nutrients

Review
Nutritional Strategies for the Management of Type 2 Diabetes
Mellitus: A Narrative Review
Tatiana Palotta Minari 1, * , Lúcia Helena Bonalume Tácito 2 , Louise Buonalumi Tácito Yugar 3 ,
Sílvia Elaine Ferreira-Melo 4 , Carolina Freitas Manzano 1 , Antônio Carlos Pires 2 , Heitor Moreno 4 ,
José Fernando Vilela-Martin 1 , Luciana Neves Cosenso-Martin 2 and Juan Carlos Yugar-Toledo 1

1 Department of Hypertension, State Faculty of Medicine of São José do Rio Preto (FAMERP),
São José do Rio Preto 15090-000, SP, Brazil
2 Department of Endocrinology, State Faculty of Medicine of São José do Rio Preto (FAMERP),
São José do Rio Preto 15090-000, SP, Brazil
3 School of Medical Sciences, State University of Campinas (UNICAMP), Campinas 13083-887, SP, Brazil
4 Cardiovascular Pharmacology & Hypertension Laboratory, School of Medical Sciences,
State University of Campinas (UNICAMP), Campinas 13083-887, SP, Brazil
* Correspondence: [email protected]

Abstract: Background: Thinking about greater adherence to dietary planning, it is extremely impor-
tant to be aware of all nutritional strategies and dietary prescriptions available in the literature, and
of which of them is the most efficient for the management of T2DM. Methods: A search was carried
out in 2023 for randomized clinical trials, systematic reviews, meta-analyses, and guidelines in the fol-
lowing databases: Pubmed, Scielo, Web of Science, CrossRef and Google Scholar. In total, 202 articles
were collected and analyzed. The period of publications was 1983–2023. Results: There is still no
consensus on what the best nutritional strategy or ideal dietary prescription is, and individuality is
necessary. In any case, these references suggest that Mediterranean Diet may of greater interest for the
management of T2DM, with the following recommended dietary prescription: 40–50% carbohydrates;
15–25% proteins; 25–35% fats (<7% saturated, 10% polyunsaturated, and 10% monounsaturated); at
Citation: Minari, T.P.; Tácito, L.H.B.; least 14 g of fiber for every 1000 kcal consumed; and <2300 mg sodium. Conclusions: Individuality
Yugar, L.B.T.; Ferreira-Melo, S.E.; is the gold standard for dietary prescriptions, however, the Mediterranean diet with low levels of
Manzano, C.F.; Pires, A.C.; carbohydrates and fats seems to be the most promising strategy for the management of T2DM.
Moreno, H.; Vilela-Martin, J.F.;
Cosenso-Martin, L.N.; Keywords: nutritional interventions; nutritional therapy; type 2 diabetes mellitus; nutritional strategies;
Yugar-Toledo, J.C. Nutritional
dietary prescription
Strategies for the Management of
Type 2 Diabetes Mellitus: A Narrative
Review. Nutrients 2023, 15, 5096.
https://doi.org/10.3390/nu15245096
1. Introduction
Academic Editor: Iskandar Idris
Type 2 diabetes mellitus (T2DM) is a highly prevalent chronic disease worldwide, and
Received: 20 November 2023 represents one of the biggest public health problems of the 21st century. Its high incidence
Revised: 1 December 2023 and prevalence are attributed to population aging and lifestyle, which is characterized by
Accepted: 5 December 2023 physical inactivity and eating habits that predispose individuals to obesity and metabolic
Published: 13 December 2023 syndrome [1].
At the same time, this epidemiological scenario is worsening with the increase in
obesity rates [2]. According to the literature, obesity can predispose individuals to the
development of chronic noncommunicable diseases such as T2DM, hypertension and car-
Copyright: © 2023 by the authors.
diovascular diseases that probably reflect changes in lifestyle characterized by an increase
Licensee MDPI, Basel, Switzerland.
in energy intake and a reduction in physical exercise [2–4].
This article is an open access article
For patients with T2DM and who are overweight, progressive weight loss is rec-
distributed under the terms and
conditions of the Creative Commons
ommended to improve quality of life and treatment. This recommendation is based on
Attribution (CC BY) license (https://
short-term studies that point to the several benefits of the weight loss process, including im-
creativecommons.org/licenses/by/
provements in glycemic modulation, cardiorespiratory markers, and quality of life [3,5–7].
4.0/).

Nutrients 2023, 15, 5096. https://doi.org/10.3390/nu15245096 https://www.mdpi.com/journal/nutrients

Nutrients 2023, 15, 5096 2 of 27

However, the big question is “what is the patient’s motivation to form new healthy habits
and control the disease in the long term?” [8].
Thinking about greater adherence to dietary planning, it is important for the nutri-
tionist to be aware of all dietary prescriptions and nutritional strategies available in the
literature. Another step would be a critical analysis of them, thus verifying which would
be the most efficient in the management of T2DM.

2. Methods
A search was carried out in 2023 for randomized clinical trials, systematic reviews,
meta-analyses, and guidelines in the following databases: Pubmed, Scielo, Web of Science,
CrossRef, and Google Scholar. In total, 202 articles were collected and analyzed. The
period of publications was 1983–2023. The MeSH indexed terms searched were nutri-
tional interventions, nutritional therapy, type 2 diabetes mellitus, nutritional strategies and
dietary prescription.

3. Results
3.1. The Importance of Individuality in Nutritional Management of T2DM
The treatment of patients with T2DM can be controlled through structured lifestyle
programs, which include dietary education, intensive interdisciplinary therapy and physi-
cal exercise [6,9–12]. The individuality of the treatment and the synergy of interdisciplinary
team (nutritionist, endocrinologist, cardiologist, physical educator, and psychologist) are
fundamental to increase the patient’s quality of life. Another relevant factor is maintaining
empathy and trust between professionals and patients, including the person with T2DM,
who is the protagonist of the intervention [9,11–16].
The strongest evidence for T2DM prevention includes intensive lifestyle interven-
tion resulting in weight loss, reduced incidence of T2DM in overweight adults, and de-
creased glucose tolerance over three years [17]. Other studies with lifestyle interventions
have shown a reduction of 43% in T2DM progression over 20 years [18,19], of 34% over
10 years [17], and of 27% over 15 years [20], and have demonstrated a reduction in all-cause
cardiovascular mortality [21].
Over the years, nutritional interventions have gained increasing prominence in the
prevention, treatment, and maintenance of the disease. Strong evidence supports the
high effectiveness and cost-effectiveness of nutritional therapy for the treatment of T2DM.
Therefore, it is extremely important that all members of the healthcare team know the
benefits of improving the quality of life of T2DM patients in the long term [6,22–26].
Nutritional management must consider life cycles, nutritional diagnosis, eating habits,
individual characteristics, sociocultural issues, the patient’s economic situation, metabolic
profile, use of drugs, physical exercise, and other factors. The dietary prescription, nutri-
tional strategy, and eating plan must be individualized, taking into account the following
objectives: to improve glycemic markers, to increase weight loss, and to reduce cardiovas-
cular risk [9,27–31].
A generic healthy living plan is not enough to prevent and control T2DM, being unre-
alistic and incompatible with the peculiarities of each patient’s clinical case. This review
provides clarity about the many dietary choices and patterns that can help people achieve
health and a better quality of life [9,27–31]. Individualized nutritional management with
a multidisciplinary approach can help reduce glycated hemoglobin (HbA1C), presenting
similar or even greater results than would be expected with pharmacological treatment for
T2DM. According to evidence, reductions in HbA1C could reach up to 2.0% in patients
with T2DM in 3–6 months [32,33]. The cost–effect relationship of various lifestyle inter-
ventions for diabetes prevention and control have also been documented in several other
studies [32–36].
Nutrients 2023, 15, 5096 3 of 27

3.2. Dietary Prescription and Macronutrient Distribution

Evidence suggests that there is no nutritional strategy or ideal percentage of calories
from carbohydrates, proteins, and fats for all people with T2DM. Therefore, the type of strat-
egy and distribution of macronutrients should be based on an individualized assessment
of current eating patterns, preferences, and metabolic goals. The strategy should include an
individualized dietary prescription on carbohydrate intake and glycemic self-monitoring to
improve the patient’s meal timing, portioning, and food choices. Health professionals must
advise the correct use of medications and regular physical exercise. Moreover, patients
with T2DM should also be encouraged to consume fiber, vegetables, legumes (beans, peas,
and lentils), fruits, and whole grains for the reduction of HbA1C [9,27,28,36–38].

