Danielle Fanelle

N00906232

HUN 3800

Literature Review Paper

October 25, 2016

The Effects of A High

Fiber Diet on Type 2

Diabetes .
Introduction

It is estimated that there are approximately 29.1 million people suffering from type 2

diabetes in America alone and it is currently the 7th leading cause of death1. Some of the most

common complications include: hypertension, cardiovascular disease, stroke, insulin resistance

and hyperglycemia, with the latter two being the hallmarks of the disease. Although physical

activity and a healthy balanced diet are also suggested to improve the effects of the disease, most

patients will be required to take some medications such as metformin, sulfonylureas or

thiazolidinediones, depending on their stage of diabetes2. The role of a high fiber diet is

primarily to effect blood glucose, with its potential positive effect on insulin resistance being

secondary, along with weight loss, blood lipids and heart disease. Foods with high fiber content

are known to also have a low glycemic index3. Foods such as vegetables, whole grains and

certain low glycemic fruits are some of the most common and easily accessible high fiber foods.

Fiber can also indirectly effect some of the complications caused from type 2 diabetes by

delaying gastric emptying and preventing the absorption of some macronutrients in the intestinal

lumen. One should be aware of the fact that some of the research has been inconsistent in

indicating that the type, source or amount of fiber could have an effect on the potential benefits.

Fibers various effects on glucoregulation

Prediabetes (mild hyperglycemia)

Prediabetes is defined as a state in which a person has blood glucose levels that are higher

than the normal but are not yet considered within diabetic range, which is defined as an A1C

level of 6.5% or greater1. There have been several studies conducted that suggest when a person

is at risk for type 2 diabetes, it can be delayed and/or prevented by an adjustment in the patients

diet along with weight loss. In a 12-month study, conducted by Dodevska et al., 47 obese

prediabetic patients ranging from the ages of 45-74 were divided into two groups; one group was

placed on a high fiber, low fat diet and the other a high resistant starch, low fat diet. The subjects

whom were placed on the diet high in resistant starch showed an overall decrease in cholesterol.

However, it was the group who consumed a high fiber diet that showed the most significant

improvement in postprandial blood glucose, with a 12% decrease in the oral glucose challenge

and a 7% decrease in serum insulin. It is important to note though, that it did not have a

significant effect on fasting blood glucose. The results of this study demonstrated that over a 12-

month period, consuming a diet high in fiber can improve glucoregulation in prediabetics and it

also showed a 58% prevention in the onset of diabetes. Patients in the above mentioned diet had

a much higher improvement percentage than patients on on medications such as metformin,

which only showed only a 34% improvement4. It has also been suggested that the specific type

of fiber could have an effect on glucoregulation. Gibb et al. at Duke University conducted a

meta-analysis on the effects of psyllium fiber in prediabetic patients with type 2 diabetic
patients. Psyllium is a viscous, soluble, non-fermented fiber supplement that showed to cause a

moderate improvement in the subjects that were prediabetic. In a similar study, conducted by

Kobayakawa and his associates in Osaka, Japan they tested the effects of a moderate amount of

dietary fiber in mildly hyperglycemic (prediabetic) men. In this study, the test group consumed

7.5 g/day of fiber while the placebo group consumed no fiber in their diet. The results from this

12 week study showed an average decrease in blood glucose from 6.43 mmol/L to 5.96 mmol/L,

in those consuming the fiber, whereas the placebo group showed no significant change in blood

glucose6. These results indicate that fiber can have a beneficial effect on glucoregulation

whether the source of fiber is dietary or in isolated supplement form. Even in smaller quantities

positive results can be observed, albeit the results are not the same, some degree of improvement

can be seen with the different variations. The results from these studies show to be very

promising for preventing the full onset of type 2 diabetes.

Diabetes (hyperglycemia)

Fiber has not only proven to be beneficial in improving and possibly preventing

hyperglycemia in prediabetic patients, but has also demonstrated similar effects in type 2

diabetes. With hyperglycemia being the hallmark of diabetes, and often the most damaging

symptom, it is helpful that fiber is able to lend its effects to the improvement of it. Fiber can

delay digestion and absorption of nutrients ultimately leaving the patient feeling more satiated,
leading to an improvement in postprandial glycemic levels7. In a Japanese analysis, 4,399 type 2

diabetes patients were asked to fill out a questionnaire that determined diet history of 58 food

and beverages items and the averages of total energy, and some specific nutrients, including

fiber, were determined using an algorithm. The study successfully demonstrated that an

