Diabetes

Diabetes affects an estimated 25.8 million Americans (8.3% of the population) and is a growing public health burden. This report introduces the two types of diabetes (type 1 and type 2), their potential causes and management. Diet is a cornerstone of therapy for individuals with diabetes. According to the 2010 Dietary Guidelines for Americans, moderate evidence indicates that consumption of milk and milk products is associated with a reduced risk of type 2 diabetes. The report discusses key research findings on the role of dairy foods in reducing the risk of type 2 diabetes and the dairy nutrients and components -such as calcium, vitamin D, and dairy protein -- that may contribute to its beneficial effect.

Scientific Status Report _____________

In partnership with National Dairy Council, the Dairy Research Institute is providing this report for informational purposes only. The Dairy Research Institute expresses no opinion about the suitability of the information for use and suggests that any recipient obtain appropriate expert advice with regard to any statements or information herein contained. Although efforts are made to ensure that the information is complete and accurate, the Dairy Research Institute, its officers, employees and agents cannot and do not offer any representation or warranties, express or implied, as to the accuracy, completeness, currency or suitability of the information provided, whether based on warranty, contract, tort or any other legal theory and whether or not advised of the possibility of such damages. In no event shall the Dairy Research Institute or its affiliates be liable for any damages whatsoever arising out of the use, inability to use or the resulting use of information herein provided. All damages, including without limitation direct or indirect, special, incidental, consequential or punitive are hereby excluded to the fullest extent allowed by law. Any and all liability for the content or any omissions from this information, including any inaccuracies, errors or misstatements is expressly disclaimed.

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Diabetes is a growing public health burden in the U.S.1 An estimated 25.8 million Americans (8.3% of the population) have diabetes and approximately 7.0 million of those cases are undiagnosed.1 In 2007 diabetes cost the nation $174 billion and was the seventh leading cause of death.1 Diabetics are at increased risk of blindness, kidney disease, coronary heart disease, stroke, high blood pressure, nerve damage, and leg and foot amputations.1 There are two main types of diabetes. Type 1 diabetes, previously called insulin-dependent diabetes mellitus or juvenile-onset diabetes, is the most severe form of this disease. 1 This type of diabetes accounts for 5% to 10% of all diagnosed cases, and an individual with type 1 diabetes is dependent upon insulin for control of this disease. 1 About 90% to 95% of all diagnosed diabetics have type 2 diabetes mellitus, previously called non-insulin-dependent diabetes mellitus or adult-onset diabetes. 1 This type of diabetes is associated with older age, obesity, family history of diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. 1 In recent years, type 2 diabetes has increased among children and adolescents concurrent with the epidemic of overweight and obesity. 1,2 Diet is a cornerstone of therapy for type 2 diabetics, although in some cases insulin may also be needed to maintain blood levels of the sugar, glucose. The specific cause of type 2 diabetes is unknown. However, genetic, environmental, and lifestyle factors can increase an individual's risk for developing this disease. 1 Although diabetes can result from any of over 150 gene mutations, this disease is considered to be the result of an interaction among diet, lifestyle, and genetics.3 Metabolic syndrome, a cluster of metabolic risk factors (e.g., abdominal obesity, atherogenic lipoprotein profile, glucose intolerance, hypertension), can be a precursor of type 2 diabetes.4 Diabetes is characterized by an inability of the body to regulate its own blood glucose. This inability may be caused by a defect in the endocrine system, specifically lack of insulin (a hormone needed to convert sugars into energy) production, secretion, function, and/or body cells inability to take up glucose. Because the diabetic patients body cells have a limited ability to take up circulating glucose from the blood, the level of glucose in the blood remains high and this sugar is excreted in high amounts in the urine. Diet (or medical nutrition therapy) is an essential component of successful diabetes management.5,6 The nutrition goals include attaining and maintaining blood glucose and blood pressure levels as close to normal as possible, achieving optimal serum lipid levels, attaining a healthy body weight, and consuming adequate calories and nutrients to improve overall health.5,6 According to nutrition guidelines issued by the American Diabetes Association, there is no one "diabetic diet" for all individuals with diabetes.5 The recommendations focus on tailoring nutrition goals to the individual with diabetes or at risk for this disease.5 Also, the recommendations are flexible with emphasis on achieving desired health and quality of life goals.5 The American Diabetes Association and the American Dietetic Association have released a food exchange booklet for diabetes.7 Current dietary recommendations emphasize weight management.5-7 Overweight increases the risk for type 2 diabetes and weight loss is an important intervention for overweight or obese patients with this disease or who are at risk of developing diabetes.5 Mild to moderate weight loss can improve diabetes control, even if desirable body weight is not achieved.5 Caloric restriction and weight loss have independent effects on blood sugar levels and insulin sensitivity in patients with type 2 diabetes. Regular exercise also is recommended for diabetics, while monitoring blood glucose levels, lipids, and blood pressure is essential.5,6