3.2.1. Carbohydrates
Carbohydrate is a source of energy used by the body, and is responsible for the
postprandial increase in blood glucose [36–39]. Foods that contain carbohydrates (sug-
ars, starches, or fiber) have a wide range of effects on the individual glycemic response.
Some types of carbohydrate prolong the increase and slow the decrease in blood glucose
concentrations, while others cause a rapid rise followed by a rapid fall [40].
Food sources of carbohydrates, especially those made up predominantly of dietary
fiber, vitamins, and minerals (those low in added sugars, fats, and sodium) should be
highlighted in individualized eating plans [32,36–38,41]. The amount of carbohydrates
needed for optimal health in patients with T2DM is still uncertain, and studies vary greatly
in the types of approaches and percentages of prescriptions. However, the literature
indicates that dietary intake of carbohydrates in T2DM should be around 130 g/day or
40–50% of carbohydrates within the total energy value (TEV), aiming mainly to meet brain
glucose requirements. The body’s other metabolic processes could be supplied by other
energy substrates, such as fatty acids, amino acids (glycogenolysis and gluconeogenesis),
and ketone bodies (ketogenesis) [39–42].
-Glycemic Index and Glycemic Load
The use of glycemic index (GI) and glycemic load (GL) to classify foods rich in car-
bohydrates according to their effects on glycemia still remains of interest to the scientific
community, especially in the management of T2DM. According to studies, GI and GL
could provide a prediction of postprandial blood glucose, the glycemic response curve,
and may also classify carbohydrate-rich foods according to their postprandial glycemic
response [43].
However, two systematic reviews with GI reported no significant impact on HbA1C,
and had mixed results on fasting glucose [32,40]. Furthermore, studies use various defini-
tions to classify low- and high-GI foods, leading to uncertainty regarding their usefulness in
clinical care, and this would be a too simplistic metric for consideration in the management
of T2DM. The authors discuss that several factors can have an impact, such as the following:
(1) Individual glycemic response; (2) The preparation method and cooking time of foods
that are sources of carbohydrates; (3) The addition of other food types to the meal, such
as vegetables, legumes, proteins, and poly and monounsaturated fats; (4) The addition of
drinks to the meal; (5) The order of food intake; (6) The gut microbiota [44–48].
A recent study showed that the order of food intake during a meal affects postprandial
glucose and insulin peaks in pre-diabetes. The researchers suggest that eating vegetables
and protein-rich foods at the beginning of meals and subsequently eating carbohydrate-rich
foods may present an innovative and economically accessible behavioral strategy to reduce
postprandial glycemic and insulinemic peaks in pre-diabetes, or to prevent T2DM [46].
Another study monitored glucose levels in 800 participants, and their glycemic re-
sponses were measured in 46.898 meals. A high individual variability was found in the
different responses to the identical meals offered. Some participants had greater postpran-
dial blood sugar spikes after eating cookies, and others did not have such good responses.
Other participants did not show an increase in postprandial blood glucose after eating
bananas, and others showed an increase. These findings suggest that universal dietary
Nutrients 2023, 15, 5096 4 of 27

recommendations may have limited usefulness, because there are several factors that can
alter these glycemic responses, such as genetics, sex, age, diet, mental health, and even
composition of the gut microbiota [45]. Therefore, individuality must be taken into consider-
ation when creating a dietary prescription, especially for T2DM patients who continuously
monitor their blood glucose levels [45,46].
According to guidelines, glycemic load has more relevance in treatment of T2DM, as
it takes into account the amount of carbohydrates presents within a 100 g portion [9,49].
Counting carbohydrates in the distribution of the patient’s meals is essential when putting
together dietary planning. The ‘Carbohydrate Counting Manual’ is a great guide formu-
lated by the Brazilian Diabetes Society that provides a resource for patients with T1DM
or T2DM to educate themselves and understand the disease [49]. Therefore, carbohydrate
counting, that is, knowing the amount of carbohydrates present in a 100 g portion (glycemic
load), seems to be more important for dietary management than analyzing the GI alone. In
this way, foods that are sources of carbohydrates (fruits, tubers, cereals, and whole grains)
can be included in the dietary plan, as long as they are within the daily carbohydrate
quantification and are combined with other foods [9,47,49].

3.2.2. Proteins
The references show a wide disparity in the percentage of protein prescription in
the management of T2DM. Some comparisons of protein amounts did not demonstrate
differences in results related to T2DM. Prescriptions ranged from 15 to 20% of TEV, but
more studies are needed [50–54]. It is worth remembering that in individuals with T1DM
and T2DM, the intake of some foods that are sources of protein, such as dairy products, can
also increase the postprandial insulin response. Therefore, the use of high-carbohydrate
hypercaloric diets in conjunction with high protein should be avoided when treating
patients, due to the potential increase insulin [9].
However, high-protein diets are advocated by some researchers as a strategy to facili-
tate weight loss, compared to other energy restriction strategies. The hypothesis would be
that patients with T2DM could benefit from high-protein diets due to better blood glucose
control. One study compared 30% protein intake within TEV vs. 15% protein within TEV
for 12 weeks. The results showed a reduction in weight, fasting glucose, and medication
use in the group that consumed 30% of their TEV in protein [54]. Other studies lasting 4 to
24 weeks reported that high-protein diets (25–32% of TEV) resulted in 2 kg more weight
loss and a 0.5% greater improvement in HbA1C, but without significant improvements in
fasting blood glucose, total cholesterol or blood pressure [55,56].
A recent meta-analysis analyzed the effect of protein intake on the metabolism of
T2DM patients. The results showed that there were no significant differences in relation
to HDL and LDL cholesterol in the groups with a high-protein and low-protein diet. The
same applies to HbA1C. However, significant reductions in blood pressure and greater
weight reduction were observed [56].
Researchers who develop high-protein diets can provide positive regulation of anorec-
tic hormones {cholecystokinin (CCK), peptide YY (PYY) and glucagon-like peptide-1
(GLP-1)}, which suppress brain reactions that are linked to increased appetite. Furthermore,
protein consumption also helps to increase gastric emptying time, promoting a greater
satietogenic effect. In the long term, reduced appetite may contribute to weight loss, blood
pressure, and molecular biomarkers. In any case, a protein intake range of 15% to 20% of
TEV is the most prevalent in the literature, and so far appears to be the most fair prescription
for the management of T2DM. Additionally, more studies are needed [56].

