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Soya-Based Diets for

Diabetes Mellitus
Stephen Holt, M.D.,
Igor Muntyan, M.D., and
Larisa Likyer, M.D.
t is agreed by medical practitioners that diabetes mellitus has its cause and treatment deeply rooted in dietary factors. Two
types of diabetes exist but some overlap between types occurs. Type I diabetes mellitus is the insulin-dependent type of
diabetes that often presents in childhood or early adult life. In Type I diabetes mellitus the requirement for insulin is
generally absolute and the afflicted may tend toward metabolic problems, such as ketoacidosis. Type II diabetes is sometimes
called late-onset diabetes and it involves some resistance to the actions of insulin but Insulin secretion from the pancreas may be
diminished. Approximately three-quarters of all patients with Type II diabetes are obese and major forms of obesity are
associated per se with resistance to insulin. The American Diabetes Association has produced guidelines for the diagnosis of
diabetes mellitus that are summarized in Table 1.
Dietary Fibers and Diabetes
The history of the recognition of diabetes mellitus and the modes of applied therapy are very interesting. Diabetes mellitus
can be regarded as the oldest dietary deficiency disease known to humanity. For one hundred years physicians have suspected
that diabetes mellitus may be caused by refined diets. Several types of gel fiber or so-called "soluble" fiber, such as that contained
within soyabeans, apples, and legumes, exert a beneficial effect on controlling blood glucose in diabetic patients.
1-5
The gel-forming carbohydrates guar gum (derived from the Indian calabar bean), pectin (derived from apples), and soluble
fiber from soyabeans are types of dietary fiber that resist digestion and absorption by the human alimentary tract. When added to
glucose test meals, they reduce postprandial blood glucose levels in healthy volunteers and in diabetic patients.
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The fibers of
guar gum or soyafiber reduce insulin requirements in diabetics.
3~5,7
It has also been suggested that pectin (a gel fiber derived
from apples) can reduce-symptoms caused by "dumping" in patients after gastric surgery.
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Dumping is a process of rapid
emptying of the stomach that can contribute to hypoglycemia following meals. Two mechanisms have been suggested to account
for these effects. The addition of gel fiber, such as guar or pectin, to a glucose test meal may delay gastric emptying and so slow
the rate of absorption of glucose.
8
Alternatively, or in addition, it has been postulated that these nonabsorbable carbohydrates
may interfere with the process of absorption of sugars from the small intestine.
In a study performed by Holt et al. in 1979, the effects of the soluble fibers, guar, and pectin on the absorption of ingested
glucose and a model drug was studied in healthy subjects. Although there had been considerable interest in the potential
therapeutic role of soluble fiber in disease management in the 1970s, few studies had attempted to explain their effect on
absorptive processes. The study by Holt et al.
8
confirmed the results obtained by J enkins et al.,
6
which demonstrated that gel
fibers reduced postprandial blood glucose in healthy volunteers. After simultaneous pectin and glucose ingestion in this study,
8
a
reduction in blood glucose was noted throughout the first hour of a glucose tolerance test. The flattening of the glucose tolerance
test after propantheline (a drug that slows stomach emptying) indicated that the effect of pharmacologic inhibition of
gastrointestinal motility in the test resembled that achieved with the gel fiber, pectin, but was more pronounced. These findings,
together with the failure of gel fiber to alter glucose tolerance in a gastrectomized patient, suggested that the effects of gel fiber
on glucose absorption in normal subjects could be due simply to delayed gastric emptying.
The delay in gastric emptying produced by gel fibers, such as soya-derived fibers, guar, and pectin, is
presumably related to their physical form after hydration. Soluble fiber forms a viscous, colloidal suspension when
hydrated with the viscosity of the dispersion beginning to develop after ten to fifteen minutes. J enkins et al. ('1977)
have suggested that viscosity is an important property of dietary fiber and is related to its ability to reduce postprandial
hyperglycemia. The viscous nature of soluble fiber suspensions is probably responsible for the effects of these gels on gastric
I
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ALTERNATIVE & COMPLEMENTARY THERAPIES~MARCH/APRIL 1996
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After simultaneous pectin and glucose ingestion in this study, a reduction in blood glucose was noted throughout the first
hour of a glucose tolerance test.
emptying that have been observed, because the addition of
soluble fibers to liquids causes no substantial changes in the
osmotic pressures or pH of the ingested fluids.