While the American Diabetes Association recommends a protein intake of 15 to 20 percent of calories5, some emerging evidence indicates that a slightly higher protein intake (still within the Acceptable Macronutrient Distribution Range for protein of 10 to 35 percent of calories) may be beneficial for some people with diabetes.8 The percentage of calories from carbohydrate and fat depends on individual goals for glucose and lipid levels and body weight.5,6 Moderate amounts of sucrose and other simple sugars can be incorporated into the total carbohydrate content of the diet. Naturally occurring foods that are rich in dietary fiber are recommended.5,6 The American Diabetes Association states that the best mix of carbohydrate, protein, and fat for diabetes management varies according to individual circumstances.5 During the past decade, researchers have investigated the effect of early exposure to many dietary components and foods, including cow's milk, on the development of type 1 diabetes, particularly in individuals at high risk of this disease.9,10. Limited research has reported higher levels of antibodies to cow's milk proteins, for example bovine serum albumin (BSA), in some children genetically susceptible to or newly diagnosed with type 1 diabetes compared to normal children. Some researchers have proposed that milk proteins, particularly beta-casein, trigger an autoimmune response that destroys pancreatic beta cells in genetically susceptible children causing type 1 diabetes.11,12 However, findings from multiple scientific studies fail to support a positive association between cow's milk proteins and type 1 diabetes.9,10,13-21 One study found that children who developed B-cell autoimmunity (BCA), an early predictor of type 1 diabetes, were no more likely to have been exposed to cow's milk protein than children without BCA.16 Also, blood levels of antibodies to BSA have been found to be a poor indicator of diabetes.17,18 A study found that variations in the intake of cows milk proteins did not explain differences in the incidence of type 1 diabetes in Nordic countries.19 Researchers in Sweden found no difference in immune responses between children with type 1 diabetes and healthy children following exposure to cows milk antigens.14 Further, scientific evidence is insufficient to implicate beta-casein A1 in diabetes.13 More research is needed to determine the contribution of dietary factors in infancy to the risk of type 1 diabetes.10 Evidence to-date does not support a recommendation to avoid cow's milk during childhood or change current infant feeding guidelines to reduce the risk of type 1 diabetes.9,13,15-23 A review of research related to infant feeding practices and type 1 diabetes concluded "there is no causal relationship between early exposure to cows milk and the development of autoimmune diabetes mellitus in children." 9 This conclusion is supported by findings of a secondary analysis of a study initially designed to examine the effect of the type of feeding during the first year of life in 6,209 healthy Finnish infants on the development of allergy to cows milk.23 Very early exposure to cows milk formula was not a risk factor for type 1 diabetes and it may even protect against the development of type 1 diabetes during the first seven years of life.23 Data from a number of observational studies demonstrate an inverse association between dairy food intake and type 2 diabetes.24-26 Risk of type 2 diabetes was significantly lower in subjects consuming the highest dairy intake compared to those with the lowest intake, according to a review of five large observational studies in adults conducted between 2005 and 2009.25 A systematic review and metaanalysis of observational studies published in 2007 showed that the risk of type 2 diabetes was 14% lower for the highest compared to the lowest dairy intake (3-5 vs. <1.5 servings/day).26 More recent studies support the above findings. A systematic review and meta-analysis of seven prospective studies, published in 2011 and which examined the association between dairy