3.2.3. Fats
The Dietary Guidelines for Americans defines a dietary fat prescription with a 25
to 35% TEV fat range. Dietary patterns that recommend replacing saturated fats with
polyunsaturated and monounsaturated fats have demonstrated positive results in reducing
blood glucose, triglycerides, LDL cholesterol, and increasing HDL cholesterol. The types or
Nutrients 2023, 15, 5096 5 of 27

quality of fats in dietary plans can influence results associated with a greater likelihood of
developing cardiovascular diseases [57–60].
The American Heart Association (AHA) recommends a low-fat diet, given that the
world population consumes, on average, 36–46% of their TEV in fats. This high intake has
been associated in several studies with increased cardiovascular risk. Additionally, only for
individuals with hypercholesterolemia and T2DM, the American College of Cardiology
(ACC) and the AHA recommend limiting the TEV of saturated fats to 5% to 6%. European
and Brazilian guidelines recommend limiting the consumption of saturated fats to <7% of
the TEV and total fats to <35% of the TEV to control dyslipidemia and T2DM [16,61–63].
High-fat diets, especially those rich in saturated fatty acids, are capable of altering the
composition of the gut microbiota, causing a decrease in bacterial diversity and an increase
in intestinal permeability. This process raises lipopolysaccharides (LPS) and activation
of TLR4 (toll-like receptor 4), generating metabolic endotoxemia and low-grade systemic
inflammation. This process add to development of several chronic diseases such as obesity,
diabetes, and atherosclerosis [64]. In addition, patients also pay attention to trans fatty
acids. Foods containing trans fatty acids (hydrogenated vegetable fat) should be minimized
as much as possible from the diet [16,33]. Excess trans and saturated fat intake above the
recommendation has been associated with a higher risk of T2DM [16,61,64,65], and can
also increase the inflammatory response in the gut microbiota [65].
-Cholesterol
The Dietary Guidelines for Americans concluded that the available evidence does
not support the recommendation to limit dietary cholesterol for the general population;
the exact recommendations for patients with chronic noncommunicable diseases, such as
T2DM, are still less clear. Some researchers argue that the body produces enough cholesterol
to perform its physiological and structural functions, so that people do not need to obtain
it from food [33]. The studies also indicate that dietary cholesterol intake is correlated
with an increase in total cholesterol levels, but this is not linked to a greater likelihood
of cardiovascular diseases. More research is needed on the relationship between dietary
cholesterol, blood cholesterol, and cardiovascular events in people with T2DM [16,60,66].
-Saturated fat
Guidelines recommend that patients with dyslipidemia and T2DM consume an av-
erage of <7% of their TEV of saturated fat [16,33,62,63,67]. The scientific justification for
reducing saturated fat in the diet is based on the significant effect of saturated fat intake
on increasing LDL-C, a factor that contributes to the development and increased risk of
atherosclerosis [68]. The American Heart Association concluded that reducing saturated
fat intake and replacing it with unsaturated fats, especially polyunsaturated fats, reduces
the incidence of cardiovascular disease [69].
A meta-analysis showed a 17% reduction in the risk of cardiovascular events in studies
that reduced saturated fat intake from 9% of the TEV, but no reductions in stroke, car-
diovascular mortality, or all-cause mortality were found. Benefits have also been seen
when replacing saturated fat with polyunsaturated fat, but not with carbohydrates or
proteins [70]. In another study, with patients with T2DM, intake of food sources of mo-
nounsaturated and polyunsaturated fats was associated with a lower risk of CVD and
death, while intake of saturated fat and trans fats was associated with a higher risk of
cardiovascular disease. Replacing saturated fat with monounsaturated or polyunsaturated
fat and replacing trans fat with monounsaturated fat have been associated with a reduced
risk of developing cardiovascular disease [71,72].
In general, replacing saturated fat with unsaturated fats, especially polyunsaturated
fat, significantly reduces total cholesterol and LDL-C, and replacing it with monounsatu-
rated fat from plant sources such as olive oil and nuts reduces the risk of cardiovascular
disease [67]. Replacing saturated fat with carbohydrates also lowers total cholesterol and
LDL-C, but significantly increases triglycerides and lowers HDL-C [68,73].
Nutrients 2023, 15, 5096 6 of 27

Recently, there has been an increase in the consumption and prescription of foods that
are sources of saturated fats by doctors and nutritionists, so guidelines have taken a strong
stance against the use of coconut oil, lard, bacon, and other foods rich in saturated fatty
acids. They have high levels of lauric, myristic, and palmitic acid, so daily consumption
should be avoided; they should be replaced by vegetable oils rich in monounsaturated and
polyunsaturated fatty acids, such as olive oil, canola oil, and sunflower oil [48].
A systematic review and meta-analysis analyzed the effect of coconut oil consumption
on LDL-C, HDL-C and other cardiovascular risk factors compared to other cooking oils. The
results showed that coconut oil consumption significantly increased LDL-C +10.47 mg/dL
and minimally increased HDL-C +4.00 mg/dL. The authors concluded that even when
HDL-C is increased, its daily consumption should be avoided, as it results in higher LDL-C
than other vegetable oils [74]. Coconut oil is rich in saturated fatty acids, especially lauric
acid (12 carbon atoms), myristic acid (14 carbon atoms), and palmitic acid (16 carbon atoms).
These types of fatty acids can contribute to increasing concentrations of total cholesterol
and LDL-C [74].
Another meta-analysis also demonstrated that all these saturated fatty acids (lauric,
myristic, and palmitic acid were included in items such as coconut oil, hydrogenated
vegetable fat, and palm oil) increase LDL cholesterol. Therefore, the authors suggest that
coconut oil should be replaced with other unsaturated vegetable oils (olive oil, canola
oil, and sunflower oil). The results are extremely relevant for nutritional and dietary
guidelines [75].
However, other studies did not show an association between intake of some foods that
contain a small portion of saturated fat, such as dairy products and eggs, with an increased
risk of diabetes and cardiovascular diseases. Dairy products also have carbohydrates
and proteins in their composition, and their saturated fat contents would not be too high
compared to other sources of saturated fat. Studies suggest that dairy products can be
included in the diet of T2DM, as long as they are quantified in <7% of saturated fats in
the TEV. Therefore, there should also be more interest in giving preference to low-fat
dairy products to ensure that the daily intake of saturated fats does not exceed 7% of the
TEV [76–78].
A similar result was found for eggs. Although they contain fat, they are also rich
in proteins, water, phytochemicals, carotenoids, and micronutrients. Their consumption
was not associated with cardiovascular risk, as long as it is properly quantified within the
energy need for saturated fats within the TEV (<7% for T2DM). Unfortunately, there is still
no consensus on the amount of egg intake per day or week, as there is great divergence in
the literature regarding the intake protocols used [51,62,63,68].
Some research has shown an increase in the risk of T2DM in individuals who consumed
3 to 4 eggs per week, and an increase in those who consumed more than 5 eggs per week.
Separation of intake by sex was also studied, illustrating that an intake of 5 eggs per week
in men and above 7 eggs per week in women could increase the risk of T2DM. Opposite
results were observed in other studies, as higher egg consumption was associated with
a lower risk of T2DM. In systematic reviews and meta-analyses that evaluated healthy
individuals, there was also no consensus on the association between egg consumption and
a higher risk of cardiovascular disease or T2DM. Confounding factors between saturated
fat intake and the amount of calories ingested per day (which favor weight gain and the
development of metabolic syndrome) can limit study results. In any case, more long-term
research is needed [62,63].
-Monounsaturated fats
Monounsaturated fatty acids have been recommended in the literature for their great
capacity to reduce inflammatory response and cardiovascular risk. Two clinical trials
applied the Mediterranean Diet, which is rich in food sources of monounsaturated fatty
acids (extra virgin olive oil and walnut oil), and showed a reduction in the incidence of
disease, cardiovascular risk, blood glucose, and body weight in T2DM [79,80].
Nutrients 2023, 15, 5096 7 of 27

