreover, negative behaviors in physical lifestyle were more prevalent in students from human/social/exact sciences and worse psychological lifestyle was observed among health sciences students. These results were confirmed by a structural model.

Conclusion

The PEVI data presented validity and reliability. Negative lifestyle choices had high prevalence among students. Moreover, individual characteristics had different impact on physical and psychological lifestyle choices.

Ethnopharmacological review of medicinal plants used to manage diabetes in Morocco

Diabetes is a chronic metabolic disorder which affects millions of people every year. If diabetes is not controlled, it can cause serious damage and a number of health complications. The aim of this paper was to review published ethnobotanical and ethnopharmacological evidences of Moroccan plants with antidiabetic potentials. Publications describing the medicinal plants used for the treatment of diabetes in Morocco were searched from the databases, including Google Scholar, Elsevier, Medline, Web of Science, SCOPUS and Pubmed. Other literature source was also used including books and theses available in library. About 750 literature references were studied, and only 240 research publications based on data from different Moroccan provinces published until June 2019 were included in this review. In total, 255 plants species belonging to 70 families were reported. Compositae and Lamiaceae were mentioned as the most represented families. The frequently used plant species in the dwellers of most regions of Morocco are Trigonella foenum-graecum, Artemesia herba-alba, Nigella sativa, Olea europaea, Allium cepa and Marrubium vulgare. This review provides useful information and current scientific knowledge on the medicinal plants used to manage diabetes in Morocco. Medicinal plants reported should be submitted to chemical, pharmacological and clinical studies to identify pharmacologically active metabolites and to confirm their antidiabetic activity.

The Role of the Mediterranean Dietary Pattern on Metabolic Control of Patients with Diabetes Mellitus: A Narrative Review

Diabetes mellitus (DM) is a metabolic disorder characterised by hyperglycemia and abnormalities in carbohydrate, fat and protein metabolism. Several studies demonstrated that foods typical of the Mediterranean diet (MedDiet), including vegetables, fruits, oilseeds, extra virgin olive oil and fish, can promote health benefits for individuals at risk of or with type 2 diabetes (T2DM). In this review, we summarised randomised clinical trials, cohort studies, meta-analyses and systematic reviews that evaluated the effects of the MedDiet on metabolic control of T2DM. The data suggest that the MedDiet influences cardiovascular risk factors, including blood pressure, lipid profile, insulin resistance, inflammation and glucose metabolism, in T2DM patients. In conclusion, the MedDiet appears to protect patients from macro- and microangiopathy and should be considering in the management of diabetic patients.

Barriers and Strategies to Lifestyle and Dietary Pattern Interventions for Prevention and Management of TYPE-2 Diabetes in Africa, Systematic Review

BACKGROUND

Diabetes mellitus is a major chronic illness in Africa that requires lifelong lifestyle interventions and pharmacological therapy. Lifestyle change is the most important aspect of diabetes care and includes diabetes self-management education and support, medical nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care.

PURPOSE

The purpose of this project was to review published articles that investigate lifestyle and dietary pattern interventions for diabetes prevention and management in Africa. Barriers to lifestyle interventions and strategies to overcome the barriers are also reviewed in this study.

METHODS

The article search was conducted in an electronic database search of PubMed, Google Scholar, and Cochrane Library. Studies were included if they were published between 2011 and 2019, if they were conducted in an African country, and were written in the English language.

RESULTS

Articles reviewed included several that examined the basic lifestyle and dietary pattern changes for all patients diagnosed with type 2 diabetes, on self-care behavior of type 2 diabetes patients, on the cost of diabetes in Africa, and on barriers for adherence to lifestyle and dietary changes in Africa, with strategies to address those barriers.

CONCLUSION

Lifestyle interventions including regular physical exercise, weight management, and adherence to health care professionals' recommendations on a healthy diet are the cornerstone in the prevention and management of diabetes in Africa. The main barriers to adherence were both systemic (population changes, poor access, western cultural influences, and low-quality healthcare) and personal (poverty and cost, educational status, and perceptions about the disease) in nature. The strategies for the barriers include health education programs, advocacy, and capacity building.