increased fiber intake could improve glycemic control. This study shows to be very important

because it indicates that a diet with increased fiber intake could be beneficial in Asian countries

where diabetes is becoming an increasingly larger problem. One very interesting aspect to note

about this study in particular is the ratio of fiber that is consumed from vegetables is much higher

than that obtained from cereal grains of fruit which suggests that it may not be cereal grains

alone that have a large impact on lowering blood glucose7. This proves to be thought provoking,

because some studies have suggested that the ratio of starch to total fiber can have an effect on

blood glucose. In many Asian cultures white rice is highly consumed so that would decrease the

potential benefits of the fiber. When a diet is high in glycemic load and glycemic index (such as

in white rice) and low in fiber, it can decrease adiponectin concentrations by increasing blood

glucose. The type of fiber can also effect different variants of hyperglycemia, such as cereal

fiber, which is negatively associated with CRP and positively associated with adiponectin, and

fruit and vegetable fibers which are inversely associated with HbA1c concentrations8. This

proves to be very useful because if a diabetes patient with consistent hyperglycemia consumes a
diet that has a balance of different forms of fiber, then the healthful benefits of fiber would be

able to target multiple factors that lead to hyperglycemia.

Fibers effects on insulin resistance

In prediabetics

Arguably the second largest hallmark to type 2 diabetes is insulin resistance. This is

when muscle, fat and liver cells can no longer respond to insulin properly which results in

glucose not being absorbed from the blood. The beta cells of the pancreas can respond for a short

time by increasing their insulin production but after a while it can no longer produce enough

insulin for body to properly metabolize glucose. This eventually will lead to prediabetes and

possibly diabetes if proper preventative measures are not put into place. Prediabetics are

commonly already insulin resistant8, so the incorporation of fiber into their diets is very

important. As opposed to fibers immediate direct effect in hyperglycemia, its effects on insulin

resistance is more indirect9. There is certainly an opportunity for more studies to be conducted

on fibers correlation to insulin resistance in prediabetes.

In Type 2 Diabetics

There is a larger quantity of evidence available that demonstrates fibers effects on

insulin resistance in type 2 diabetes than there is on prediabetes. A study by Nowotny has
suggested that a diet high in cereal fiber is able in increase insulin sensitivity partly by

enhanceing non-oxidative glucose metabolism, ie. glycogen synthesis in skeletal muscle. The

study also suggests that it is the combination of both weight loss and the increased fiber intake

that leads to an improvement in insulin sensitivity. It is very important to remember that an

increased fiber diet does not effect insulin secretion but insulin sensitivity. This is very important

because it suggests that an increase in dietary fiber does not necessarily lead to an increase in the

synthesis of insulin often because the pancreatic beta cells are impaired meaning that they will

still produce insulin but only at a decreased level10. This is somewhat supplemented by the fact

that it is whole-body insulin sensitivity that is improved and not just reduced hepatic insulin

clearance after an increased fiber intake11. This means that even though there is an impaired

function of the pancreatic beta cells and fiber will not increase their production, fiber is capable

of improving insulin sensitivity throughout the whole body and not just in the liver alone. The

study by Weickert et al was not able to distinguish what the specific mechanism was that

improved insulin sensitivity but it did identify that in a study lasting 72 hours, consisting of

patients placed on a high fiber diet consisting of 31.2 g of insoluble fiber and a control group

was able to demonstrate a whole body improvement in insulin sensitivity. As stated above there

is some discrepancy over what type of fiber is needed for the insulin sensitivity benefits to be

possible, or if it is a combination of both soluble and insoluble that produces beneficiary effects.

In a study by Chunya et al. it was demonstrated when patients were placed on a diet of either 10

g/day or 20 g/day of soluble fiber a greater increase in insulin sensitivity was shown compared to
the 10 g/day and control group. The results of all these studies can be combined to determine

that a diet that consisted of a balanced portion of both soluble and insoluble fiber will improve

insulin sensitivity.