A systematic review and meta-analysis including 1460 participants compared the

effect of eating plans high in monounsaturated fat with eating plans high in carbohydrates.
Eating plans high in monounsaturated fat showed significant reductions in fasting glucose,
triglycerides, body weight and systolic blood pressure, along with significant increases
in HDL-C. The researchers also compared eating plans rich in polyunsaturated fat with
monounsaturated fat, and found a significant reduction in fasting plasma glucose in
both [57].
Canola oil is another excellent source of monounsaturated fatty acids (omega 9), and
unfortunately has a bad reputation due to distorted information published in the media.
Moreover, it is an economically accessible source of fat, and rich in bioactive compounds.
Its consumption is safe, and is assessed through the extremely rigorous processing quality
control standards of regulatory bodies in all countries. A systematic review and meta-
analysis published in the Journal of American College Of Nutrition analyzed the lipid
profile performance of 1359 participants who ingested canola oil. The results showed
that its consumption reduced total cholesterol (−7.24 mg/dL) and LDL-C (−6.4 mg/dL)
compared to sunflower oil and coconut oil. There were no effects on HDL -C, triglycerides,
Apo B and Apo A. These results are extremely relevant for delaying the progression of
heart disease [81].
-Polyunsaturated fats
Recommendations suggest increasing intake of food sources of omega-3 polyunsat-
urated fatty acids (long-chain) containing a good proportion of EPA and DHA, such as
salmon, tuna, mackerel, prego fish, anchovies, sardines, hake, algae, seeds, vegetable
oils and others. Omega-3 and are recommended for T2DM because they have an anti-
inflammatory and antioxidant effects on cytokines and low-density lipoproteins (LDL), and
help to prevent heart disease. For vegetarians or vegans, omega-3 α-linoleic acid (ALA)
is found in plant-based foods such as olive oil, canola oil, avocado oil, walnut oil, seeds,
and algae. They are substitutes for foods high in saturated fat, and provide benefits for
preventing and decreasing the risk of cardiovascular disease [16,33,82,83].
Large epidemiological studies have shown the consumption of polyunsaturated fatty
acids is associated with a lower risk of T2DM [84]. Furthermore, in a randomized clinical
trial with cardiac patients with T2DM, researchers demonstrated the benefits of the addition
of 2 g of omega-3, twice a day, for patients on statin therapy, resulting in lower mortality
rates from cardiovascular diseases [85,86].
In any case, many studies do not recommend omega-3 supplementation for the pre-
vention or treatment of cardiovascular events and T2DM. A recent clinical trial found
that omega-3 supplementation at a dose of 1 g/day did not reduce cardiovascular risk in
people with T2DM [86–88]. Another research showed that vitamin D supplementation with
1 g of omega-3 in patients with T2DM also did not result in a lower incidence and fewer
predictors of major adverse cardiovascular events [89]. Studies are inconclusive, and did
not present solid evidence for the reduction of cardiovascular diseases events or mortality,
but this may be useful in people who require a reduction in triglycerides and attenuation
of inflammatory response [87,89].
A recent study carried out 4 g/day omega-3 supplementation in 823 participants
diagnosed with T2DM. The results showed a significant reduction in cardiovascular events
by 25% when compared to placebo. However, this dose is very high, which makes this
dietary supplementation more expensive. Therefore, further research is needed [16,86].
-Trans fats
The use of trans fats in industry provides advantages to food factories, such as cost
reduction, longer shelf life, high melting point, and wide potential for use. However, the
literature shows an association between intake and an increase in systemic inflammatory
response and cardiovascular risk. Furthermore, a meta-analysis showed that trans fat
intake resulted in an increase in total cholesterol and LDL-C, and a decrease in HDL-
C concentration [90]. Trans fats have also been associated with all-cause mortality and
Nutrients 2023, 15, 5096 8 of 27

cardiovascular disease mortality. Therefore, the intake of trans fatty acids should be avoided
and excluded from the diets of T2DM patients [13,16,63,71].

3.2.4. Fibers
The Dietary Guidelines for Americans 2020–2025 recommend that patients with T2DM
consume at least 14 g of fiber per 1000 kcal (or 28 g per 2000 kcal), which must come from
the consumption of grains, whole grains, vegetables, legumes, fruits and legumes (beans,
peas, and lentils) [33]. Regular intake of dietary fiber is associated with reduced all-cause
mortality in T2DM, and should therefore be encouraged, as it also provides additional
benefits in obtaining micronutrients and phytochemicals [36,37,39]. Some studies have
shown a reduction in total cholesterol, LDL cholesterol and HbA1C with an intake of 25 g of
fiber per day. However, this excessive intake may cause flatulence, bloating, and diarrhea.
Therefore, supplementation should occur in specific cases, and is not recommended in the
long term [39,91].

3.2.5. Sodium
Many groups of Health Sciences researchers recognize that the average sodium intake
of the population is greater than 3500 mg per day, and must be reduced to prevent and
control hypertension [26,33,39,92–94]. Reducing sodium to the general recommended
intake of 2300 mg/day (5 g of table salt) demonstrates positive effects on blood pressure
and for patients with T2DM, especially those with hypertension and heart disease [31,95].
However, high reductions in sodium should be avoided, as some studies have shown
an increased risk of mortality associated with very low sodium intake. This can be explained
by the increased excretion of sodium in urine in T2DM. Therefore, sodium intake targets
below 2300 mg/day should be avoided and considered individually according to dietary
preference and palatability, using medical monitoring [96–99].

3.2.6. Alcohol
Guidelines suggest moderation for adults with T2DM who drink alcoholic beverages.
It is recommended that healthcare professionals warn patients about the signs, symptoms
and self-care of reactive hypoglycemia after drinking alcohol, especially when using hy-
poglycemic medications, so monitoring glucose after drinking alcoholic beverages should
also be encouraged [9,16,33,63].
Some studies demonstrate that moderate alcohol consumption has a minimal, if any,
effect on blood glucose in T2DM [100–103]. The maximum daily intake recommendation
is defined as 15 g for women and 30 g for men. This 15 g a day may be represented by a
12-ounce (355 mL) bottle of beer, a 5-ounce (150 mL) glass of wine, or a 1.5-ounce (45 mL)
portion of distilled beverages [9,33]. Excessive alcohol use (more than 3 drinks per day or
21 drinks per week for men, and more than 2 drinks per day or 14 drinks per week for
women) may contribute to hyperglycemia [9,104,105].
However, studies have shown glycemic and cardiovascular benefits from moderate
alcohol consumption, but this needs to be analyzed carefully, because chronic intake can
put people with T2DM at risk of reactive hypoglycemia [103,106–109]. This effect may be
the result of inhibition of gluconeogenesis, reduced perception of hypoglycemia due to the
cerebral effects of alcohol, and reduced counterregulatory response to hypoglycemia. This
is relevant for patients who use insulin secretagogues and may have a fasting hypoglycemia
following alcohol consumption at night [32,33]. To minimize the risk of nocturnal hypo-
glycemia, it is suggested that patients eat some food when they drink alcohol [32,33,109]. It
is essential that people with T2DM receive education about recognizing the symptoms and
managing reactive hypoglycemia, as well as engaging in frequent blood glucose monitoring
after alcohol consumption [32,33,110].
Other reviews and meta-analyses also suggest a protective effect of moderate alcohol
intake on the risk of developing T2DM [101,111,112]. Moderate alcohol intake ranging
from 6–48 g/day (0.5–3.4 drinks) has been associated with a 30–56% lower incidence of
Nutrients 2023, 15, 5096 9 of 27

T2DM [32,33,101,110–112]. Some studies have found an intake of 20 to 30 g of alcohol per

day from wine or beer to decrease the incidence of T2DM by 20% for wine and 9% for beer.
However, the authors do not advise that patients who do not drink alcohol should start
consuming it [113]. In any case, alcohol consumption is an individual choice, but additional
factors such as history, religion, genetic factors, mental health, and drug interactions, should
be considered before alcohol use [33].