Estimating the Composition of Food Nutrients from Hyperspectral Signals Based on Deep Neural Networks

There is an increasing demand for acquiring details of food nutrients especially among those who are sensitive to food intakes and weight changes. To meet this need, we propose a new approach based on deep learning that precisely estimates the composition of carbohydrates, proteins, and fats from hyperspectral signals of foods obtained by using low-cost spectrometers. Specifically, we develop a system consisting of multiple deep neural networks for estimating food nutrients followed by detecting and discarding estimation anomalies. Our comprehensive performance evaluation demonstrates that the proposed system can maximize estimation accuracy by automatically identifying wrong estimations. As such, if consolidated with the capability of reinforcement learning, it will likely be positioned as a promising means for personalized healthcare in terms of food safety.

Impact of food pattern on glycemic control among type 2 diabetic patients: a cross-sectional study in the United Arab Emirates

BACKGROUND

Optimum nutrition has an integral role in glycemic control of diabetic patients. In this study, we intend to explore the frequency of food group/item consumption and its association with the risk of poor glycemic control (Hb_A1c >7%) among type 2 diabetes (T2D) patients in the United Arab Emirates (UAE), since there are no data available in this region.

METHODS

In this retrospective cross-sectional study, data on frequency of food group/item consumption of 843 T2D patients aged ≥18 years were collected from records documented by dietitians in a tertiary care center in the UAE.

RESULTS

The trends of food consumption demonstrate that one-third of the participants consumed all five major food groups, and 10% adhered to the recommended "MyPlate" meal pattern with the optimum mix of food groups. Univariate analysis indicated that participants who adhered to the MyPlate meal pattern presented lower Hb_A1c (β=-0.78, 95% CI -1.22, -0.25; P<0.01). Daily intake of fresh fruit was shown to be protective (β=-0.64, 95% CI -1.26, -0.04; P=0.04) while fruit juice intake >1 time/day increased the risk of poor glycemic control (β=1.53, 95% CI 0.72, 2.35; P<0.001). Multiple logistic regression models (area under the receiver operating characteristics curve =0.67) showed consumption of fizzy drinks and fast food ≥1 time/week increased the odds of poor glycemic control by 2.05 (95% CI 1.16, 3.68; P=0.01) and 1.83 (95% CI 1.02, 3.3 P=0.04), respectively, while fresh fruit consumption indicated a clinically relevant protective effect  (OR=0.65, 95% CI 0.23, 1.79; P=0.4).

CONCLUSION

Consuming food such as fizzy drinks and fast food ≥1 time/week could possibly serve as an independent predictor for poor glycemic control, while fresh fruit could have a protective effect on glycemic control among T2D patients.Clinical Trial Registry: ClinicalTrials.gov Identifier: NCT03388229.

Biochemical and Physiological Parameters in Rats Fed with High-Fat Diet: The Protective Effect of Chronic Treatment with Purple Grape Juice (Bordo Variety)

High-fat-diet (HFD) has been related to metabolic and cardiovascular diseases. Consumption of grapes and their byproducts containing phenolic compounds has been reported due to the benefits they produce for human health. The purpose of this study was to investigate the antioxidant and protective effect of chronic intake of purple grape juice on certain biochemical and physiological changes promoted by the consumption of HFD. Forty male rats were randomly divided into four groups to receive standard or HFD diet and/or conventional (CGJ) or organic grape juice (OGJ) for three months. Dietary intake, body weight gain, cardiometabolic parameters, and serum lipoperoxidation were investigated. Results showed that consumption of CGJ and OGJ changed the pattern of food and drink intake of the animals. There was a reduction in the body weight of animals that consumed grape juices and an increase in the weight gain in HFD and OGJ rats. HFD increased abdominal fat and the abdominal fat/weight ratio, and both grape juices prevented these modifications. HFD increased hepatic enzymes levels (aminotransferase (AST) and gamma-glutamyl transpeptidase (GGT)) and reduced urea. Purple grape juices prevented some of these changes. HFD enhanced lipid peroxidation (thiobarbituric acid reactive substances (TBARS)) in serum and CGJ and OGJ prevented this increase. The consumption of purple grape juice has the potential to prevent and ameliorate most of the alterations provoked by HFD, therefore regular intake of grape products could promote beneficial effects.

