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DIABETES, OBESITY AND METABOLISM                                                                 original article   Given ...
original article                                                                             DIABETES, OBESITY AND METABOL...
DIABETES, OBESITY AND METABOLISM                                                                             original arti...
original article                                                                                         DIABETES, OBESITY...
DIABETES, OBESITY AND METABOLISM                                                                                 original ...
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A low carbohydrate mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients


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A low carbohydrate mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients

  1. 1. original article Diabetes, Obesity and Metabolism 12: 204–209, 2010. © 2010 Blackwell Publishing Ltd A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control amongoriginalarticle overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study A. Elhayany1,2,5 , A. Lustman2,3 , R. Abel2 , J. Attal-Singer4,5 & S. Vinker2,3 1 CEO, Meir Medical Center, Kfar Saba, Israel 2 Department of Family Medicine, Central District Clalit Health Services, Rishon Le Zion, Israel 3 Department of Family Medicine, Tel Aviv University, Tel Aviv, Israel 4 Endocrinology Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel 5 Department of Family Medicine, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Background: The appropriate dietary intervention for overweight persons with type 2 diabetes mellitus (DM2) is unclear. Trials comparing the effectiveness of diets are frequently limited by short follow-up times and high dropout rates. Aim: The effects of a low carbohydrate Mediterranean (LCM), a traditional Mediterranean (TM), and the 2003 American Diabetic Association (ADA) diet were compared, on health parameters during a 12-month period. Methods: In this 12-month trial, 259 overweight diabetic patients (mean age 55 years, mean body mass index 31.4 kg/m2 ) were randomly assigned to one of the three diets. The primary end-points were reduction of fasting plasma glucose, HbA1c and triglyceride (TG) levels. Results: 194 patients out of 259 (74.9%) completed follow-up. After 12 months, the mean weight loss for all patients was 8.3 kg: 7.7 kg for ADA, 7.4 kg for TM and 10.1 kg for LCM diets. The reduction in HbA1c was significantly greater in the LCM diet than in the ADA diet (−2.0 and −1.6%, respectively, p < 0.022). HDL cholesterol increased (0.1 mmol/l ± 0.02) only on the LCM (p < 0.002). The reduction in serum TG was greater in the LCM (−1.3 mmol/l) and TM (−1.5 mmol/l) than in the ADA (−0.7 mmol/l), p = 0.001. Conclusions: An intensive 12-month dietary intervention in a community-based setting was effective in improving most modifiable cardiovascular risk factors in all the dietary groups. Only the LCM improved HDL levels and was superior to both the ADA and TM in improving glycaemic control. Keywords: cardiovascular risk, diabetes mellitus, dietary intervention, Mediterranean diet Date submitted 16 April 2009; date of first decision 29 July 2009; date of final acceptance 07 August 2009 Introduction The recommendations focus on the quantity of carbohydrates consumed, but not on the source or type of carbohydrate. The prevalence of diabetes among the Israeli population in Diets based on carbohydrates with a low glycaemic 2000 was 3.4% [1]. According to the Centers for Disease index (LGI) have been found to improve HbA1c levels Control and Prevention (CDC), the prevalence of diabetes and reduce insulin resistance, as well as lower cholesterol, in the USA in 2004 was 5.1% [2]. Weight reduction in triglyceride (TG) and very low-density lipoprotein cholesterol overweight patients with type 2 diabetes mellitus (DM2) concentrations [8]. However, the relative importance of has been proven to be effective in diabetes treatment [3,4]. glycaemic index and of glycaemic load as well as the relative Proper dietary intervention can restore insulin sensitivity and prevent disease progression and complications [5,6]. However, advantages of higher fat diets and the type of dietary fat vs. recommendations differ as to which diet is more effective diets with high carbohydrate content are debated [9–11]. The in achieving weight loss and glycaemic control and reducing lack of consensus is largely due to the relatively small number cardiovascular risk factors. of participants in some studies and the difficulties with patient In 2004, the American Diabetic Association (ADA) follow-up over long periods particularly in community-based recommended that carbohydrates and monounsaturated fats studies. (MUFA) together should provide 60–70% of energy intake [7]. Previous studies [12–15] have suggested that a diet enriched in MUFA elevates blood levels of high-density lipoprotein cholesterol (HDL-C), reduces low-density lipoprotein choles- Correspondence to: Asher Elhayany, Meir Medical Center, 59 Tchernichovsky Street, Kfar Saba 44821, Israel. terol (LDL-C) and TGs in DM2 and has a positive effect on E-mail: cardiovascular disease risk factors [16,17].