3.2.7. Sweeteners
The Dietary Guidelines for Americans suggest replacing sugar-sweetened beverages
(non-diet soft drinks/sodas, flavored juice drinks, sports drinks, sweetened tea, coffee
drinks, energy drinks, and electrolyte replacement drinks) with water [33]. One study
found that replacing sugary drinks with an equal amount of water reduced the risk of
T2DM by 7–8% [114]. When low-energy sweeteners are used to reduce overall calorie
and carbohydrate intake, people should be advised to avoid compensatory behaviors like
additional calorie intake from other food sources [33].
Consumption of sugary drinks by the general population contributes to a significantly
increased risk of T2DM, weight gain, heart disease, kidney disease, non-alcoholic liver
disease, and tooth decay [115]. A meta-analysis reported that consuming one serving of a
sugary drink per day increased the risk of T2DM in adults with prediabetes by 26% [116].
Another study showed that regular soda intake increased the risk of T2DM by 13%, while
diet soda consumption increased the risk of T2DM by 8% [117].
The Food and Drug Administration (FDA) and Health Surveillance Agency have
reviewed the safety of ingesting various types of sweeteners, approving them for con-
sumption by the general public, including T2DM patients. The term “sweeteners” refers to
high-intensity sweeteners, artificial sweeteners, non-nutritive sweeteners, and low-calorie
sweeteners. These include saccharin, neotame, acesulfame-K, aspartame, sucralose, advan-
tame, stevia, and others. Replacing table sugar and sweetened beverages with sweeteners
can reduce carbohydrate and calorie intake. These dietary changes can beneficially affect
blood glucose, weight, and cardiometabolic control [118,119].
Unfortunately, there is not enough evidence to determine whether the use of sweeten-
ers could really contribute to weight loss, reduced cardiometabolic risk, and attenuation of
glycemia in the long term [118]. Moreover, it may be said that the use of sweeteners is inter-
esting, as long as individuals do not compensate for calories throughout the day. Studies
conclude that sweeteners can be useful in reducing caloric intake, especially carbohydrates,
but more research is needed [120,121]. Regarding adverse effects, studies have investigated
hypotheses regarding (1) changing the sensation of hunger and satiety; (2) excessive use of
dietary products and consequent dysregulation of the intestinal microbiota; and (3) reduced
perception of calorie intake [118,122]. Therefore, for people who looking to reduce intake
of sugary drinks, drinking water is more encouraged than substituting diet drinks [118].
Sugar alcohols/polyols represent a separate category of sweeteners, and have been
approved by the FDA for consumption by the general public and in T2DM. Sugar alcohols
have fewer calories per gram than sugars, and they are not as sweet. Therefore, a larger
amount is needed to match the sweetness of the sugars, generally raising caloric content to
a level similar to sugars [123]. The use of sugar alcohols should be moderate, as they can
cause gastrointestinal effects in sensitive individuals. Currently, there is little research on
the benefits of sugar alcohols for people with T2DM [9,124].

3.2.8. Micronutrients and Supplements

The benefits of multivitamins or mineral supplements on glycemia and cardiovascular
disease risk in T2DM have little literary support, and routine use is not recommended
for people who are not deficient [22,125,126]. However, metformin is associated with
vitamin B12 (B12) deficiency, and annual monitoring of blood levels are recommended for
people who are undergoing therapy, especially those who are anemic or have peripheral
neuropathy [127], because metformin can reduce absorption of B12 [128–131].
Nutrients 2023, 15, 5096 10 of 27

The use of micronutrient and nutraceutical supplements, such as chromium, chromium

picolinate, L-carnitine, zinc, propolis, spirulina, chorella, vitamin D, cinnamon, curcumin,
aloe vera, coconut oil, cardamom oil or any other supplements to improve blood glucose in
T2DM is not supported by evidence and is not recommended [9,16,48,125,126,131]. Patients
who do not meet glucose targets may be at increased risk of micronutrient deficiencies [126].
Therefore, it is essential to maintain a balanced intake of food sources that provide at least
the Recommended Dietary Allowance [22]. For pregnant, celiac, elderly, and vegetarian
patients and those who wish to lose weight, supplementation may be fair and adjusted for
each clinical case [126,132,133].
A systematic review on the effect of chromium supplementation on glucose and lipid
metabolism concluded that the evidence is limited by poor-quality primary studies and
heterogeneity in methodology [133,134]. Evidence from clinical studies evaluating magne-
sium and vitamin D supplementation to improve blood glucose in T2DM is also equally
contradictory [134–138]. Clinical trials and meta-analyses that evaluated vitamin D supple-
mentation to improve glycemia in T2DM have concluded that prescription is unnecessary
in patients who are not deficient. Those who are deficient must be supplemented and
monitored every 6 months [137–146].
Creatine has been gaining prominence in the literature within the treatment of T2DM.
Evidence suggests that creatine supplementation alone or in combination with exercise
training can reduce glucose intolerance and insulin resistance in T2DM. The mechanism of
the effects is an increase in glucose transport into the muscle cells through translocation of
glucose transporter type 4 (GLUT-4) to the sarcolemma. It is believed that creatine increases
the amount and speed of translocation too. The evidence is considered promising, but more
research is needed [147].
In any case, some nutritional supplements, herbal, and nutraceutical products are not
yet regulated by supervisors and standard-setting bodies. Health professionals should
consider the real costs, benefits, adverse effects, and drug interactions. The variability of
herbal and micronutrient supplements makes research challenging, making it difficult to
conclude on their effectiveness. Unfortunately, there is limited evidence supporting the use
of supplements and nutraceuticals to control blood glucose [148,149].

3.3. Nutritional Strategies

Many types of dietary patterns for the nutritional management of T2DM have been
studied, but the scientific community always highlights: (1) increased intake of fruits,
vegetables, and legumes; (2) minimizing added sugars and refined grains; (3) choosing
natural and minimally processed foods rather than ultra-processed foods [13,22,132].

3.3.1. Mediterranean Diet

The Mediterranean diet is an intervention that has the highest level of scientific
evidence, and consists of foods of high nutritional quality, such as fruits, vegetables,
legumes, seeds, whole grains, fish, lean meats, skimmed dairy products, and olive oil.
Several epidemiological studies have reported the protective effect of this diet on metabolic
disorders, chronic diseases, and mental health. This diet has good adherence in the long
term, and is recommended within the prescription of individualized, flexible, and balanced
eating plans that match the patient’s goals [9,16,132,150].
Studies show that the Mediterranean lifestyle with a low-fat or low-carb diet offers
multiple benefits to T2DM patients [79,150–153]. A randomized controlled trial compared
the Mediterranean diet (low-carb) to the low-fat diet, aiming to analyze the prevention
of T2DM. The results showed that the Mediterranean diet resulted in a 30% lower rel-
ative risk compared to the low-fat diet [80]. Moreover, epidemiological studies corre-
late the Mediterranean, vegetarian and DASH (Diet Approach to Stop Hypertension)
diets with a lower risk of developing T2DM, with no effect shown for the Ketogenic diet
in the long term [115,154–165]. Large clinical trials show that a low-fat diet optimizes
Nutrients 2023, 15, 5096 11 of 27

weight loss and improves glucose tolerance, and causes a decrease in the incidence of
T2DM [151,152,160,161].
Studies have also pointed out that the Mediterranean diet may have a mixed effect on
HbA1C, weight and cholesterol. In a clinical trial, obese patients with T2DM were divided
in to three groups: the Mediterranean diet with calorie restriction vs. a low-fat diet with
calorie restriction vs. a very low-carbohydrate diet (28% of TEV carbohydrates) with calorie
restriction. The results showed that fasting glucose was lower in the Mediterranean diet
than in the low-fat and very low-carb groups [165].
Another study compared the Mediterranean diet with the low-fat diet for 4 years. The
results showed an improvement in the control of the glycemic profile in the Mediterranean
diet, and the need for the use of hypoglycemic medications was lower too [166]. Another
study showed that a Mediterranean diet with olive oil and nuts significantly reduced the
incidence of cardiovascular disease in T2DM patients [29].
A randomized crossover study evaluated the impact of the Ketogenic diet vs. the
Mediterranean diet on T2DM. Both diets incorporate the inclusion of non-starchy vegeta-
bles, the restriction of added sugars, and limitation of refined grains. The main differences
are the consumption of legumes, fruits, and whole grains only in the Mediterranean. The
authors concluded that both diets produced beneficial effects for individuals and a signifi-
cant reduction in HbA1c, but the ketogenic diet increased LDL, making it impossible to
rule out the potential cardiovascular risks that this change presents; in addition, it reduced
intake of vitamins and minerals, which is closely correlated with the restriction of important
food groups. Although controlling and reducing carbohydrate intake is beneficial and
recommended for controlling prediabetes and T2DM, more studies are needed [167].