Beneficial Effect of Intestinal Fermentation of Natural Polysaccharides

With the rapid development of modern society, many chronic diseases are increasing including diabetes, obesity, cardiovascular diseases, etc., which further cause an increased death rate worldwide. A high caloric diet with reduced natural polysaccharides, typically indigestible polysaccharides, is considered a health risk factor. With solid evidence accumulating that indigestible polysaccharides can effectively prevent and/or ameliorate symptoms of many chronic diseases, we give a narrative review of many natural polysaccharides extracted from various food resources which mainly contribute their health beneficial functions via intestinal fermentation.

Cognitive impairment in metabolically-obese, normal-weight rats: identification of early biomarkers in peripheral blood mononuclear cells

BACKGROUND

Metabolically-obese, normal-weight (MONW) individuals are not obese in terms of weight and height but have a number of obesity-related features (e.g. greater visceral adiposity, insulin resistance, and increased risk of cardiovascular disease). The MONW phenotype is related to the intake of unbalanced diets, such as those rich in fat. Increasing evidence shows a relationship between high-fat diet consumption and mild cognitive impairment and dementia. Thus, MONW individuals could be at a greater risk of cognitive dysfunction. We aimed to evaluate whether MONW-like animals present gene expression alterations in the hippocampus associated with an increased risk of cognitive impairment, and to identify early biomarkers of cognitive dysfunction in peripheral blood mononuclear cells (PBMC).

METHODS

Wistar rats were chronically fed with a 60% (HF60) or a 45% (HF45) high-fat diet administered isocalorically to control animals to mimic MONW features. Expression analysis of cognitive decline-related genes was performed using RT-qPCR, and working memory was assessed using a T-maze.

RESULTS

High-fat diet consumption altered the pattern of gene expression in the hippocampus, clearly pointing to cognitive decline, which was accompanied by a worse performance in the T-maze in HF60 animals. Remarkably, Syn1 and Sorl1 mRNA showed the same expression pattern in both the hippocampus and the PBMC obtained at different time-points in the HF60 group, even before other pathological signs were observed.

CONCLUSIONS

Our results demonstrate that long-term intake of high-fat diets, even in the absence of obesity, leads to cognitive disruption that is reflected in PBMC transcriptome. Therefore, PBMC are revealed as a plausible, minimally-invasive source of early biomarkers of cognitive impairment associated with increased fat intake.

Inhibition of key enzymes linked to type 2 diabetes by compounds isolated from Aframomum melegueta fruit

CONTEXT

The use of Aframomum melegueta K. Schum. (Zingiberaceae) fruit for treatment of diabetes has recently been established in Nigeria. However, compounds responsible for the antidiabetic action have not been identified.

OBJECTIVE

The present study carried out the bioassay-guided isolation of possible bioactive compounds responsible for the antidiabetic action of A. melegueta fruit.

MATERIALS AND METHODS

The A. melegueta fruit was sequentially extracted using ethyl acetate (EtOAc), ethanol and water, and the most active extract (EtOAc) was subjected to column chromatography on a silica gel column using solvent gradient systems of hexane (HEX):EtOAc and EtOAc:MeOH and the isolation of compounds was guided by α-glycosidase and α-amylase inhibitory activities at various concentrations (30-240 μg/mL).

RESULTS

According to the results, 3 arylalkanes, 6-paradol (1), 6-shogaol (2) and 6-gingerol (3) and a pentacyclic triterpene, oleanolic acid (4) were isolated from A. melegueta fruit. All the compounds exhibited inhibitory effects against α-amylase and α-glucosidase. 6-Gingerol (3) and oleanolic acid (4) showed higher inhibitory activity against α-amylase (IC50: 6-gingerol: 81.78 ± 7.79 μM; oleanolic acid: 91.72 ± 1.63 μM) and α-glucosidase (IC50: 6-gingerol: 21.55 ± 0.45 μM; oleanolic acid: 17.35 ± 0.88 μM) compared to the standard drug, acarbose and other isolated compounds. The kinetics of the enzyme action of the compounds showed a noncompetitive mode of inhibition.

