The relationships between macronutrient and micronutrient intakes and type 2 diabetes mellitus in South Asians: A review
Introduction
South Asians (Indians, Pakistanis, Bangladeshis, Nepalese, and Sri Lankans) have a higher prevalence of type 2 diabetes mellitus (T2DM) compared to other populations. This paper reviews the epidemiology of T2DM in South Asians (SA), examines the role of nutrient intakes in T2DM in this population, and identifies gaps in the literature. This review also describes the mechanisms by which intake of various nutrients contributes to the risk for T2DM. In addition, dietary intake assessment methodology is briefly reviewed before the section on the role of nutrient intakes in T2DM. Lastly, it identifies areas of future research and provides an overall perspective.
The literature search on the relationship between nutrient intakes and T2DM was conducted by searching the MEDLINE database (National Library of Medicine, Bethesda, MD) for relevant articles from the year of MEDLINE's inception through November 2018. Key phrases such as dietary intake and type 2 diabetes, nutrient intake and type 2 diabetes, and correlates of type 2 diabetes with and without the terms SA or Asian Indians were used to identify relevant articles.
Section snippets
Epidemiology of T2DM in SA
SA living in South Asia or western countries have a higher prevalence of T2DM than other races. Hills et al.1 have conducted an extensive review on the epidemiology of T2DM in south Asia including data from the Chennai Urban Rural Epidemiology Study (CURES),2 Indian Council of Medical Research–INdia DIABetes (ICMR-INDIAB) study,3 the National Urban Diabetes Survey (NUDS),4 two household surveys in India,5 and the International Diabetes Federation (IDF) report.6 Mohan et al.2 reported a 14.3%
Dietary assessment methodology
Because the focus of this paper is to examine the relationship between nutrient intakes and T2DM, a description of the methods14,15 used to assess dietary intake in various studies is given in this section. Also provided are the strengths and limitations of each method.14,15 All the methods used were valid.
Majority of the studies in this area used a food frequency questionnaire (FFQ) to assess dietary intake. A FFQ consists of a set of foods with response categories to determine the usual
Relationship between nutrient intakes and T2DM in non-SA populations
Many prospective observational studies conducted among whites, Hispanics, African-Americans, and/or East Asians have shown that macronutrient (protein, carbohydrate, and fat) and micronutrient (vitamins and minerals) intakes determine the risk for T2DM. Studies in these populations have shown that total dietary fiber, cereal fiber, and fats derived from plants reduce the risk whereas high intakes of carbohydrate and protein, especially animal protein, enhance the risk for T2DM.17., 18., 19., 20.
Applicability of findings from non-SA to SA
Very little is known about the role of macronutrient and micronutrient intakes in T2DM in SA. Data from studies in other populations may not be applicable to SA because of differences in macronutrient and micronutrient intakes and consumption of very ethnic specific diets among SA. Based on a number of studies conducted in India and western countries, SA tend to consume more percent energy from carbohydrate and less percent energy from fat and saturated fat compared to the general American
Relationship between nutrient intakes and T2DM in SA populations
The section below presents data from epidemiologic studies (there are no randomized studies) on the relationship between macronutrient and micronutrient intakes and T2DM in SA. This section will also identify gaps in the literature in this population.
The studies on SA migrants in western countries will be presented in a separate section from those on native SA because of the effects of acculturation on lifestyle. Talegawkar et al.42 have found that length of stay in the U.S. is associated with
Dietary fiber intake
Among the studies in SA that reported data on dietary fiber, two studies35,46 found an inverse correlation between dietary fiber and T2DM and two studies found no relationship.32,51 According to a meta-analysis of prospective cohort studies in other populations, total dietary fiber and cereal fiber are inversely related to T2DM.17 In a review paper, Gulati and Misra52 noted that SA in India are increasingly replacing foods rich in fiber such as whole wheat flour chapattis, millet chapattis, and
Future research
The current literature in the area of nutrient intakes in type 2 diabetes in SA is limited by a number of methodological issues discussed above. Identified below are the types of future studies that are needed in SA based on the methodological constraints of the current literature.
- 1.
There are very few epidemiologic studies examining the role of nutrient intakes in T2DM in SA. Most of the previous case-control and cross-sectional studies were conducted in those with known T2DM which may affect
Overall perspective
The review showed that certain nutrients are related to T2DM in SA and similar findings were also noted from studies conducted in non-SA populations. The literature on nutrient intakes and T2DM in SA is, however, limited by a small number of studies, lack of prospective cohort and randomized controlled studies, issues with dietary assessment methodology, assessing SA with known T2DM rather than those with undiagnosed T2DM or prediabetes, and examining only a few nutrients. Future research using
Acknowledgments
This work was partly supported by the Gupta-Agarwal Foundation, USA, Jiv Daya Foundation, USA, and the Southwestern Medical Foundation, USA. We thank Carmel Tovar for preparing the figure.
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Declarations of interest: None.