3.3.2. Dash (Dietary Approaches to Stop Hypertension)

The DASH diet is an intervention whose objective is weight loss and consequently a
reduction in blood pressure. It has characteristics similar to the Mediterranean pattern, but
alcohol consumption is not encouraged, and there is also sodium restriction. One study
found that the DASH diet can reduce HbA1C, blood pressure, total cholesterol and weight
levels in T2DM, but without significant differences in triglycerides [132,168].
Another study compared the DASH diet with conventional restriction. The results
showed that blood pressure and weight were lower in the DASH group, but HbA1C and
lipids showed no statistically significant differences [30,31,95]. In any case, guidelines have
stated that DASH and the Mediterranean diet can be effective in the management of T2DM,
especially for those who also have hypertension and coronary heart disease [16,63].

3.3.3. Low-Carb Diet and Ketogenic Diet (Very Low-Carb Diet)

Low-carb diets, especially the very low-carb (Ketogenic) diet were initially proposed
for the management of patients with epilepsy and autism. Over the years, there has been
interest from the scientific community in expanding these diets to treat other diseases,
especially T2DM. Despite several different types of protocol that define the low-carb diet,
the standard that most prevails in the literature has wide variability in the consumption of
fresh and minimally processed foods, with high nutritional quality. Dietary prescription
is also variable, but in general is <40% TEV carbohydrates, 20–25% TEV proteins, 30–40%
TEV fats, and a limit of <10% saturated fats in most studies [9,16,132].
Part of the challenge in interpreting low-carb research is the wide range of definitions
of a low-carb diet. Weight reduction is also an objective outlined in many studies, which
further complicates the assessment of the distinct contribution of dietary patterns, as weight
loss can also have positive effects on patients with T2DM [9]. Clinical trials have shown
that this diet could reduce HbA1C and the need for antihyperglycemic medications. A
meta-analysis compared the low-carb (≤45% of carbohydrate TEV) and high-carbohydrate
diets (>45% of carbohydrate TEV). Both groups restricted saturated fat intake to <10% of
TEV. The results showed that the benefits of improving HbA1C were more pronounced in
individuals who followed the low-carb diet [168,169].
Nutrients 2023, 15, 5096 12 of 27

Other interventions also showed benefits in improving HbA1C in patients with T2DM
who followed a Ketogenic diet (<26% of TEV in carbohydrates) for 3 and 6 months. How-
ever, the same results were not found at 12 and 24 months. The authors discuss that the
major limitations of these strategies would be low adherence to the diet and the increased
likelihood of long-term loss of lean mass. Food sources of carbohydrates are hyperpalatable,
as are fats, and alongside providing energy substrates for physiological and metabolic
functions, they also have an important emotional role. The production of ketone bodies
would not be sufficient to sustain the myocyte’s energy demand during long-term mus-
cle contraction. Therefore, researchers suggest individualized adjustments and flexibility
after 3–6 months of following this type of intervention, for greater adherence to lifestyle
changes [9,170].
Another meta-analysis compared the low-carb (<40% of the TEV from carbohydrates)
and low-fat diets (<30% TEV from fat) for 6 months. All groups restricted saturated fat
intake to <10% of the TEV. The results showed that the low-carb diet reduced HbA1C,
triglycerides, blood pressure, and the use of hypoglycemic drugs, and increased HDL-
C [171]. Another study compared the low-carb diet and high-carbohydrate diet (both
groups restricted saturated fat intake to <10% of TEV), and the results showed a reduction
in HbA1C, but this was not sustained in the long term [172].
However, the ketogenic diet is not recommended for people with T2DM who have
chronic kidney disease, people with eating disorders, or women who are pregnant. More
studies and literary support are needed before recommending this diet. Adopting the
very low-carb diet can cause diuresis and quickly reduce blood glucose levels. There-
fore, multidisciplinary team management is necessary to prevent dehydration and hypo-
glycemia [9,16,132].
Reducing carbohydrate intake in T2DM appears improve glucose metabolism and
molecular markers, thereby becoming a viable nutritional strategy. However, studies
on ketogenic diets generally indicate challenges to long-term sustainability. Therefore,
it is important to reevaluate and individualize eating plan guidance regularly for those
interested in this approach. It is worth remembering that insulin and other medications
may need to be adjusted to prevent hypoglycemia and blood pressure [9,132].
In any case, no randomized trials have been performed with people with T2DM
who increased saturated fat intake on low-carb or ketogenic diets to examine the effects
on blood glucose and risk factors for cardiovascular disease [167,171–174]. Guidelines
recommend the restriction of saturated fats, comprising 5–7% of the TEV for patients
with T2DM [9,16,47–49,68]. Therefore, more evidence is needed to analyze the real effi-
cacy, adherence, improvement of biochemical and cardiovascular parameters in the long
term [167,170–174].

3.3.4. Low-Fat Diet

The Look AHEAD (Action for Health in Diabetes) research group showed in studies
that patients who followed low-fat calorie restrictions achieved positive scores compared to
a conventional calorie-restricted diet [175,176]. The evidence has shown the several benefits
of a low-fat diet in improving biochemical markers (glucose, glycated hemoglobin, and
LDL cholesterol), cardiovascular markers, and even quality of life [3,6–8,11,16]. However,
according to some studies, reducing total fat intake did not improve blood glucose and
cardiovascular disease risk factors in people with T2DM compared to conventional calorie
restriction [177–181]. The benefit of the low-fat diet appears to be primarily related to
weight loss [16,175,176].
The American Heart Association, the Brazilian Society of Cardiology, and the Euro-
pean Guidelines emphasize that low-fat diets, especially a Mediterranean or vegetarian
dietary patterns, are very important for adapting the consumption of fats and fiber by
the population; they are potentially efficient strategies, especially for patients who have
increased LDL cholesterol. Currently, individuals consume a large amount of fat (>36–46%
of TEV), and this excess has important consequences, in particular increased cardiovas-
Nutrients 2023, 15, 5096 13 of 27

cular risk and weight gain. Therefore, this strategy is also viable for the management of
T2DM [16,60–64,74,75,132].

3.3.5. Ornish and Pritikin Diets (Very Low-Fat Diet)

Both of these types of diets are very low-fat eating patterns. The Ornish program em-
phasizes a low-fat, whole-food, plant-based eating plan (70% TEV carbohydrates, 10% TEV
fat, 20% TEV protein, and 60 g fiber per day) predominantly made up of vegetables,
legumes, fruits, grains, skimmed dairy, and egg whites [182–184]. In the same way, the
Pritikin diet recommends the consumption of 77% carbohydrates, 10% fat, 13% protein
within the TEV, and 30–40 g of fiber without caloric restriction during a 26-day stay in a
treatment center (SPA). A meta-analysis with 652 participants showed that these diets can
have positive effects on glucose levels, weight, blood pressure, and HDL-C in the long
term [182–185]. Unfortunately, these studies are old, and interest in studying these types of
interventions has reduced over time, so more evidence is needed [16,132].

3.3.6. Vegetarian and Vegan Diet (Plant-Based Diet)

Studies of vegetarian or vegan eating plans over 12 to 74 weeks have demonstrated positive
results on blood glucose, risk of cardiovascular disease, and weight loss. Two meta-analyses
concluded that vegetarian and vegan diets can reduce HbA1C, weight, waist circumference
and LDL-C in patients with T2DM. No significant effects were found on HDL-C, insulin,
triglycerides, and blood pressure [16,132,184–191].
Studies have demonstrated the benefits of plant-based diets in treating T2DM and
reducing macro and microvascular complications. The type and source of carbohydrates
(unrefined vs. refined), fats (monounsaturated and polyunsaturated vs. saturated and
trans), and proteins (plant vs. animal) play an important role in preventing and controlling
disease, and have multiple benefits such as improving insulin resistance, reducing body
weight, increasing fiber and phytonutrients, increasing interactions between food and
the microbiome, decreasing saturated fat, and advancing glycation end-products and
nitrosamines [16,132,184–191].