CONCLUSION

The data of this study suggest that the 6-gingerol (3) and oleanolic acid (4) showed higher α-amylase and α-glucosidase inhibitory action and therefore could be responsible for the antidiabetic activity of A. melegueta fruit.

Hypoglycemic effect of hawthorn in type II diabetes mellitus rat model

BACKGROUND

Hawthorn is a popular herb in many different traditional medicine systems, including traditional Chinese medicine, where it has long been used for the treatment of hyperglycemia. However, most of its varied biological activities remain unexplored. This study investigated the hypoglycemic effect of hawthorn extracts in type II diabetic (T2DM) rat model. A total of 54 rats were randomly divided into six groups: normal control group; type II diabetic model group (T2DM; these rats were induced by high-fat diet and streptozotocin); high, middle and low concentrations of hawthorn treatment (HT_H , HT_M and HT_L T2DM rats were given hawthorn extract at a dose of 50, 100 and 200 mg kg^-1 body weight, respectively); and positive control group (orlistat 40 mg kg^-1 body weight).

RESULTS

Triglyceride and total cholesterol serum levels were lower in the hawthorn extract-treated groups than in the T2DM control group (P < 0.01). Furthermore, hawthorn extracts decreased blood glucose level and increased plasma insulin release from pancreas.

CONCLUSION

Positive effects of hawthorn against streptozotocin-induced T2DM were demonstrated. This study suggests that hawthorn extract represents a useful agent for the prevention or treatment of T2DM. © 2017 Society of Chemical Industry.

Use of Bacillus amyloliquefaciens HZ-12 for High-Level Production of the Blood Glucose Lowering Compound, 1-Deoxynojirimycin (DNJ), and Nutraceutical Enriched Soybeans via Fermentation

1-Deoxynojirimycin (DNJ) is an efficient α-glucosidase inhibitor (α-GI) with potential applications in the prevention and treatment of diabetes. In this study, 16 Bacillus strains were screened for α-GI rate, and the strain HZ-12 with the highest α-GI rate was identified as Bacillus amyloliquefaciens through the analysis of physiological biochemical characteristics and 16S rDNA sequence. By LC-MS/Q-TOF analysis, the α-GI component produced by B. amyloliquefaciens HZ-12 was identified as DNJ. Soybean was used as the substrate for the solid-state fermentation; 870 mg/kg DNJ was produced by B. amyloliquefaciens HZ-12 after optimizing the fermentation conditions and media, which was 3.83-fold higher than the initial yield. Also, evaluations of nutraceutical enrichment in the form of anticoagulant activity, antioxidant activity, total nitrogen (TN), and total reducing sugars (TRS) of the B. amyloliquefaciens HZ-12 fermented soybeans were substantially higher than unfermented soybeans. This study provided a promising strain for high-level production of DNJ and produced nutraceutical enriched soybeans by fermentation.

Impact of dietary fat composition on prediabetes: a 12-year follow-up study

Objective

Dietary fatty acid composition likely affects prediabetic conditions such as isolated impaired fasting glucose (IFG) or impaired glucose tolerance (IGT); however, this risk has not been evaluated in a large population nor has it been followed prospectively.

Design

Diet, physical activity, anthropometric, socio-economic and blood glucose data from the Atherosclerosis Risk in Communities (ARIC) study were obtained from BioLINCC. Cox proportional hazards regression models were used to evaluate associations of dietary SFA, MUFA, PUFA,n-3 fatty acid (FA) andn-6 FA intakes with incidence of one (isolated IFG) or two (IFG with IGT) prediabetic conditions at the end of 12-year follow-up.

Setting

Study volunteers were from counties in North Carolina, Mississippi, Minnesota and Maryland, USA.

Subjects

Data from 5288 volunteers who participated in the ARIC study were used for all analyses reported herein.

Results

The study population was 62% male and 84 % white, mean age 53·5 (sd5·7) years and mean BMI 26·2 (sd4·6) kg/m2. A moderately high intake of dietary MUFA (10–15 % of total daily energy) was associated with a 10 % reduced risk of isolated IFG incidence, while a high intake ofn-3 FA (>0·15 % of total daily energy) was associated with a 10 % increase in risk. Curiously, moderately high intake ofn-6 PUFA (4–5 % of total daily energy) was associated with a 12 % reduction in IFG and IGT incidence.