Fibers effects on other diabetes biomarkers

Weight Loss

There are many other biomarkers associated with diabetes that can be contributing factors in the

progression of insulin resistance as well as hyperglycemia. Weight loss is generally one of the

most prescribed remedies to improve the effects of diabetes and fiber has been shown to help

with weight loss1. What proves to be helpful about a high fiber diets is that because it often

results in weight loss, other effects such as glucoregulation and insulin sensitivity are improved

in conjunction with diet. In a study by Lindstrom et. al, 522 obese men and women adults with

type 2 diabetes were divided into 2 groups and one was placed on an diet that consisted of a low

energy density, low dietary fat and high fiber in conjunction with daily exercise with the other

group being place on a high fat, high energy, low fiber diet. The low fat, low energy, high fiber

diet showed the greatest reduction in both weight loss as well as waist circumference

independent of weight loss. Though the study could not isolate t the mechanism that resulted in

weight loss, it was evident that fiber had been a contributing factor. It should be noted though

that obestity increases insulin resistance, the opposite relationship is possible as well and fiber

can be a trigger for it12.

Blood Lipid Profile

Another major biomarker of diabetes is dyslipidemia. Nutrition, particularly fiber, has shown to

have a major impact on improving the blood lipid profile. As is common with most high fiber

diets, the energy intake tends to decrease. Energy intake is inversely associated with HDL-

cholesterol and directly associated with plasma triglycerides. Patients in a study conducted by

Vitale were placed on a diets that consisted of either <10 g/day ,10-14 g/day or >14 g/day. The

patients placed on the >14 diet had the highest HDL-cholesterol of 46.9 mg/dl 3.7 as opposed

to the lowest intake of fiber which produced an HDL-cholesterol level of 44.9 mg/dl 3.8. The

high fiber diet produced a lower triglyceride content of 149.3 mg/dl 14.5 whereas the low fiber

content produced a higher triglyceride level of 155.0 mg/dl 15.9. The findings of this study

prove to be extremely important in the knowledge of how to prevent the progression of

cardiovascular disease caused by diabetes, which is one of the most severe long-term effects13.

Conclusion

Based on the results presented in the above studies, there is sufficient evidence to

conclude that a diet consisting of a moderate to high amount of fiber can improve the symptoms

of type 2 diabetes. Though researchers have had a difficult time pinpointing what specific

mechanism produces some of the results, it is clear that it does have beneficial effects. Arguably
one of the most beneficial effects is the positive results that it has shown in prediabetes. It is well

known that diabetes is irreversible but the inclusion of fiber in a prediabetes was shown to

improve glucoregulation by improving postprandial glucose levels. What showed to be even

more intriguing was that in a study that used a supplemental form of fiber, the blood glucose

levels were still shown to improve. This is very significant because even though diet changes are

necessary across the board with prediabetic patients, they have the option of consuming fiber in

a non-food form. This could also be important because if a prediabetic cannot consume enough

fiber because of dietary restrictions, cost or other reasons , they can still incorporate it into their

diet in the form of supplemental psyllium. Prediabetics also showed improvement in controlling

the onset of insulin resistance with a high fiber diet. This information combined is extremely

relevant to prediabetics whom are at risk for developing type 2 diabetes because the implication

of more dietary fiber combined with weight loss and medication could likely reverse the

symptoms and prevent the onset of type 2 diabetes. It cannot be dismissed though the

significance of the incorporation of fiber into a type 2 diabetics diet in an effort to control some

of the effects of diabetes in its later stages. A high fiber diet was shown to improve long term

glucose levels in diabetics by increasing satiety, delaying gastric emptying and reduction of

glycemic load and index. A diet high in fiber is inversely associated with total energy

consumption and this has shown to improve other aspects associated with type 2 diabetes like

dyslipidemia. The inverse relationship between caloric intake and fiber has also shown to help
with weight loss, which has shown to be one of the most beneficial treatments to diabetes.

Overall, the incorporation of a high fiber diet has shown to improve the effects of diabetes and if

implemented over a long period of time it could likely assist in the prevention of many

complications that arise from diabetes such as neuropathy, heart disease and kidney disease.

There is certainly an opportunity for more research to be done on what types of fiber show the

best results and in what quantities, as studies vary in both findings. There is also an opportunity

to study the length of time that the patient should consume a high fiber diet in order for it to have

long term effects or if the patients would need to be on a high fiber diet lifelong in order to

control the symptoms.

Applications

There are many ways in which fiber can be applied to the nutrition field. Some of the

foods that are considered high fiber include: raspberries, pears, apples, oat bran, whole wheat

spaghetti, legumes, artichokes and green peas. This information will become valuable when we

are dealing with client that has a known family history or are at risk for diabetes. We can use

this information in developing meal plans in order to help prevent type 2 diabetes in these

patients. This information can also be applied when developing meal plans for type 2 diabetes

patients because fiber would still be able to lend its benefits even if the patients symptoms were

well controlled.
 References

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