  2. 2. DIABETES, OBESITY AND METABOLISM original article Given the unclear data, and the lack of community-based diets included only LGI carbohydrates whereas the ADAlong-term clinical trials, our group conducted a large diet included mixed glycaemic index carbohydrates. TMcommunity-centered interventional study comparing three and ADA included the same percentages of carbohydratestypes of isocaloric diets in overweight DM2 patients. (50–55%), fat (30%) and protein (15–20%); LCM included We compared the 2003 ADA diet (50–55% carbohydrates, 35% carbohydrates and 45% fat (50% MUFA). Participants30% fats and 20% proteins) with a traditional Mediterranean were counselled to eat 4–6 meals/day according to their(TM) diet (50–55% LGI carbohydrates, 30% fats–high monounsaturated fat content, 15–20% proteins) anda low carbohydrate Mediterranean (LCM) diet (35% LGI Dietary Questionnairescarbohydrates, 45% fats–high in monounsaturated fat content,15–20% proteins). The main outcome measures were Participants completed a 24-h food recall questionnaire, aglycaemic control and biomarkers for cardiovascular risk. validated food frequency questionnaire (FFQ) and a physical activity questionnaire that included quality of life measures, at baseline, 3 and 6 months [19,20]. Before the study, the dietitiansMethods participated in a training workshop to ensure standardizationThe study population has been described elsewhere [18]. in questionnaire administration.Briefly, 259 eligible patients with DM2 were enrolled betweenMarch 2003 and April 2004. Eligible patients were recruited Outcome Measuresfrom 10 urban primary care clinics in Israel’s central regionusing the electronic medical records of Clalit Health Services, a Clinical MeasurementsHealth Maintenance Organization. Weight, height, waist and hip circumferences were measured Inclusion criteria were: (i) age 30–65 years; (ii) DM2 at every visit. Blood pressure was obtained monthly as a meandiagnosed within 1–10 years; (iii) body mass index (BMI) of three readings.27–34 kg/m2 ; (iv) last HbA1c measurement 7–10%; (v) lastplasma TG level 1.8–4.5 mmol/l; (vi) last serum creatinine<123.2 μmol/l; and (vii) no change in diabetes medication for Laboratory Measurementsat least 3 months before entering the study. All tests were performed in the Clalit Health Services Central Exclusion criteria were: (i) proliferative diabetic retinopathy; District laboratory. Fasting blood glucose, plasma insulin levels,(ii) current insulin treatment; (iii) active oncologic or HbA1c, total cholesterol, HDL-C, TGs, liver enzymes, serumpsychiatric disease; and (iv) uncontrolled hypothyroidism or creatinine and urea were measured at baseline and everyhyperthyroidism. 3 months. We identified 2486 patients with DM2, 1063 (42.8%) ofwhom met the inclusion criteria and 644 (60.6%) of those werewilling to participate. Before the study entry, patients were Statistical Analysisasked to repeat laboratory tests and to undergo fundoscopy: To compare the differences between diets and changes from244 patients did not comply and an additional 141 were baseline, t-test, one way ANOVA, chi-square or Fisher’s exactexcluded as a result of new findings, thus 259 patients were tests were used as appropriate. To evaluate the effect of theenrolled (figure 1). diets and examine the changes over time, as well as the interaction between diet and time, we examined the repeatedIntervention measures using generalized linear models. Measurements taken at baseline, 3, 6, 9 and 12 months were used in the analyses,Prior to randomization, the 259 eligible patients entered a 2- and TG levels were examined after log transformation. Postweek maintenance period. During this time, the patients were hoc Scheffe test was used to identify the statistically differentasked to continue their usual diet and keep a food intake diary. diets. All p values were two-sided; p < 0.05 was