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consumption and type 2 diabetes, showed a significant (14%) reduction in type 2 diabetes risk in adults with the highest consumption of dairy products compared with the lowest intakes.27 Low-fat dairy consumption and yogurt were associated with a 18% and 17% reduction in risk of type 2 diabetes, respectively.27 Intake of full-fat dairy foods overall was not associated with type 2 diabetes risk. Similar findings are reported in a recent prospective study of more than 82,000 postmenopausal women enrolled in the Womens Health Initiative Observational Study.28 This study found that low-fat dairy foods and yogurt were inversely associated with risk of type 2 diabetes.28 No significant association between full-fat dairy products and type 2 diabetes was found. In the Australian Diabetes, Obesity and Lifestyle Study, a 47% reduction in risk for type 2 diabetes was found in men with the highest dairy consumption vs. those with the lowest consumption, with a similar but not statistically significant result in women.29 Lastly, in a recent report from a French prospective cohort study over nine years, dairy consumption (excluding cheese) was associated with a reduced risk for type 2 diabetes and/or impaired fasting glucose in men and women, while cheese consumption was associated with a reduced risk for metabolic syndrome.30 High dairy intake during the teenage years may lower risk of type 2 diabetes by middle-age (34-53 years), according to a prospective study in more than 37,000 adult women enrolled in the U.S. Nurses Health Study.31 Women who had a high intake (2 servings/1,000 calories/day) of dairy foods (both fullfat and low-fat) in their mid-teens had a 38% lower risk of developing type 2 diabetes in middle age than those who had a low intake (0.5 servings/1,000 calories) after adjusting for other risk factors.31 Further, those who continued to consume dairy throughout adulthood had an even lower risk of developing type 2 diabetes (i.e., 43%). According to the researchers, this is the first study to demonstrate that dairy consumption in adolescence may affect risk of type 2 diabetes in adulthood.31 The potential mechanism(s) by which dairy foods could reduce risk of type 2 diabetes may be related to the effect of dairy nutrients or components. Studies suggest that calcium, vitamin D, and magnesium may lower risk of type 2 diabetes.24,26,32,33 A meta-analysis of observational studies and clinical trials in adults concluded that suboptimal vitamin D and calcium intakes may negatively impact blood glucose homeostasis, while combined supplementation with both nutrients in at-risk populations may be beneficial.26 A recent prospective study in more than 5,000 Australian adults reported that 5year higher vitamin D status, but not higher dietary calcium, was associated with reduced risk of type 2 diabetes.32 According to a clinical trial in 90 adults with type 2 diabetes, consuming a vitamin Dfortified yogurt drink with or without calcium twice a day for 12 weeks improved glycemic control.34 Other dairy nutrients such as trans-palmitoleic acid, a monounsaturated fatty acid in milkfat35, and milk protein, particularly whey protein36, may also be beneficial in lowering the risk of type 2 diabetes. Including the DASH dietary pattern a dietary pattern rich in fruits, vegetables, and low-fat dairy foods and low in fat as part of a comprehensive lifestyle intervention for blood pressure control has been shown to increase insulin sensitivity.37 Findings from a multi-center five-year prospective study of 862 adults at four clinical centers in the U.S. suggest that adherence to the DASH diet may potentially reduce the risk of type 2 diabetes.38 When researchers examined the association between diet quality scores from various diets, including the DASH diet, and risk of type 2 diabetes, they found that participants with the highest DASH score had a 25% lower risk of type 2 diabetes than those with the lowest score.39 An investigation in middle-aged Japanese men found that a dietary pattern characterized by frequent consumption of dairy products, fruits and vegetables and low in alcoholic beverages was associated with reduced risk of impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes.40 In youth with either type 1 or type 2 diabetes, consuming a DASH-type meal pattern that includes dairy foods may help reduce the risk of and manage cardiovascular disease.41

