Journal

Introduction

▹ Ever-increasing number of DM patient

▹ Economic burden
▹ Mostly type 2
▹ More children is affect
Introduction

▹ Its complication impact both mental and physical

▹ Increased mortality (5M 2015)
▹ 3 times depression
Introduction

▹ Jan 2018 new guideline suggest plant-based diet

▹ Poor diet = DM
▹ More meat = more DM
▹ Plant-based diet protect
against DM
▹ No study focus solely on
mental and medical outcome
Objective

▹ The aims of this review are to systematically analyze the

available literature on plant-based diet interventions
targeting and/or including adults with diabetes and to
clearly define the benefits on well-being of such
interventions.
Method

▹ The incorporation of the Preferred Reporting Items for

Systematic Reviews and Meta-Analyses guidelines
Inclusion Exclusion

Plant-based diet interventions Diet interventions for diabetes

targeting or including adults with
T2D
Age of participants ≥ 18 years
Clearly defined health outcomes
Controlled trials with length of ≥ 3
weeks
Peer-reviewed studies
other than type 2
Age of participants <18 years
Uncontrolled studies
Diet interventions that included
more than 10% of daily calories
on animal products
Duplicate results
Method

▹ Computerized systematic search

▹ 10 November 2017
▸ Allied and Complementary Medicine, Cochrane Central Register of
Controlled Trials, Cumulative Index to Nursing and Allied Health
Literature, E-Journals, Excerpta Medica Database, MEDLINE, Health
Management Information Consortium, PsycARTICLES, PsycINFO,
PubMed, SocINDEX and Web of Science
▹ Search term
▸ plant based OR plant-based OR “plant based” OR plant food OR
“plant food” OR vegan* OR vegetarian* OR “Daniel fast”; (2) diabet*
OR T2D OR DT2; and (3) intervention* OR program* OR “controlled
trial*” OR “randomised controlled trial*” OR “randomized controlled
trial*” OR RCT
Method

▹ quality of life ▹ Weight

▹ self-esteem ▹ fasting blood glucose
▹ depression ▹ total cholesterol
▹ perceived pain and neuropathy ▹ LDL
symptoms ▹ triglycerides
▹ foot conductance ▹ diabetes-related medication
▹ nutritional efficacy ▹ baseline characteristics
▹ general efficacy
▹ dietary adherence
▹ dietary restraint
▹ dietary disinhibition
▹ diet acceptability
▹ quality of life HbA1c
Method

▹ The Quality Assessment Tool for Quantitative Studies

 Results: Study selection process
12
 Results : Study characteristics
14
▹ 11 included studies (1999 – 2017)
Country USA Czech Itary New South
Zealand Korea
▹Numbers
Community-based
6 2 settings.
1 Except
1 1 1
supervised residential environment
4
3
▹ Total sample size 433 participants (Mean
sample size 48)
▸ Intervention groups 219
▸ Control groups 214
▹ Age 27 - 80 years (mean 54.8 years).
▹ withdrawals rates 3.5% - 29.1% (reported in
 Results : Study characteristics
15
▹ All studies targeted populations T2D
except 3 studies, 39,
40
▸ 2/3 studies: BMI ≥25 and/or T2D
▸ 1/3 study: BMI ≥25 and 4 at least one
4
Dx of T2D or IHD or HTN or
hypercholesterolemia.
▹ But results specific outcomes related to
individuals with T2D
 Results : Study characteristics
16
▹ All included studies: Controlled trials
duration 3 - 74 weeks (mean 23.2
weeks)
▹ 9 studies: controlled trials
▸ 7 studies: RCTs
⬩ 4 studies: reported the
randomization process
⬩ 3 studies: failed to describe
▸ 2 studies: a parallel design and a
cluster study design.
▹ 8 studies: vegan diets in intervention groups
 Results : Study characteristics
17
▹ All studies primary or secondary
outcome: HbA1c
(baseline and at the end of each study)
▹ 4/11 Studies outcomes: psychological 36,38,42,
well-
43,45
being
39,40,41,
▹ 5 controlled trials: nutritional education in
44
both groups
▹ 4 controlled trials: provided education only
to intervention group
▹ All studies: both baseline and end-line
results
 Results : Study characteristics
18

4
4
4
5
4
1

4
supervised
3 residential
environment
3
9
3
5
*CG, control group; IG,
 Results: Study characteristics (continue)
19

3
6
5
1
3
7
3
8

4
2
 Finding
- Quality of life, psychological and social well-
being
- Adherence, acceptability and diet behavior
- HbA1c and diabetes control
- Further medical outcomes