consideredThe patients were then randomly assigned to one of three statistically significant. All analyses were conducted using SPSS-isocaloric diets: TM, LCM or ADA. PC version 15. Patients were followed up by the same dietitian every 2weeks for 1 year. All dieticians followed a structured protocolfor the 24 scheduled meetings and treated patients from each Resultsof the three diet groups. All patients were advised to engage in30–45 min of aerobic activity at least 3 days a week. Of the 259 patients enrolled in the study, 85 were randomly assigned to the ADA diet, 89 to TM, and 85 to the LCM diet. There were no significant differences at baseline inDietary Intervention demographic, clinical or laboratory measurements amongTable A1 (Appendix) outlines the composition of each diet. the three groups (table 1). Cumulative dropouts were 43,The daily recommended intake of calories, protein, sodium 56 and 65 patients at 3, 6 and 9 months respectively. The(up to 3000 mg), potassium (more than 3000 mg), calcium discontinuation rates in the three diet groups were similar(approximately 1300 mg) and magnesium (more than 800 mg) (figure 1). The 80 individuals who did not complete the 12-were similar in the three diet programs. The TM and LCM month follow-up had, at baseline, statistically significant higherVolume 12 No. 3 March 2010 doi:10.1111/j.1463-1326.2009.01151.x 205
  3. 3. original article DIABETES, OBESITY AND METABOLISM Assessed for eligibility n =2486 Enrollment Not meeting inclusion criteria n =1423 Refused to participate n=419 Agreed to participate Other reasons (unable to contact, and randomized moved, changed to another HMO) n=259 n=385 Total exclusions n=2227 ENROLLMENT ADA diet n=85 TM diet n=89 LCM diet n=85 FOLLOW-UP Lost to follow-up Lost to follow-up Lost to follow-up Up to 3 months n=15 Up to 3 months n=13 Up to 3 months n=14 Up to 6 months n= 11 Up to 6 months n= 8 Up to 6 months n= 6 6 to 12 months n= 4 6 to 12 months n= 5 6 to 12 months n= 4 Due to: Due to: Due to: Noncompliance n= 10 Noncompliance n= 11 Noncompliance n=13 Changed residence n=2 Unrelated health Changed residence n=3 Domestic problems n=3 problems n=5 Domestic problems n=4 Unrelated health Other n=1 Unrelated health problems n=7 Incomplete 12-month problems n=2 Other n=2 follow up data n=9 Other n=2 Incomplete 12-month follow up data n=6 Completed 12-month follow-up n=55 n=63 n=61Figure 1. Flow chart of the study population.fasting plasma glucose, total cholesterol and LDL-C levels than blood lipids and HOMA decreased in all three groups, whilepatients who completed the study. No differences were observed fasting insulin levels increased over time. Differences betweenin HbA1c, weight, waist circumference, systolic and diastolic diets were found for HbA1c, TGs and HDL-C as well as forblood pressures, HDL-C and TG levels. LDL-C. The reduction in HbA1c was significantly greater for To determine patient adherence to the recommended diets, patients on the LCM than for patients on the ADA diet. Thewe evaluated the results of the FFQ administered at 6 months. decrease in TGs was greater for the LCM and TM than forThe mean reported energy intake was similar in the three diets the ADA group (p = 0.001). Patients on the LCM achieved a(2221.6 calories ± 1086.6). There was a statistically significant significant increase in HDL-C levels compared to the ADA, buttrend in the percentage of polyunsaturated fat intake of total did not differ significantly from those on the TM diet. LDL-Cenergy, from highest (12.9%) in LCM, to 11.5% in TM, and levels were reduced for all three diets after a year; we found thatlowest in ADA 11.2% (p = 0.002). The same significant trend the decrease was greatest in LCM, but not significantly greaterwas observed for monounsaturated fat intake (14.6, 12.8, and than the TM diet.12.6% for LCM, TM, and ADA, respectively, p < 0.001). The Additional analysis