Conclusions

MUFA,n-3 andn-6 FA contribute differently to the development of isolated IFGv. IFG with IGT; and their mechanism may be more complex than originally proposed.

Impact of performance grading on annual numbers of acute myocardial infarction-associated emergency department visits in Taiwan: Results of segmented regression analysis

To reduce patient boarding time at the emergency department (ED) and to improve the overall quality of the emergent care system in Taiwan, the Minister of Health and Welfare of Taiwan (MOHW) piloted the Grading Responsible Hospitals for Acute Care (GRHAC) audit program in 2007-2009.The aim of the study was to evaluate the impact of the GRHAC audit program on the identification and management of acute myocardial infarction (AMI)-associated ED visits by describing and comparing the incidence of AMI-associated ED visits before (2003-2007), during (2007-2009), and after (2009-2012) the initial audit program implementation.Using aggregated data from the MOHW of Taiwan, we estimated the annual incidence of AMI-associated ED visits by Poisson regression models. We used segmented regression techniques to evaluate differences in the annual rates and in the year-to-year changes in AMI-associated ED visits between 2003 and 2012. Medical comorbidities such as diabetes mellitus, hyperlipidemia, and hypertensive disease were considered as potential confounders.Overall, the number of AMI-associated patient visits increased from 8130 visits in 2003 to 12,695 visits in 2012 (P-value for trend < 0.001), corresponding to an average annual growth rate of 5.3% (95%confidence interval [CI]: 0.5-10%). Although age was a major risk factor for AMI-associated ED visits, the statistical association was observed in middle-to-old (aged 40-64; P-value < 0.001) and older aged individuals (aged ≥65; P-value <0.001). As compared to 2003-2007, AMI-associated ED visits increased slightly during the intervention roll-in period (2007-2009, slope = 394.5, P-value = 0.117) followed by a dramatic uptake in the early post-intervention period (2010-2012, slope = 1037, P-value = 0.083).There was evidence suggesting for a significant intervention effect of the GRHAC program on identifying critically ill patients with AMI-associated diagnosis at the ED. As the program evaluation is still ongoing, we expect to observe a sustained program effect on hospitals' capacity for timely and correctly diagnosing and managing patients presenting with AMI-associated symptoms or signs at the ED.

Digestibility of new dietary fibre materials, resistant glucan and hydrogenated resistant glucan in rats and humans, and the physical effects in rats

Resistant glucan (RG) and hydrogenated resistant glucan (HRG) are newly developed non-digestible carbohydrate materials that decrease lifestyle-related diseases. The bioavailability of RG and HRG was investigated by in vitro experiments using human and rat small intestinal enzymes and by in vivo experiments using rats in the present study. Oligosaccharides, which are minor components of RG and HRG, were hydrolysed slightly by small intestinal enzymes of humans and rats, and the hydrolysing activity was slightly higher in rats than in humans. The amount of glucose released from HRG was greater than that from RG. However, the high-molecular-weight carbohydrates of the main components were hardly hydrolysed. Furthermore, neither RG nor HRG inhibited disaccharidase activity. When rats were raised on a diet containing 5 % of RG, HRG, resistant maltodextrin or fructo-oligosaccharide (FOS) for 4 weeks, all rats developed loose stools and did not recover during the experiment, except for the FOS group. Body weight gain was normal in all groups and was not significantly different compared with the control group. Caecal tissue and content weights were significantly increased by feeding RG or HRG, although other organ and tissue weights were not significantly different among the groups. In conclusion, RG and HRG consist of small amounts of glucose and digestible and non-digestible oligosaccharides, and large amounts of glucose polymers, which were hardly hydrolysed by α-amylase and small intestinal enzymes. RG and HRG, which were developed newly as dietary fibre materials, had no harmful effects on the growth and development of rats.