The above findings are consistent with the 2010 Dietary Guidelines for Americans which states that moderate evidence indicates that consumption of milk and milk products is associated with a reduced risk of type 2 diabetes.42

References
1. Centers for Disease Control and Prevention. National diabetes fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. http://apps.nccd.cdc.gov/DDTSTRS/FactSheet.aspx. Accessed October 10, 2011. 2. Mayer-Davis, E.J. Type 2 diabetes in youth: epidemiology and current research toward prevention and treatment. J. Am. Diet. Assoc. 108: 45s-51s, 2008. 3. Romao, I., and J. Roth. Genetic and environmental interactions in obesity and type 2 diabetes. J. Am. Diet. Assoc. 108: 24s-28s, 2008. 4. Grundy S.M., J.I. Cleeman, S.R. Daniels, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 112: 2735-2752, 2005. 5. American Diabetes Association. Nutrition recommendations and interventions for diabetes: A position statement of the American Diabetes Association. Diabetes Care 31 (suppl 1): 61s-78s, 2008. 6. Franz, M.J., M.A. Powers, C. Leontos, et al. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J. Am. Diet. Assoc. 110: 1852-1889, 2010. 7. American Diabetes Association and American Dietetic Association. Choose Your Foods: Exchange Lists for Diabetes. Alexandria, VA: American Diabetes Association, 2008. 8. Layman, D.K., P. Clifton, M.C. Gannon, et al. Protein in optimal health: heart disease and type 2 diabetes. Am. J. Clin. Nutr. 87(suppl): 1571s-1575s, 2008. 9. Berdanier, C.D. Diabetes mellitus: is there a connection with infant-feeding practices? Nutr. Today 36(5): 241-248, 2001. 10. Knip, M., S.M. Virtanen, and H.K. Akerblom. Infant feeding and the risk of type 1 diabetes. Am. J. Clin. Nutr. 91 (suppl): 1506s-1513s, 2010. 11. Cavallo, M.G., D. Fava, L. Monetini, et al. Cell-mediated immune response to B casein in recent-onset insulin-dependent diabetes: implications for disease pathogenesis. Lancet 348: 926-928, 1996. 12. Pozzilli, P. Cow's milk and Type I diabetes: new evidence about casein. Practical Diabetes Int. 15: 4950, 1998. 13. Hill, J.P., R.A. Crawford, and M.J. Boland. Milk and consumer health: a review of the evidence for a relationship between the consumption of beta-casein A1 with heart disease and insulin-dependent diabetes mellitus. Proc. New Zealand Soc. Animal Production 62: 111-114, 2002. 14. Karlsson, M.G.E., J. Garcia, and J. Ludvigsson. Cows milk proteins cause similar Th1- and Th2-like immune response in diabetic and healthy children. Diabetologia 44: 1140-1147, 2001. 15. Harrison, L.C., and M.C. Honeyman. Cows milk and type 1 diabetes. Diabetes 48: 1501-1507, 1999. 16. Norris, J.M., B. Beaty, G. Klingensmith, et al. Lack of association between early exposure to cow's milk -cell immunity. JAMA 276: 609-614, 1996.

17. Fuchtenbusch, M., W. Karges, E. Standl. H.-M. Dosch, and A.G. Ziegler. Antibodies to bovine serum albumin (BSA) in type 1 diabetes and other autoimmune disorders. Exp. Clin. Endocrinol. Diabetes 105: 86-91, 1997. 18. Hammond-McKibben, D., and H.M. Dosch. Cow's milk, bovine serum albumin, and IDDM: can we settle the controversies? Diabetes Care 20(5): 897-901, 1997. 19. Birgisdottir, B.E., J.P. Hill, D.P. Harris, and I. Thorsdottir. Variation in consumption of cow milk proteins and lower incidence of Type 1 diabetes in Iceland vs the other 4 Nordic countries. Diab. Nutr. Metab. 15: 240-245, 2002. 20. Ziegler, A.-G., S. Schmid, D. Huber, M. Hummel, and E. Bonifacio. Early infant feeding and risk of developing type 1 diabetes associated autoantibodies. JAMA 290: 1721-1728, 2003. 21. Persaud, D.R., and A. Barranco-Mendoza. Bovine serum albumin and insulin-dependent diabetes mellitus: is cows milk still a possible toxicological causative agent of diabetes? Food and Chem. Toxicol. 42: 707-714, 2004. 22. Schatz, D.A., and N.K. Maclaren. Cow's milk and insulin-dependent diabetes mellitus. Innocent until proven guilty. JAMA 276: 647-648, 1996. 23. Savilahti, E., and K.M. Saarinen. Early infant feeding and type 1 diabetes. Eur. J. Nutr. 48: 243-249, 2009. 24. Tremblay, A., and J. Gilbert. Milk products, insulin resistance syndrome and type 2 diabetes. J. Am. Coll. Nutr. 28: 91s-102s, 2009. 25. Elwood, P.C., J.E. Pickering, D.I. Givens, et al. The consumption of milk and dairy foods and the incidence of vascular disease and diabetes: an overview of the evidence. Lipids 45: 925-939, 2010. 26. Pittas, A.G., J. Lau, F.B. Hu, and B. Dawson-Hughes. The role of vitamin D and calcium in type 2 diabetes. A systematic review and meta-analysis. J. Clin. Endocrinol. Metabol. 92: 2017-2029, 2007. 27. Tong, X., J.-Y. Dong, Z.-W. Wu, et al. Dairy consumption and risk of type 2 diabetes mellitus: a metaanalysis of cohort studies. Eur. J. Clin. Nutr. 65: 1027-1031, 2011. 28. Margolis, K.L., F. Wei, I.H. de Boer, et al. A diet high in low-fat dairy products lowers diabetes risk in postmenopausal women. J. Nutr. 141: 1969-1974, 2011. 29. Grantham N.M., D.J. Magliano, A. Hodge, et al. The association between dairy food intake and the incidence of diabetes in Australia: The Australian Diabetes, Obesity, and Lifestyle Study (AusDiab). Public Health Nutrition. [E-pub ahead of print] 2012. 30. Fumeron F., A. Lamri, C. Abi Khalil, et al. Dairy consumption and the incidence of hyperglycemia and the metabolic syndrome. Diabetes Care. 34:813-817, 2011. 31. Malik, V.S., Q. Sun, R.M. van Dam, et al. Adolescent dairy product consumption and risk of type 2 diabetes in middle-aged women. Am. J. Clin. Nutr. 94: 854-861, 2011. 32. Gagnon, C., Z.X. Lu, D.J. Magliano, et al. Serum 25-hydroxyvitamin D, calcium intake, and risk of type 2 diabetes after 5 years. Diabetes Care 34: 1133-1138, 2011.