was performed including the 80opposite trend was observed for the percentage of carbohydrate individuals without 12-month data using the latest available ofintake, being highest in the ADA, and lowest in the LCM 3-, 6- or 9-month follow-up data. The results were comparablediet (45.4, 45.2, 41.9 for ADA, TM and LCM, respectively, to the analysis of those who completed the study.p = 0.011).Clinical Measurements DiscussionAt the end of the 12-month study period, weight, BMI and waist In recent years, low carbohydrate diets have been shown tocircumference were reduced in all the dietary interventions with be effective in improving glycaemic control and body weightno significant difference between the groups (table 2). HbA1c, in type 2 diabetes [21–24] as well as weight loss in obese206 Elhayany et al. Volume 12 No. 3 March 2010
  4. 4. DIABETES, OBESITY AND METABOLISM original articleTable 1. Baseline characteristics of the patients in the three diet groups in part by increased consumption of dietary fat in the LCM group [29], however, the non-significant differences in caloric Diet [data presented as mean (±s.d.)] intake between groups may have contributed to this weight ADA TM LCM loss.Characteristics (n = 55) (n = 63) (n = 61) p-value The LCM reduced the LDL levels by an extra 8% whenMale/female (n) 27/28 35/28 31/30 0.764 compared to the ADA and TM, which themselves each reducedAge (year) 56.0 (6.1) 57.4 (6.1) 55.5 (6.5) 0.229 LDL by 20% (LCM reduced 24.8%, TM 20.9% and ADAYears since DM 5.1 (2.6) 6.2 (9.9) 5.5 (3.8) 0.229 13.8%). This finding is of particular note, as other studies using diagnosis high MUFA diets have not shown significant reductions in LDLWeight (kg) 87.9 (13.7) 85.5 (10.6) 86.7 (14.3) 0.544 [16]. These studies had a follow-up between 4 and 6 weeks. ItBMI 31.8 (3.3) 31.1 (2.8) 31.4 (2.8) 0.483 is possible that the reduction of LDL in high MUFA diets takesWaist circumference 113.4 (10.0) 111.1 (9.1) 112.7 (9.6) 0.401 (cm) considerably longer to manifest than 4–6 weeks and thereforeHbA1c (%) 8.3 (0.8) 8.3 (1.0) 8.3 (1.0) 0.980 in these earlier studies the full effect of the MUFA diet was notFasting plasma 10.3 (1.7) 10.1 (1.8) 10.5 (2.0) 0.454 recorded. glucose (mmol/l) In our study, LCM was the only diet that led to an increaseFasting plasma 12.7 (6.2) 12.1 (6.5) 13.5 (5.7) 0.476 in HDL-C levels (12%). Although the ADA recommends insulin (μU/ml) reducing fat calories to less than 30% of the total daily caloricHOMA 5.8 (3.3) 5.0 (2.9) 5.9 (4.0) 0.549 intake, several recent studies underlined the superiority of dietsTotal cholesterol 5.4 (0.9) 5.5 (0.8) 5.4 (0.9) 0.848 (mmol/l) containing higher amounts of MUFA. Garg et al. [30] foundHDL-C (mmol/l) 1.1 (0.2) 1.1 (0.2) 1.1 (0.2) 0.732 a 7–13% increase in HDL-C levels when comparing a dietLDL-C (mmol/l) 3.0 (0.9) 3.2 (0.8) 3.1 (0.8) 0.769 rich in MUFA with a diet rich in carbohydrates in diabeticTriglycerides 3.1 (0.8) 3.0 (0.7) 3.2 (0.8) 0.792 patients. These findings together with our study suggest that a (mmol/l) low carbohydrate, high MUFA diet might be the best method to increase HDL-C, while still reducing LDL.patients [25–27]. Based on this increasing evidence, in 2008 Previous studies were unable to clarify the effect of a highthe ADA included a low carbohydrate diet as a possible MUFA diet on HbA1c. In our study, both TM and LCM dietsintervention. induced a greater decrease in HbA1c than did the ADA. As We found that an intensive community-based dietary both Mediterranean diets were based on LGI carbohydrates,intervention reduced cardiovascular risk factors in overweight while the reference diet included mixed glycaemic indexpatients with DM2 for all three diets. The LCM group had carbohydrates, this study supports the suggested protectiveimproved cardiovascular risk factors compared to either the effects of LGI carbohydrates on glycaemic control in patientsADA or the