3
Following these
early observations by Holt et al., several studies have confirmed
that the effect of the gel fiber on absorptive processes is related to
modulation of upper gastrointestinal motility.
Protein Content of Soya and Diabetes
Although some authors have ascribed the beneficial effects of
soya products in diabetes mellitus to the dietary fiber content of
soyabeans,
1
other more important and beneficial constituents
exist in soyabean products with ameliorating or posssible
preventive effects for diabetes. One important component of
soyabeans that has a very useful effect in the dietary management
of diabetes is the protein quality and amino-acid content of soya
protein isolates. Soya protein contains large amounts of glycine
and arginine which will tend to reduce blood insulin levels. Low
blood insulin levels decrease the hepatic synthesis of cholesterol.
9
In contrast, animal proteins are low in glycine and arginine but
tend to contain more lysine than vegetable proteins. Lysine will
tend to raise insulin levels and it promotes cholesterol synthesis.
This occurrence is confirmed by the recognition that the greater
the lysine content of certain foods, the greater the likelihood that
blood cholesterol will increase.
10
It is well recognized that hypercholesterolemia and abnormal
blood holds make a major contribution to complication of
diabetes mellitus, and atherosclerosis is a major cause of
morbidity and mortality among diabetics. Furthermore, diabetics
have a much higher prevalence of coronary artery disease than
nondiabetic individuals and the potential cardiovascular
protective effects of soya protein dietary supplements may be
relevant to the patient with diabetes mellitus.
11
Diet Therapy in Diabetes
It is generally regarded that the key to the treatment of diabetes mellitus involves long-term precise control of blood glucose
levels. Overall, good control of blood glucose is believed to reduce long-term complications of diabetes mellitus such as
peripheral neuropathy, diabetic retinopathy, and diabetic nephropathy. As well as protecting the long-term health of the patient
with diabetes mellitus, it is important to attempt to reduce the impact of the disease on the lifestyle of the patient. Diet is the most
important aspect of diabetes treatment but for a variety of reasons, it is the area of therapy and health maintenance apt to receive
the least attention in clinical practice.
Dietary therapy for diabetes mellitus differs depending on the type of diabetes (Type I or Type II) and other factors such as
body habitus and other metabolic needs of the patient. There are, therefore, many circumstances which require a "tailor-made"
diet for an individual diabetic. In Type II or adult onset diabetes, the obesity is treated with special attention to calorie restrictions
in the diet, obese diabetics tend to be hypertensive and often have hypercholesterolemia. The use of soya-based diets in maturity
onset diabetes is a good option for such patients, because they can assist with reversing the devastating triad of obesity,
tiypercholesterolemia,
11
and hypertension
12
that occur in the diabetic patient. Soya diets are generally lower in tat and soya
proteins exert specific cholesterol-lowering effects which are highly desirable in the diabetic with a significant risk of
atherosclorosis. Products that contain soya fiber may be useful because they appear to have an insulin-sparing effect and they
may promote Satiety by providing a bulky diet with a relatively low caloric value. The promotion of satiety is particularly useful
in weight loss programs.
In Type I diabetes, or juvenile onset, insulin-requiring diabetes, dietary therapy is much more slanted toward a good balance
of nutrients, especially carbohydrates that are metabolized with the assistance of administered insulin. In this context, food is
given following insulin, so, in the diabetic food does not regulate insulin secretion but follows its artificial administration.
Table 1. Diagnosis of
Diabetes in Adults
In nonpregnant adults, any one of the
following can indicate diabetes:
Unequivocal elevation of plasma glucose (>
200 mg/dl) and classic symptoms of diabetes,
including polyphagia and weight loss
Fasting plasma glucose 140 mg/dl or
greater on two occasions
Fasting plasma glucose less than 40
mg/dl, and two oral glucose tolerance
tests, with the 2-hour plasma glucose of 200
mg/dl or greater, and one intervening value of
200 mg/dl or greater after 75 gm of glucose
Impaired glucose tolerance
Fasting plasma glucose less than 140
mg/dl, and an oral glucose tolerance test with
the 2-hour plasma glucose less than 200 but at
least 140 mg/dl. and one intervening value of
200 mg/dl or greater after 75 gm of glucose
Gestational diabetes mellitus
Two or more of the following
(OSullivan criteria) plasma glucose
concentrations met or exceeded
with a 100-gm glucose load; fasting
plasma glucose of: 105 mg/dl; 1-hour, 190
mg/dl; 2-hour, 165 mg/dl; 3-hour, 145 rng/dl.
