**6.3. A Mediterranean diet**

membranes), attenuate platelet aggregation, produce coronary vasorelaxation, and protect from cellular injury [126]. Sudden death was examined in US males who participated in the Physicians' Health Study over 12 years of follow-up. Men who consumed light to moderate amounts of alcohol (2–6 drinks/week) had a significantly reduced risk of CVD compared to those who never or rarely consumed alcohol [127]. Daily intake of red wine decreased plasma malondialdehyde and oxidized LDL-C, indicating the antioxidant activity of wine polyphenols [128]. The NO-mediated vasorelaxant effects of red wine phenolic extracts acted mainly through activating endothelial NO synthase [129]. Mild to moderate beer drinking (12.5–25 g/day) provides cardiac protection, improves endothelial function by inhibiting vascular oxidative damage and modulating the Akt/eNOS pathway, which should be attributed to the non-alcohol components in beer [130]. PPARγ plays an important role in glucose and lipid metabolism [131]. Ellagic acid and epicatechin gallate, active components of wine, were reported to have similar affinity to PPARγ of rosiglitazone, which is a standard drug for the treatment of T2DM [132]. Xanthohumol is a flavonoid which was reported to exist in hops and beer could decrease the activity of alpha glucosidase in a non-competitive and reversible way

via directly binding to the enzyme and triggering conformational alterations [131].

Low-fat diets may improve quality of life and extend life expectancy in healthy people, as well as in patients with overweight issues, diabetes, and CVD [77]. Due to the high risk of CVD in individuals diagnosed with T2DM, the goal in dietary fat intake (amount and type) is similar to that of patients with CVD without diabetes [77]. Certain saturated fatty acids (SFA), trans fatty acids (TFA), conjugated linoleic acids (CLA), and cholesterol adversely affect blood lipid levels, whereas viscous fiber, unsaturated MUFA and PUFA, plant sterols/ stanols, and to a certain extent, polyphenols have favorable effects [113]. Diet recommendations include obtaining 25 to 35% of daily calories from fats, and restricting saturated fats to less than 7% of total calories, TFA less than 1%, and cholesterol to less than 200 mg/day [133]. These levels can be achieved by eating more grain products, vegetables and fruits, low-fat dairy products, and fat-free milk, and by reducing food containing TFA [134]. A randomized controlled trial found that diets containing ≥7% SFA and ≥200 mg/day cholesterol led to a reduction of the LDL-C level by 9–12% compared to baseline values or to a more standard

Low-carbohydrate diets are preferable to a low-fat diet in reducing triglycerides (TG) levels and for increasing HDL-C blood levels [77]. A low-carbohydrate diet is defined as consumption of 30–130 g of carbohydrates per day or up to 45% of total calories [136]. There is no justification for the recommendation of very low carbohydrate diets in T2DM. Carbohydrate quantities, sources, and distribution should be selected to facilitate near-normal long-term

**6. Dietary patterns**

Western-type diet [135].

**6.2. Low-carbohydrate diets**

**6.1. Low-fat diets**

42 Diabetes Food Plan

A Mediterranean diet characterized by a relatively high fat intake (40–50% of total daily calories), of which SFA comprises ≤8%, and MUFA 5–25% of calories is associated with a higher life expectancy in healthy people, as well as with lower rates of stroke, coronary heart disease, and diabetes [77]. Mediterranean-style diets are preferable to a low-fat diet in reducing cardiovascular events, increasing blood HDL-C levels, decreasing plasma TG levels, and improving insulin sensitivity [77]. This diet is characterized by abundant legumes, unrefined cereals, vegetables, fresh fruit, olive oil as the principal source of fat, moderate to high consumption of fish, dairy products (mostly as cheese and yogurt), wine consumed in low to moderate amounts, and red meat consumed in low amounts [139]. The Mediterranean-style eating pattern has been observed to improve cardiovascular risk factors in individuals with diabetes [140]. Interventional studies demonstrate the beneficial role of the Mediterranean diet in T2DM management, greater improvements in glycemic control, and reduction of CVD risk factors [141]. The Mediterranean diet is associated with a lower incidence of all-cause mortality [142].

#### **6.4. The dietary approach to stop hypertension (DASH) diet**

The dietary approach to stop hypertension (DASH) diet is a dietary pattern to prevent and control hypertension. Its main target is to lower blood pressure, and therefore CVD incidence, by dietary means [77]. The DASH diet includes a relatively high daily content of fruit, vegetables, and grain; moderate amounts of low-fat dairy products, fats, and oils; a decreased content of meat, regular-fat dairy products, snacks, and sweets. All meals have similar sodium content (approximately 3000 mg/day) [77, 143]. Several observational studies in adults have shown that adherence to a DASH-like diet has positive effects on cardiovascular health, including reduced risk of hypertension, T2DM, heart failure, coronary heart disease, stroke [144]. The PREMIER trial reported that standard dietary treatment of hypertensive patients often showed unfavorable control of lipid profile and other cardiovascular risk factors [145]. In the Diabetes Control and Complications Trial, intensive glucose control significantly reduced total cholesterol and LDL-C and TG. The DASH-sodium results indicate that low sodium levels are correlated with the largest reductions in blood pressure for participants at both pre-hypertensive and hypertensive levels [146].