Oral supplementations with L-glutamine or L-alanyl-L-glutamine do not change metabolic alterations induced by long-term high-fat diet in the B6.129F2/J mouse model of insulin resistance

In this work, we aimed to investigate the effects of long-term supplementations with L-glutamine or L-alanyl-L-glutamine in the high-fat diet (HFD)-fed B6.129SF2/J mouse model over insulin sensitivity response and signaling, oxidative stress markers, metabolism and HSP70 expression. Mice were fed in a standard low-fat diet (STA) or a HFD for 20 weeks. In the 21th week, mice from the HFD group were allocated in five groups and supplemented for additional 8 weeks with different amino acids: HFD control group (HFD-Con), HFD + dipeptide L-alanyl-L-glutamine group (HFD-Dip), HFD + L-alanine group (HFD-Ala), HFD + L-glutamine group (HFD-Gln), or the HFD + L-alanine + L-glutamine (in their free forms) group (HFD-Ala + Gln). HFD induced higher body weight, fat pad, fasted glucose, and total cholesterol in comparison with STA group. Amino acid supplementations did not induce any modifications in these parameters. Although insulin tolerance tests indicated insulin resistance in all HFD groups, amino acid supplementations did not improve insulin sensitivity in the present model. There were also no significant differences in the immunocontents of insulin receptor, Akt, and Toll-like receptor-4. Notably, total 70 kDa heat shock protein (HSP72 + HSP73) contents in the liver was markedly increased in HFD-Con group as compared to STA group, which might suggest that insulin resistance is only in the beginning. Apparently, B6.129SF2/J mice are more resistant to the harmful effects of HFD through a mechanism that may include gut adaptation, reducing the absorption of nutrients, including amino acids, which may explain the lack of improvements in our intervention.

Non-small cell lung cancer cell survival crucially depends on functional insulin receptors

Insulin plays an important role as a growth factor and its contribution to tumor proliferation is intensely discussed. It acts via the cognate insulin receptor (IR) but can also activate the IGF1 receptor (IGF1R). Apart from increasing proliferation, insulin might have additional effects in lung cancer. Therefore, we investigated insulin action and effects of IR knockdown (KD) in three (NCI-H292, NCI-H226 and NCI-H460) independent non-small cell lung cancer (NSCLC) cell lines. All lung cancer lines studied were found to express IR, albeit with marked differences in the ratio of the two variants IR-A and IR-B. Insulin activated the classical signaling pathway with IR autophosphorylation and Akt phosphorylation. Moreover, activation of MAPK was observed in H292 cells, accompanied by enhanced proliferation. Lentiviral shRNA IR KD caused strong decrease in survival of all three lines, indicating that the effects of insulin in lung cancer go beyond enhancing proliferation. Unspecific effects were ruled out by employing further shRNAs and different insulin-responsive cells (human pre-adipocytes) for comparison. Caspase assays demonstrated that IR KD strongly induced apoptosis in these lung cancer cells, providing the physiological basis of the rapid cell loss. In search for the underlying mechanism, we analyzed alterations in the gene expression profile in response to IR KD. A strong induction of certain cytokines (e.g. IL20 and tumour necrosis factor) became obvious and it turned out that these cytokines trigger apoptosis in the NSCLC cells tested. This indicates a novel role of IR in tumor cell survival via suppression of pro-apoptotic cytokines.

Hypoglycemic and antioxidant effects of Daraesoon (Actinidia arguta shoot) in animal models of diabetes mellitus

BACKGROUND/OBJECTIVES

The primary objective of the treatment of diabetes mellitus is the attainment of glycemic control. Hyperglycemia increases oxidative stress which contributes to the progression of diabetic complications. Thus, the purpose of this study was to investigate the hypoglycemic and antioxidant effects of Daraesoon (Actinidia arguta shoot) in animal models of diabetes mellitus.

MATERIALS/METHODS

Rats with streptozotocin-induced diabetes received an oral administration of a starch solution (1 g/kg) either with or without a 70% ethanol extract of Daraesoon (400 mg/kg) or acarbose (40 mg/kg) after an overnight fast and their postprandial blood glucose levels were measured. Five-week-old C57BL/6J mice were fed either a basal or high-fat/high-sucrose (HFHS) diet with or without Daraesoon extract (0.4%) or acarbose (0.04%) for 12 weeks after 1 week of adaptation to determine the effects of the chronic consumption of Daraesoon on fasting hyperglycemia and antioxidant status.