3.3.7. Paleolithic Diet (Paleo Diet)

The Paleolithic diet is an intervention made to mimic the eating habits of our ances-
tors. Unfortunately, Westernization makes it difficult to follow this strategy, and it is not
applicable in the 21st century. It is worth remembering the individuals who lived in the
Paleozoic era were hunters, gatherers, and nomadic peoples. They consumed raw meat,
fruits, vegetables, and roots, and they survived from what nature could offer and spent
long periods fasting [192–194].
This lifestyle has become impossible, especially due to eating raw meat and high
levels of food contamination. Studies using the Paleolithic diet in T2DM are scarce. They
have a short duration (3 months), few participants (n = 13–29), and other methodologi-
cal limitations. The most studies findings found mixed effects on HbA1C, weight, and
lipids [193,194]. Due to the lack of literature, this dietary pattern is not recommended by
guidelines [16,47,132].

3.3.8. Intermittent Fasting

Intermittent fasting is not an eating pattern by definition, but it was included in this
literature review due to increased interest from the scientific community. Fasting means
going without eating and drinking and abstaining from foods and drinks that contain
macronutrients and calories. People fast for any reasons, such as rapid weight loss, and
religious or spiritual practices. Intermittent fasting is a strategy that focuses more on time,
i.e., “when” you eat, rather than “what” you eat. Daily caloric intake occurs within a
defined dietary window during the day [195].
Nutrients 2023, 15, 5096 14 of 27

Studies on intermittent fasting with T2DM demonstrate a variety of protocols: (1) restriction
of food intake for 18–20 h a day; (2) fasting all day (24 h fasting with days of normocaloric
intake); and (3) severe calorie restriction (intake < 1000 kcal/day) for up to 8 consecutive
days or more [196]. Some clinical trials with few participants (≤63 participants) and a
short duration (≤20 weeks) have demonstrated that fasting protocols on consecutive days
with severe caloric restriction (<1000 kcal/day) and fasting > 16 h per day can result in
weight loss in T2DM. However, there were no improvements in HbA1C compared with
conventional calorie restriction. One of the studies showed modest reductions in HbA1C,
weight, and medication doses when patients underwent 2 days of severe energy restriction
compared to conventional energy restriction [195–197].
A study has analyzed the applicability of fasting in patients with pre-diabetes. The
individuals were divided into two groups: (1) intervention with a dietary window of just
6 h (last meal at 3 p.m.); and (2) a control group with a 12 h food window. The results
showed improved insulin sensitivity, greater responsiveness of β cells, and a reduction in
blood pressure and oxidative stress in the intervention group. However, the study did not
control diet and exercise [197].
The results of intermittent fasting in T2DM are still controversial, and have limitations
(short-term studies, few participants, low long-term adherence, lack of control over diet
and physical exercise). Therefore, its practice requires great caution, especially for patients
who use hypoglycemic medications [197]. The safety of fasting in other specific subgroups,
including pregnant women and patients with eating disorders, has not yet been studied
and is also not recommended [16,47,132].

3.3.9. Mindful Eating Program

The ‘Mindful Eating Program’ has also shown strong evidence for the treatment of
different diseases, even T2DM. This therapy mixes the science of nutrition, body awareness,
and self-control. Studies have demonstrated significant improvement in eating regulation in
T2DM, as prioritizing self-control can be a great alternative to severely restrictive diets. The
practices can also help to increase knowledge of the factors (physiological, environmental,
or emotional) that dictate excess food intake and train patients in intuitive eating (respecting
hunger/satiety signals and chewing food). The program not only emphasizes the quantity
and quality eaten, but also the enjoyment of the experience, thus changing the reward value
of the food without restricting it [198,199].
The Mindful Eating intervention has been gaining increasing prominence in the
scientific community, as it is closely linked to mental health care [198,199]. The American
Diabetes Association emphasizes that the psychological factors of patients with T2DM
must be respected and valued by health professionals. Therefore, it is extremely important
to welcome and understand what happens on an emotional, physiological and metabolic
level. More evidence is needed on applicability in T2DM in the long term [16,132,198,199].

3.4. Summary of Dietary Patterns for the Management of T2DM

Table 1 below summarizes all descriptions of dietary patterns, their level of evidence,
adherence, and comments.
Nutrients 2023, 15, 5096 15 of 27

Table 1. Summary of dietary patterns for the management of T2DM.

Dietary Patterns Description Level of Adherence and Comments

Evidence
Mediterranean diet encourages consumption of foods with
high nutritional quality, such as fruits, vegetables, legumes, (1) High long-term adherence [16,132,163–167].
Mediterranean Diet whole grains, cereals, tubers, roots fish, low-fat dairy products, High (2) There is a lot of evidence in the literature for the
improvement of molecular markers, glycemic control,
vegetable oils, nuts, seed oils, and wine in moderation cardiovascular health, and weight loss [16,132,163–167].
[16,132,163–167].
DASH diet is similar to the Mediterranean pattern, but alcohol (1) High long-term adherence [16,30,31,63,95,132].
consumption is not encouraged and there is also sodium (2) There is a lot of evidence in the literature for the
improvement of molecular markers, glycemic control,
restriction. It consists of fruits, vegetables, legumes, whole
Dash Diet cardiovascular health, reduce blood pressure and weight
(Dietary Approaches to Stop Hypertension) grains, cereals, tubers, roots, fish, chicken breast, lean meats, High
loss [16,30,31,63,95,132].
low-fat dairy products, vegetable oils, nuts, oilseeds and (3) Severe sodium restriction (1500 mg) requires caution and
sodium restriction (<2300 mg or 1500 mg for severe heart monitoring, and is indicated for some specific
disease) [16,30,31,63,95,132]. cases [16,30,31,63,94–99,132].
(1) Low long-term adherence [16,132,167–174].
(2) There are many controversies in the
literature [16,132,167–174].
(3) No advantages over other nutritional
A dietary pattern composed of 5–10% carbohydrates, 15–25% strategies [16,132,167].
proteins and 60–70% fats of the total energy value (TEV). (4) The severe carbohydrate restriction may not really be
Includes raw vegetables, very low-carb fruits (avocado and necessary and safe [16,132,167].
Ketogenic Diet Low/ (5) New evidence shows results that it improves weight loss
strawberries), all types of meat (beef, pork, fish and chicken), Moderate
(very low-carb diet) and glycemic control in the short term, but increases markers
full-fat dairy products, vegetable oils, animal fat and eggs. It
has a low intake of fruits, legumes, whole grains, cereals, roots of cardiovascular risk, such as LDL cholesterol [16,132,167].
(6) This dietary pattern also can increase the risk of
and tubers [16,132,167,173]. dehydration and hypoglycemia; there is a high probability of
food monotony, low fiber and micronutrients
intake [16,132,167].
(7) More studies are needed in patients with diabetes,
especially in the long term [16,132,167].
(1) High long-term adherence [16,132,167].
Low-carb diet promotes reducing the consumption of (2) In recent years, good evidence has been published in the
ultra-processed foods. The carbohydrate intake range is literature for the modulation of molecular markers, glycemic
40–45% of the TEV. Encourages the consumption of fruits, control, cardiovascular health and weight
Low-Carb Diet vegetables, legumes, whole grains, tubers, fish, lean meats, High loss [16,132,167–174].
skimmed dairy products, vegetable oils, nuts, avocados, eggs (3) There are several types of protocols, and those that restrict
and seed oils. Carbohydrates of high nutritional quality are saturated fats (<7% of TEV) and prioritize sources of
allowed, but without excess [16,132,167–174]. polyunsaturated and monounsaturated fats show good
results [16,132,167–174].
Nutrients 2023, 15, 5096 16 of 27

Table 1. Cont.

