**4. Using food to meet dietary guidelines**

enzyme in the conversion of glucose to GFAT blocks hyperglycemia-induced increases in the transcription of TGF-b1 and plasminogen activator inhibitor-1 [64, 65]. This pathway also plays an important role in hyperglycemia-induced and fat-induced insulin resistance [66, 67]. A prospective study examined the effect of strict blood glucose control through intravenous insulin aimed at euglycemia on the concentration of UDP-GlcNAc and UDP-GalNAc in the

12/15-LOs are enzymes that insert molecular oxygen into polyunsaturated fatty acids, such as arachidonic acids, leading to formation of 12(S)- and 15(S)-hydroxyeicosatetraeonic acid [69]. 12/15-LO enzymes and their products, namely HETEs (hydroxyeicosatetraeonic acid) and hydroxyoctadecadienoic acids, have been implicated in the pathogenesis of atherosclerosis [70]. Several studies have shown that the 12/15-LO pathway is also able to mediate oxidative modification of LDL-C [71, 72]. 12/15-LO seems to be involved in hyperglycemia, as well as minimally modified LDL-mediated adhesion of monocytes to the endothelium and promotes smooth vascular muscle cell hypertrophy [73]. Also 12(S)- HETE promotes monocyte adhesion to endothelial cells, probably in part by inducing the fibronectin splice variant CS-1 (C-terminal fragment of the connecting segment 1) and VCAM-1 on endothelial cells [73]. Some metabolites of the 12/15-LO system, i.e., 13-hydroxyoctadecadieonic acid (13-HODE) reduces platelet adhesion to endothelial cells and binds to PPARγ thereby reducing macro-

muscles of severely insulin resistant, uncontrolled, obese, T2DM patients [67, 68].

phage expression of matrix metallopeptidase 9 and proinflammatory cytokines [74].

**3. The potential of diet in preventing cardiovascular disease and** 

sion lower by 25% in the Mediterranean diet group [80, 81].

The 2016 American Diabetes Association (ADA) Lifestyle Guidelines support the idea of a healthy diet to improve overall health, in light of achieving body weight, individualized glycemic, blood pressure, and lipid goals [75]. The 2016 European Guidelines on CVD prevention in clinical practice acknowledge that the Mediterranean diet is the most studied specific dietary pattern, which comprises many of the foods and nutrients that have been recommended previously, such as high intake of fruits, vegetables, whole grain products, fish, and unsaturated fatty acids [76]. The PREDIMED study (Prevention with Mediterranean Diet) demonstrated that Mediterranean diet reached a statistically significant reduction in the rate of the composite cardiovascular primary end-point of myocardial infarction (MI), stroke, or cardiovascular death [77]. The Mediterranean diet protects the heart, improves lipid profile, reduces blood pressure, and improves glucose tolerance [78]. Current evidence indicates that the Mediterranean diet is effective in improving glycemic control and reducing cardiovascular risk factors in people with T2DM and should therefore be considered in the overall strategy for the management of people with diabetes [79]. In the most extensive study assessing the effects of the Mediterranean diet on patients with newly diagnosed T2DM, the follow-up results over 8.1 years show that compared to a traditional low-fat diet, the rate of regression in the intima-media thickness of the carotid artery was higher by 49%, and the rate of progres-

**2.5. 12/15-lipoxygenase (12/15-LO) pathway**

**diabetes**

38 Diabetes Food Plan

Evidence-based nutrition practice guidelines are devised to guide clinicians in assisting dietitians and patients/clients in taking appropriate decisions regarding nutrition care for specific disease, or conditions in typical settings [82, 83]. The 2015–2020 US Dietary Guidelines are a critical tool for professionals to help Americans make healthy choices in their daily lives to help prevent chronic disease. It serves as the evidence-based foundation for nutrition education materials that are developed by the US Federal Government for the public [77]. Strong evidence reflects a large, high-quality, and/or consistent body of evidence. Moderate evidence reflects sufficient evidence to draw conclusions. Limited evidence reflects a small number of studies, studies of weak design or with inconsistent results, and/or limitations on the generalizability of the findings [77, 84]. The ADA uses the Create Your Plate system, which divides a plate into three sections: non-starchy vegetables (the largest section), starchy foods, and meat or meat substitutes [85]. The Harvard School of Public Health uses the Healthy Eating Pyramid, which is split into nine sections, including a base of daily exercise and weight control [86]. The LiveWell for LIFE project uses National Plates to show the ideal composition of diets in various European Union countries which are both healthy, environmentally sustainable and affordable [87]. Prospective Urban Rural Epidemiology (PURE study) is an epidemiological study carried out in 18 countries, examining associations between diet and total mortality, CVD mortality, CVD events, and non-CVD mortality. [88] The PURE study carried out between 2003 and 2009 on 153,996 adults, aged 35–70 from urban and rural communities in low, middle, and high-income households, found that elevated carbohydrate diets (74.4– 80.7% of daily calories from carbs) had a mortality hazard ratio 1.28 (1.12–1.46) times greater the median follow-up period of 7.4 years [88]. Total fat and individual types of fat were associated with lower risk of total mortality, but were not significantly associated with risk of CVD mortality [89]. Reducing saturated fatty acid intake and replacing it with carbohydrate have an adverse effect on blood lipids [88]. Global dietary guidelines should be reconsidered in light of these findings.