RESULTS

Compared to the control group, rats that received Daraesoon extract (400 mg/kg) or acarbose (40 mg/kg) exhibited a significant reduction in the area under the postprandial glucose response curve after the oral ingestion of starch. Additionally, the long-term consumption of Daraesoon extract or acarbose significantly decreased serum glucose and insulin levels as well as small intestinal maltase activity in HFHS-fed mice. Furthermore, the consumption of Daraesoon extract significantly reduced thiobarbituric acid reactive substances and increased glutathione levels in the livers of HFHS-fed mice compared to HFHS-fed mice that did not ingest Daraesoon.

CONCLUSIONS

Daraesoon effectively suppressed postprandial hyperglycemia via the inhibition of α-glucosidase in STZ-induced diabetic rats. Chronic consumption of Daraesoon alleviated fasting hyperglycemia and oxidative stress in mice fed a HFHS diet.

Diabetes, diet-health behavior, and obesity

High-quality diets play an important role in diabetes prevention. Appropriate dietary adherence can improve insulin sensitivity and glycemic control, and thus contribute to lifestyle improvement. However, previous research suggests that dietary adherence is arguably among the most difficult cornerstones of diabetes management. The objectives of this study are (1) to estimate whether and to what extent individuals diagnosed with diabetes show significant differences in diet quality [healthy eating index (HEI)] compared to healthy individuals, (2) to quantify whether and to what extent diabetics experience significantly higher outcomes of body mass index (BMI), and (3) to estimate whether and to what extent dietary supplementation impacts diabetes patient's diet quality and/or BMI outcomes. We use data from the 2007-2008 U.S. National Health and Nutrition Examination Survey (NHANES). The NHANES is the primary, randomized, and nationally representative survey used to assess the health and nutritional status in the U.S. We apply propensity score matching (PSM) to account for selection bias and endogeneity between self-reported diet and health behavir (treatment) and BMI outcomes. We control for an individual's BMI as to capture the impact of past dietary behavior in its impact on HEI. Matching results suggest that regular dietary supplement consumption is associated with significant lower BMI outcomes of almost 1 kg/m(2). The close relationship between diabetes and obesity has been at the center of the diet-health policy debate across Canada and the U.S. Knowledge about this linkage may help to improve the understanding of the factors that impact dietary choices and their overall health outcomes, which may lead to a more efficient and effective promotion of dietary guidelines, healthy food choices, and targeted consumer health and lifestyle policies.

Cocoa-rich diet ameliorates hepatic insulin resistance by modulating insulin signaling and glucose homeostasis in Zucker diabetic fatty rats

Insulin resistance is the primary characteristic of type 2 diabetes and results from insulin signaling defects. Cocoa has been shown to exert anti-diabetic effects by lowering glucose levels. However, the molecular mechanisms responsible for this preventive activity and whether cocoa exerts potential beneficial effects on the insulin signaling pathway in the liver remain largely unknown. Thus, in this study, the potential anti-diabetic properties of cocoa on glucose homeostasis and insulin signaling were evaluated in type 2 diabetic Zucker diabetic fatty (ZDF) rats. Male ZDF rats were fed a control or cocoa-rich diet (10%), and Zucker lean animals received the control diet. ZDF rats supplemented with cocoa (ZDF-Co) showed a significant decrease in body weight gain, glucose and insulin levels, as well as an improved glucose tolerance and insulin resistance. Cocoa-rich diet further ameliorated the hepatic insulin resistance by abolishing the increased serine-phosphorylated levels of the insulin receptor substrate 1 and preventing the inactivation of the glycogen synthase kinase 3/glycogen synthase pathway in the liver of cocoa-fed ZDF rats. The anti-hyperglycemic effect of cocoa appeared to be at least mediated through the decreased levels of hepatic phosphoenolpyruvate carboxykinase and increased values of glucokinase and glucose transporter 2 in the liver of ZDF-Co rats. Moreover, cocoa-rich diet suppressed c-Jun N-terminal kinase and p38 activation caused by insulin resistance. These findings suggest that cocoa has the potential to alleviate both hyperglycemia and hepatic insulin resistance in type 2 diabetic ZDF rats.