Dietary Patterns Description Level of Adherence and Comments

Evidence
This dietary pattern involves ingesting 25–30% fats within the (1) High long-term adherence [175–181].
TEV. It encourages the consumption of fruits, vegetables, (2) There is a lot of evidence in the literature for the
Low-Fat legumes, whole grains, tubers, fish, chicken breast, lean meats, High modulation of molecular markers, glycemic control,
and skimmed dairy products. This eating pattern is similar to cardiovascular health, reduced blood pressure, and weight
DASH [175–181]. loss [175–181].
(1) Low long-term adherence [16,132,182–185].
Both eating patterns have very low fat consumption (10% fat (2) Over the years, the scientific community has lost interest in
Ornish and of the TEV). They encourage the consumption of whole foods, studying this type of diet, since it has low adherence, small
Pritikins Low
(very low-fat diet) vegetables, legumes, fruits, grains, low-fat dairy products, and palatability, and can possibly cause metabolic damage
egg whites [16,132,182–185]. (hormone production, protection, and energy
storage) [16,132,182–185].
(1) Moderate long-term adherence [16,132,184–191].
Plant-based diet consisting eat of foods with high nutritional (2) There is a lot of evidence in the literature for the
quality, such as fruits, vegetables, legumes, whole grains, modulation of molecular markers, glycemic control,
Plant-Based Diet cereal, tubers, roots, vegetable oils, nuts and seed oils. In this cardiovascular health, reduced blood pressure, and weight
(or vegetarian/ diet there is no intake of any type of food from an animal High loss (intake of high-fiber foods) [16,132,184–191].
vegan diet) source (intake of high-fiber foods). It encourages questioning (3) However, this diet needs constant nutritional monitoring,
about food choices, autonomy, and ethical and cultural because in the long term it can reduce intake of some
issues [16,132,184–191]. micronutrients, such as iron, calcium, and vitamin
B12 [16,132,184–191].
(1) Low long-term adherence [16,132,192–194].
The Paleolithic diet consists of following similar eating habits
(2) It has become technically impossible to follow a diet
as our ancestors. It encourages the consumption of all types of
identical to the Paleolithic period in Westernized
Paleolithic Diet meat, animal fat, fruits, vegetables, roots, raw foods and all Low
society [16,132,192–194].
types of food that nature can offer. The habit of fasting is also
(3) More studies are needed in patients with
recommended in this type of dietary pattern [16,132,192–194].
Diabetes [16,132,192–194].
(1) Low long-term adherence [16,132,195–197].
Fasting means abstaining from foods and drinks that contain (2) It can increase the risk of dehydration, headache,
macronutrients and calories. Daily caloric intake occurs within hypoglycemia, and lack of glycemic control [16,132,195–197].
Intermittent a defined eating window during the day, and there are several Low (3) It is strongly discouraged by guidelines for patients with
Fasting
types of fasting protocols (16 to 24 h), aiming to enhance the diabetes, mainly in diabetic ketoacidosis [16,132,195–197].
production of ketone bodies [16,132,195–197]. (4) More studies are needed in patients with
diabetes [16,132,195–197].
The practices of Mindful Eating can help increase knowledge (1) Moderate long-term adherence [16,132,198,199].
of the factors (physiological, environmental, or emotional) that (2) It is a type of nutritional strategy that has been gaining
lead to excessive food consumption and training in intuitive prominence in the literature with good results [16,132,198,199].
eating (respecting signs of hunger/satiety and chewing food). (3) However, more studies are needed to evaluate the impact
Mindful Eating Moderate
The program not only values the quantity and quality of mindful eating on weight loss, glycemic control, and
consumed, but also the pleasure of the experience, thereby improvement in cardiovascular markers [16,132,198,199].
changing the value of the food reward without restricting (4) Seems to be a good strategy to take care of the subjective
it [16,132,198,199]. issues of nutritional management [16,132,198,199].
Nutrients 2023, 15, 5096 17 of 27

3.5. Nutritional Management of T2DM in the COVID-19 Pandemic

The COVID-19 lockdown clearly affected the lifestyle of the population and entailed
changes in their daily habits. These transformations involved potential health consequences,
especially in T2DM. Recent studies have examined the impact of lockdown on eating habits,
exercise, and the psychological effects in T2DM, and showed that there was an increase
in the consumption of foods high in sugar and sandwiches during the pandemic. An
association between food craving levels and sandwich consumption was also found. The
research also showed a high prevalence of physical inactivity before lockdown, which was
even higher during home confinement. These findings emphasize the great importance of
developing new research with larger samples, aiming to expand public health policies that
promote a healthy lifestyle in T2DM, especially after lockdown [200].
However, another study shows the more than 60% of participants with T2DM and
T1DM started eating more nutritious meals at the pandemic, and increased their personal
and environmental hygiene habits, especially through the use of hand sanitizers. Addi-
tionally, 40% of all respondents stated that their glycemic self-management had improved.
These positive results may be related to patients’ fear of knowing that they belong to a
risk group, thus having a high probability of suffering with COVID-19. However, the data
collection has limitations, because they were obtained through patient reports [201].
Another study found no changes in physical activity and adherence to diet in more
than 80% of participants. There was an increase in the consumption of vegetables (81%) and
fruits (43%), and a decrease unhealthy snacks (63%). No significant changes were observed
in HbA1c or body weight before and after lockdown. The majority watched television
and spent time with their families. However, the quality of food intake and glycemic
control worsened in those with mental stress, insufficient sleep and physical inactivity [202].
Therefore, it is concluded that measures to promote healthy lifestyle practices, along with
ways to reduce psychosocial stress, should be implemented to better management T2DM
after the pandemic [200,202].

4. Authors’ Comments—The Best Nutritional Strategies and Dietary Prescription

Recommended for the Management of T2DM
Based on the data analyzed, the Mediterranean Diet is the nutritional strategy with
the highest level of evidence in the literature, and can bring greater benefits to patients
with T2DM in the long term. The best recommended dietary prescription is composed of
40–50% carbohydrates, 15–25% proteins, 25–35% fats (<7% saturated, 10% polyunsaturated,
and 10% monounsaturated), at least 14 g of fiber for each 1000 kcal consumed, and <2300 mg
of sodium. In any case, it is necessary to individualize the diet based on the stage of the
disease, the patient’s goals, socioeconomic situation, and preferences, aiming for greater
adherence and significant changes in lifestyle.

5. Conclusions
There is no consensus on what the ideal nutritional strategy and percentages of calories,
carbohydrates, proteins, and fats for patients with T2DM. Therefore, the type of strategy
and distribution of macronutrients should be based on an individualized assessment of
current eating patterns, preferences, and metabolic goals. However, several references show
that Mediterranean diet may bring greater benefits in the long term, with the following
recommended dietary prescription: 40–50% carbohydrates; 15–25% proteins; 25–35% fats
(<7% saturated, 10% polyunsaturated, and 10% monounsaturated); at least 14 g of fiber for
every 1000 kcal consumed; and <2300 mg sodium.

Author Contributions: All individuals contributed significantly to the conception, design, and data
collection of the work, and participated sufficiently in the writing of this critical review article to
establish ownership of the intellectual content. All authors have read and agreed to the published
version of the manuscript.
Nutrients 2023, 15, 5096 18 of 27

Funding: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de
Nível Superior—Brasil (CAPES)—Finance Code 001.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: We are grateful to the State Faculty of Medicine of São José do Rio Preto
(FAMERP), State University of Campinas (UNICAMP), and Coordenação de Aperfeiçoamento de
Pessoal de Nível Superior—Brasil (CAPES) for making this work possible.
Conflicts of Interest: The authors declare no conflict of interest.

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