ALTERNATIVE & COMPLEMENTARY THERAPIES~MARCH/APRIL 1996
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Soya diets are generally lower in fat and soya proteins exert specific cholesterol-lowering effects which are highly
desirable in the diabetic with a significant risk of atherosclerosis.
dietary fiber, and particularly soya fiber, may regulate insulin needs by delivering food more slowly and regularly to the
intestines. This insulin-sparing effect of gel fiber has received very little attention in conventional medicine. The use of dietary
fiber supplements to "smooth out" blood glucose levels, especially following meals, deserves much further study and application.
Other benefits of soya in diabetes mellitus
Soya protein isolates may be valuable in the Type II diabetic because of their cholesterol-lowering effects and other potential
benefits. The ability of gel fiber to "smooth out" blood glucose levels following meals may be very useful in individuals who are
subject to reactive hypoglycemia after meals.
One of the most devastating and common complications of diabetes mellitus is the development of diabetic retinopathy,
especially proliferative retinopathy where new blood vessel growth occurs in the eye. Although the role of soya protein isolates
containing isoflavones has not been studied in detail, the antiangiogenic effects of isoflavones
12
could be of value in this disorder
and are worthy of scientific study. The other ocular condition for which antiangiogenic compounds have a potential application is
the common disorder of neovascular glaucoma, which is a frequent cause of loss of visual acuity encountered in both diabetic and
nondiabetic individuals,
Renal disease in diabetes mellitus is common and soya protein could have a role in improving impaired renal function.
D'amico et al. reported very beneficial effects of soya diets on hvperlipidemia in patients with renal impairment caused by
nephrotic syndrome. Kontessis et al.
14
performed a clinical investigation that snowed that the human kidney can handle soya
protein more efficiently than it handles animal protein. The suggestion by thisgroup of researchers was that it may be possible to
switch the source of protein in diet from animal to soya-based protein in patients with kidney failure.
14
A number of other ancillary health benefits may accrue from the use of soya based diets in patients with diabetes mellitus or
carbohydrate intolerance. The ability of gel fiber to "smooth out" blood glucose levels following meals may be very useful in
individuals who are subject to reactive hypoglycemia after meals. Hypertension occurs commonly in the diabetic individual and
soya based diets may have an antihypertensive effect.
1
Soya may lower blood pressure because it contains natural inhibitory
peptides,
15
'
16
but the antihypertensive effect is complex.
1
Finally, soya diets are associated with health benefits for patients with
gallstones.
17,18
The mechanism of beneficial effect of soya for cholesterol containing gallstones is not well understood but is in
part related to the blood cholesterol lowering effects of soya protein containing isoflavones.
Alleged reasons for the use of soyabased diets in diabetes mellitus are reflected in Table 2. Soya-based diets in diabetes
mellitus have several potential advantages. Much further work is required to define a precise role for soya in the management of
diabetes mellitus.
Table 2. Alleged Reasons for the Use of
Soya-Based Diets in Diabetis Mellitus
Diabetes Disorder Soya component Effect Reference
Obesity Soya diets Low caloric content Ref. I
Hyperglycemia Soya fiber Gel fiber reduces Ref. 8 & 4
postprandial biood
giucose
Hypoglycemia Soya fiber Gel fiber smooths Ref. 4
giucose tolerance curves
Gallstones Soya protein, lecithin Prevention of formation Ref. 17 & 18
of gallstones
Hypercholesterolemia Soya protein isolates Reduction of blood Ref. II
containing isofiavones cholesterol
Diabetic Nephropathy Soya protein isolates Improvement of efficacy Ref. 13
containing isoflavones of glomerular filtration
Diabetic Retinopathy Soya~soflavones Antiangiogenic effect Ref. 12
ALTERNATIVE & COMPLEMENTARY THERAPIES~MARCH/APRIL 1996
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