20 ”
 Finding: Quality of life, psychological
and social well-being
21
▹ Quality of life
▹ Significantly improved only in
intervention35,gr.
41
(p=0.01; p<0.05)
▹ Significant improvements in intervention
4
group in both psychological
4
& physical
components summary
(p<0.001; p<0.0001) 4
4
▹ Control group - significant improvement
only in the physical component summary
(p=0.03)
 Finding: Quality of life, psychological
and social well-being
22
▹ Depression levels significance drop
only in the intervention gr. 3 (p=0.03)
5
▹ Pain significantly decreased between
groups favoring the 4intervention group
1
(p=0.04).
4
▹ Foot conductance:
1 significant decline in
in the control group (p=0.03),
intervention  stopped or slowed down
progress of n. impairment.
▹ Significant differences
4 in favor of the
4
intervention group for self-esteem
 Finding: Quality of life, psychological
and social well-being
23
▹ Plant-based diet could improve the
overall quality of life, psychological
well-being and chronic diabetic
neuropathy in people with T2D without
changes in food enjoyment and diet
costs. 4
1
▹ The slight increase in electrochemical
skin conductance in the intervention
group and the significant decline of the
control group  plant-based diet
intervention promising for further testing
 Finding: Adherence, acceptability and diet
behavior
24
▹ 5 studies: greater adherence among the
participants of the intervention group
36,37,39,
41,44
compared with the control group 4
3
▹ 1 study: high adherence among both
groups. 4
0
▹ 1 study: complete adherence to the plant- 4
based intervention diet in approximately 5
half of participants (44%).
▹ 1 study: control group reported higher
adherence (p=0.002),
while the percentage of participants who
reported high adherence was significantly
 Finding: Adherence, acceptability and diet
behavior
25
35,
▹ Dietary restraint increased greaterextent
37
only in the control group  Control group
felt more constrained by their assigned diet
than the participants of the plant-based diet
group. 3
5
▹ Dietary disinhibition decreased significantly
only in the intervention group (p=0.01) in 1
study 3
7
▹ Declined in both groups  individuals in
both groups3 were feeling less hungry
compared 7with baseline and they were less
likely to overeat as a response to stressful
 Finding: Adherence, acceptability and diet
behavior
26
▹ Within-group analysis: significant
improvement in levels of energy
3 only in the
7
intervention group (p<0.001) 3
7
▹ The control group: significant improvement
in digestion (p<0.05).

▹ Overall, plant-based diets were slightly

more demanding in initial effort, greater
adherence  high rates of acceptability
▹ Control group diets: constraining, and as a
result dietary restraint was higher.
 Finding: HbA1c and diabetes control
27
▹ 9 studies: baseline and end-line
measures for HbA1c.
▸ 8 studies: HbA1c was greater
decrease in the intervention groups
4
0
▸ 1 study: the decrease
4 was similar in
4
both groups.
▹ After excluding Wright et al - not
reporting HbA1c specifically

▹ Mean difference 8 studies: HbA1c decrease

0.55% in the intervention groups and 0.19%
 Finding: HbA1c and diabetes control
28
▹ Participants in the intervention groups
managed to better control their
diabetes via the plant-based diet
▹ HbA1c in36,
2 studies among participants
40
whose medication remained unchanged
▸ Greater decrease of 1% in the 4
0
intervention group compared with a
decrease of 0.2%3 in the control group in
6
one study
▸ Significantly decreased by 0.9% only in
the intervention group (p=0.002) in the
other.
 Finding: HbA1c and diabetes control
29
▹ An analysis among participants who
reported high adherence showed a 4
5
greater difference of HbA1c between 2
groups:
▸ a significant within-group decrease of
0.9% in the intervention group
(p<0.01) and a significant within-group
decrease of 0.3% in the control
4 group
5
(p<0.05).
▹ The reported decrease between the 2
groups was significantly greater in the
 Finding: Further medical outcomes
(summary) – Intervention group
30
▹ Reduction/discontinuation of DM-related
medications
(eg. DM, HTN, DLP)
▹ weight loss
▹ Decrease FBS
▹ Decrease Total cholesterol
▹ Decrease LDL
 DISCUSSION
40
▹ This systematic review demonstrates evidence that a plant based
diet can significantly improve
▸ psychological wellbeing
▸ quality of life
▸ control of T2D measured by HbA1c
▸ physical characteristics (weight loss,
FBG, total cholesterol, LDL cholesterol, triglycerides )
 DISCUSSION
41
▹ psychological wellbeing and quality of life

- significant improvements in depression,

emotional well-being, physical well-being,
general quality of life
- Decrease diabetic neuropathic pain
 DISCUSSION
42 ▹ Participants’ adherence ( IG > CG)
 DISCUSSION
43 ▹ Participants’ adherence (CG > IG)