33. Larsson, S.C., and A. Wolk. Magnesium intake and risk of type 2 diabetes: a meta-analysis. J. Intern. Med. 262: 208-214, 2007. 34. Nikooyeh, B., T.R. Neyestani, M. Farvid, et al. Daily consumption of vitamin D- or vitamin D + calciumfortified yogurt drink improved glycemic control in patients with type 2 diabetes: a randomized clinical trial. Am. J. Clin. Nutr. 93: 764-771, 2011. 35. Mozaffarian, D., H. Cao, I.B. King, et al. Trans-palmitoleic acid, metabolic risk factors, and new-onset diabetes in U.S. adults: a cohort study. Ann. Intern. Med. 153: 790-799, 2010. 36. Akhavan, T., B.L. Luhovyy, and P.H. Brown, et al. Effect of premeal consumption of whey protein and its hydrolysate on food intake and postmeal glycemia and insulin responses in young adults. Am. J. Clin. Nutr. 91: 966-975, 2010. 37. Ard, J.D., S.C. Grambow, D. Liu, C.A. Slentz, W.E. Krauss, and L.P. Svetkey. The effect of the PREMIER interventions on insulin sensitivity. Diabetes Care 27: 340-347, 2004. 38. Liese, A.D., M. Nichols, X. Sun, et al. Adherence to the DASH diet is inversely associated with incidence of type 2 diabetes: the Insulin Resistance Atherosclerosis Study. Diabetes Care 32: 1434-1436, 2009. 39. DeKoning, L., S.E. Chiuve, T.T. Fung, et al. Diet-quality scores and the risk of type 2 diabetes in men. Diabetes Care 34: 1150-1156, 2011. 40. Mizoue, T., T. Yamaji, S. Tabata, et al. Dietary patterns and glucose tolerance abnormalities in Japanese men. J. Nutr. 136: 1352-1358, 2006. 41. Liese, A.D., A. Bortsov, A.L.B. Gunther, et al. Association of DASH diet with cardiovascular risk factors in youth with diabetes mellitus. Circulation 123: 1410-1417, 2011. 42. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines th for Americans, 2010. 7 Edition. Washington, D.C.: U.S. Government Printing Office, December 2010.

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About National Dairy Council National Dairy Council (NDC), the non-profit organization funded by the national dairy checkoff program, is committed to nutrition education and research-based communications. NDC provides science-based nutrition information to, and in collaboration with, a variety of stakeholders committed to fostering a healthier nation, including health professionals, educators, school nutrition directors, academia, industry, consumers and media. Established in 1915, NDC comprises a staff of registered dietitians and nutrition research and communications experts across the country. NDC has taken a leadership role in promoting child health and wellness through programs such as Fuel Up to Play 60. Developed by NDC and the National Football League (NFL), Fuel Up to Play 60 encourages youth to consume nutrient-rich foods and achieve at least 60 minutes of physical activity every day. For more information, visit www.NationalDairyCouncil.org.
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