TM groups. with DM2. The weight loss in the LCM group at 1 year was greater Consumption of MUFA is thought to improve insulinthan in the other dietary intervention groups, although the sensitivity [31–33], an effect that may explain the favourabledifference was not significant. Similar results have been found effect of the Mediterranean diet on glucose and HbA1c levels.among moderately obese adults [28]. This may be explained Furthermore, both the Mediterranean and low carbohydrateTable 2. Results from generalized linear model analysis describing changes in clinical and laboratory measurements between baseline and 12-monthfollow-up examinations ADA (n = 55) TM (n = 63) LCM (n = 61) Baseline 12-month Baseline 12-month Baseline 12-month Change over p valueVariables (± s.d.) (± s.d.) (± s.d.) (± s.d.) (± s.d.) (± s.d.) time p value between dietsWeight (kg) 87.8 (13.7) 80.2 (13.2) 85.5 (10.6) 78.1 (9.9) 86.7 (14.3) 77.8 (13.1) <0.001 0.557BMI 31.8 (3.2) 29.0 (3.3) 31.1 (2.8) 28.5 (2.9) 31.4 (2.8) 28.1 (2.8) <0.001 0.359Waist circumference (cm) 113.1 (9.7) 104.0 (10.2) 110.9 (8.9) 101.6 (8.0) 112.6 (9.7) 102.2 (10.2) <0.001 0.388Fasting plasma glucose (mmol/l) 10.26 (1.69) 7.19 (1.85) 10.07 (1.80) 6.57 (1.34) 10.47 (2.00) 6.18 (0.84) <0.001 0.087HbA1c (%) 8.3 (0.8) 6.7 (0.9) 8.3 (1.0) 6.5 (0.8) 8.3 (1.0) 6.3 (1.4) <0.001 0.021∗,†Total cholesterol (mmol/l) 5.36 (0.89) 4.50 (0.71) 5.46 (0.85) 4.50 (0.69) 5.38 (0.97) 4.50 (0.85) <0.001 0.204LDL-C (mmol/l) 3.05 (0.87) 2.68 (0.83) 3.18 (0.76) 2.63 (0.67) 3.07 (0.81) 2.46 (0.72) <0.001 0.036∗HDL-C (mmol/l) 1.05 (0.22) 1.00 (0.19) 1.09 (0.17) 1.09 (0.21) 1.08 (0.23) 1.21 (0.21) <0.001 <0.001∗‡Triglycerides (mmol/l) 3.14 (0.81) 2.26 (1.12) 3.04 (0.68) 1.58 (0.33) 3.18 (0.78) 1.66 (0.36) <0.001 <0.001∗,†Fasting insulin (μU/ml) 12.8 (6.7) 13.7 (5.3) 11.2 (6.6) 12.4 (6.2) 12.6 (8.4) 14.9 (5.7) 0.007 0.183HOMA 5.85 (3.32) 4.32 (2.07) 4.96 (2.95) 3.69 (1.90) 5.94 (4.00) 4.20 (1.80) <0.001 0.238∗ LCM different than ADA.† TM different than ADA.‡ LCM different than TM.Volume 12 No. 3 March 2010 doi:10.1111/j.1463-1326.2009.01151.x 207
  5. 5. original article DIABETES, OBESITY AND METABOLISMdiets have been shown to reduce postprandial hyperglycaemia, 9. Hung T, Sievenpiper JL, Marchie A, Kendall CWC, Jenkins DJA. Fat versuswhich likely lowers LDL and TGs [34]. carbohydrate in insulin resistance, obesity, diabetes and cardiovascular Some limitations in our study must be underlined. disease. Curr Opin Clin Nutr Metab Care 2003; 6: 165–176.Potentially eligible patients refused to repeat fundoscopy and 10. Hu FB, van Dam RM, Liu S. Diet and risk of type II diabetes: the role ofblood tests and therefore, were not enrolled. The dropout types of fat and carbohydrates. Diabetologia 2001; 44: 805–817.rate was relatively high at 31% (80/259), although this was 11. Sargrad KR, Mozzoli M. Effect of high protein vs high carbohydrate intakein keeping with other nutritional studies [35]. Patients were on insulin sensitivity, body weight, hemoglobin A1c, and blood pressurein independent living conditions without close supervision of in patients with type 2 diabetes mellitus. J Am Diet Assoc 2005; 105:their food intake. However, food questionnaires showed a good 573–580.adherence to the assigned diet and patients were followed up 12. Garg A, Bonamone A, Grundy SM, Zhang ZJ, Unger RH. Comparison of aevery 2 weeks in an urban primary care clinic. high-carbohydrate diet with a high-monounsaturated-fat diet in patients In conclusion, we found that nutritional therapy in a with non-insulin-dependent diabetes mellitus. N Engl J Med 1988; 319: 829– population of overweight DM2 patientswas effective in reducing BMI, HbA1c, LDL and TG levels for 13. Campbell LV, Marmot PM, Dyer JA, Borkman M, Storlien LH. The high-all three of the dietary interventions. A low carbohydrate monounsaturated fat as a practical alternative for NIDDM. Diabetes Care 1994; 17: 177–182.Mediterranean diet also increased HDL-C levels and wassuperior in reducing LDL, TG and HbA1c levels compared 14. Toobert DJ, Glasgow RE, Strycker LA et al. Biologic and quality-of-lifeto ADA and standard Mediterranean diets. It would appear outcomes from the Mediterranean lifestyle program. Diabetes Care 2003; 26: 2288–2293.that the low carbohydrate Mediterranean diet should berecommended for overweight diabetic patients. 