- Lee et al used only phone consultations

- 36,37,39,41,42 weekly educational sessions
results high adherence
 DISCUSSION
44
▹ diet behavior and diet acceptability ( IG = CG, IG> CG)
 DISCUSSION
45
▹ Diabetic control
▸ plant-based diet intervention can significantly
reduce HbA1c in adults with T2D (average
decrease of 0.55% )
▸ potentially reduce diabetes medication
▸ studies reported a reduction or
discontinuation of diabetes-related
medication in the intervention groups.
▸ reported significant improvements in FBG
levels.
 DISCUSSION
46
▹ Weight loss
▸ Five studies reported significant greater weight loss
in the intervention group (mean weight loss 5.23 kg)
compared with the control group (mean weight loss
2.83 kg) from baseline to end-line.
 DISCUSSION
47
▹ Lipid lower
▸ plant-based diet can significantly lower
total cholesterol, LDL cholesterol,
triglycerides and the
overall risk for CVD.
 DISCUSSION
48
▹ strengths
▸ CTs were conducted in several different
countries
▸ reviewing CTs which focus on dietary
patterns and not
isolated nutrients makes the findings of
the review easier
to be applied to the general population.
▸ compared with official guidelines from a
number of countries, the plant-based
diet was found to be superior
 DISCUSSION
49
▹ limitations
▸ The included studies had rather small sample
sizes
▸ two of the studies were not randomized.
▸ adherence in control trials regarding diet is
difficult to be followed and measured
 CONCLUSION
50
▹ plant-based diets accompanied by educational
interventions can
significantly improve psychological health, quality
of life,
HbA1c levels and weight and therefore the
management
of diabetes.
▹ plant-based diets could potentially improve
diabetic neuropathic pain and the levels of total
cholesterol, LDL cholesterol and triglycerides in
T2D.
 PRISMA 2009

51
Prisma 2009
checklist

▹ Title “Effectiveness of plant-based diets in

promoting well-being in the management of type 2
diabetes: a systematic review”
▹ Abstract Provide a structured summary including, as
applicable: background; objectives; data
sources; study eligibility criteria, participants,
and interventions; study appraisal and
synthesis methods; results; limitations;
conclusions and implications of key findings;
systematic review registration number.
Prisma 2009
checklist

▹ Introduction ▹ Method
▸ Rationale ▸ Protocol and registration
▸ Objective ▸ Eligibility criteria
▸ Information sources
▸ Search
▸ Study selection
▸ Data collection process
▸ Data items
▸ Risk of bias in individual
studies
▸ Summary measures
▸ Synthesis of results
▸ Risk of bias across studies
▸ Additional analyses
 17. Study selection
54
Give numbers of studies screened,
assessed for eligibility, & included in the
review, with reasons for exclusions at
each stage, ideally with a flow diagram.
 PRISMA 2009 Flow Diagram

Identification
55 Records identified through Additional records identified
database searching (n = 1,240 ) through other sources (n = 0 )

Records after duplicates removed (n = 516 )

Screening

Records screened (n = 516 ) Records excluded

(n = 475 )

Full-text articles assessed for Full-text articles

Eligibility

eligibility (n = 41 ) excluded, with reasons

(n = 28 )

Studies included in
qualitative synthesis (n = - )
Included

Studies included in
quantitative synthesis (meta-
analysis) (n = 13 )
 18. Study characteristics
56
For each study, present characteristics
for which data were extracted (e.g.,
study size, PICOS, follow-up period) and
provide the citations.

PICOS = population, intervention, control,

outcome, study design
 19. Risk of bias within studies
57
Present data on risk of bias of each
study and, if available, any outcome
level assessment (see item 12).

Item12 Describe methods used for assessing risk of bias

of individual studies and
 20. Results of individual studies
58 For all outcomes considered (benefits
or harms), present, for each study:
(a) simple summary data for each
intervention group
(b) effect estimates and confidence
intervals, ideally with
a forest plot.
 21. Synthesis of results
59
Present results of each meta-analysis
done, including confidence intervals
and measures of consistency.
 22. Risk of bias across studies
60

Present results of any assessment of

risk of bias across studies (see Item 15).
Item 15 Specify any assessment of risk
of bias that may affect the cumulative
evidence (e.g., publication bias,
selective reporting within studies).
 23. Additional analysis
61
Give results of additional analyses, if
done (e.g., sensitivity or subgroup
analyses, meta-regression [see Item 16]).
Item 16 Describe methods of additional
analyses (e.g., sensitivity or subgroup
analyses, meta-regression), if done,
indicating which were pre-specified.
 24. Summarized the main finding the
62
strength of evidence for each main
outcome
 25. Discuss limitations at study
and outcome level (e.g., risk of
bias), and at review-level
63
 interpretation of the results in
the context of other evidence,
64 and implications for future
research
 27. Describe sources of funding for
the systematic review and other
65 support (e.g., supply of data); role of
funders for the systematic review