15. Garg A. High-monounsaturated-fat diets for patients with diabetes mellitus: a meta-analysis. Am J Clin Nutr 1998; 67: 577S–582S. 16. Rodriguez-Villar C, Perez-Heras A, Mercade I, Casals E, Ros E. ComparisonAcknowledgements of a high-carbohydrate and a high- monounsaturated fat, olive oil-rich diet on the susceptibility of LDL to oxidative modification in subjects withThis study was registered in Clinical Protocol type 2 diabetes mellitus. Diabet Med 2004; 21: 142–149.Registration System: IDNCT00520182. The authors would like 17. Esposito K, Marfella R, Ciotola M et al. Effect of a mediterranean-style dietto thank S. Daniel Abraham International Center for Health and on endothelial dysfunction and markers of vascular inflammation in theNutrition, Ben Gurion University, for assisting in study design metabolic syndrome: a randomized trial. JAMA 2004; 292: 1440–1446.and statistical analysis, Faye Schreiber for editorial assistance 18. Shahar DR, Abel R, Elhayani A, Vardi H, Fraser D. Does calcium intakeand Nava Yelin for helping in statistical analysis. enhance weight loss among overweight diabetic patients? Diabetes Care 2007; 30: 485–489.References 19. Shahar DR, Shai I, Vardi H, Brener-Azrad A, Fraser D. Development of a 1. The Israeli Ministry of Health Statistics. Selected health for all indicators semi quantitative food frequency questionnaire (FFQ) to assess dietary 2003. Morbidity, disability and hospital discharges. Available from URL: intake of multiethnic populations. Eur J Epidemiol 2003; 18: 855–861. 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  6. 6. DIABETES, OBESITY AND METABOLISM original article28. Shai I, Schwarzfuchs D, Henkin Y et al. Dietary intervention random- 35. Jenkins DJ, Kendall CW, McKeown-Eyssen G et al. Effect of a low-glycemic ized controlled trial (DIRECT) group. Weight loss with a low- index or a high-cereal fiber diet on type 2 diabetes: a randomized trial. carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008; 17: JAMA 2008; 300: 2742–2753. 229–241.29. Tucker LA, Thomas KS. Increasing total fiber intake reduces risk of weight Appendix and fat gains in women. J Nutr 2009; 139: 576–581.30. Garg A, Bantle JP, Henry RR, et al. Effects of varying carbohydrate content Table A1. Composition of diets of diet in patients with NIDDM. JAMA 1994; 271: 1421–1428.31. Esposito K, Marfella R, Ciotola M et al. Effect of a Mediterranean-style Diet ADA TM LCM diet on endothelial dysfunction and markers of vascular inflammation Carbohydrates∗ (% of TCI) 50 50 35 in the metabolic syndrome: a randomized trial. JAMA 2004; 292: Fibre (g) 15 30 30 1440–1446. Fat∗ (% of TCI) 30 30 4532. Schwenke DC. Insulin resistance, low-fat diets, and low-carbohydrate MUFA (% of fat) 10 10 23 diets: time to test new menus. Curr Opin Lipidol 2005; 16: 55–60. PUFA (% of fat) 12 12 15 SFA 7 7 733. Lara-Castro C, Garvey WT. Diet, insulin resistance, and obesity: zoning in Protein∗ (% of TCI) 20 20 20 on data for Atkins dieters living in South Beach. J Clin Endocrinol Metab Calories/kg body weight 20 20 20 2004; 89: 4197–4205.34. Gheewala NM. Dietary strategies for improving post-prandial glucose, MUFA, monounsaturated fats; PUFA, polyunsaturated fats; SFA, saturated lipids, inflammation, and cardiovascular health. J Am Coll Cardiol 2008; fats. ∗ 51: 249–255. Carbohydrates, fat and proteins are 100% of total caloric intake (TCI).Volume 12 No. 3 March 2010 doi:10.1111/j.1463-1326.2009.01151.x 209