A plant-based diet for the prevention and treatment of type 2 diabetes (2024)

2.1. Plant-based diets in cohort studies

Large cohort studies demonstrate that the prevalence and incidence of type 2 diabetes are significantly lower among those following plant-based eating patterns compared with omnivores and even semi-vegetarians. Those following plant-based diets tend to have lower body mass indices,^[13] which protects against type 2 diabetes. Nevertheless, differences in diabetes risk persist despite adjustments for adiposity.

The Adventist Health Study 2 examined disease prevalence by different eating patterns in an overall health-conscious cohort. Among nearly 61,000 individuals, the prevalence of type 2 diabetes decreased in a stepwise fashion with each reduction in animal products in the diet: from 7.6% in non-vegetarians, 6.1% in semi-vegetarians, 4.8% in pesco-vegetarians, 3.2% in lacto-ovo vegetarians, to 2.9% in vegans.^[13] The apparent protection of the vegan dietary pattern remained after adjustment for body mass index and other variables, with vegans having half the rate of type 2 diabetes compared with non-vegetarians (OR: 0.51; 95% CI: 0.40–0.66). Semi-vegetarians experienced intermediate benefit (OR: 0.76; 95% CI: 0.65–0.90). It is worth noting that the non-vegans in this cohort ate meat and poultry relatively infrequently (once a week or more for non-vegetarians; less than once a week for semi-vegetarians), suggesting that even small increases in red meat and poultry consumption disproportionately increase the risk of type 2 diabetes.

Prospective studies of the same Adventist cohort demonstrate similar findings. Among 41,387 individuals followed for two years, multiple logistic regression analysis controlling for body mass index and other variables demonstrated that vegans had a dramatically lower risk of developing type 2 diabetes compared with non-vegetarians (OR: 0.381; 95% CI: 0.236–0.617).^[14] In another study of 8401 members of the Adventist Mortality Study and Adventist Health Study, long-term (17-year) adherence to a diet that included at least weekly meat intake was associated with a 74% increase (OR: 1.74; 95% CI: 1.36–2.22) in odds of developing diabetes compared with long-term adherence to a vegetarian diet (zero meat intake); this association was attenuated but persisted after statistical adjustment for weight and weight change (OR: 1.38; 95% CI: 1.06–1.68).^[15]

In a cohort of 4384 Taiwanese Buddhists, vegetarian men had approximately half of the rate of diabetes (OR: 0.49, 95% CI: 0.28–0.89), and vegetarian post-menopausal women had one-quarter the rate of diabetes (OR: 0.25, 95% CI: 0.15–0.42), compared with their omnivorous counterparts, despite statistical adjustment for body mass index and other factors. Interestingly, the omnivores in this study consumed a predominantly plant-based diet with little meat or fish, again implying that small amounts of meat contribute significantly to the development of insulin resistance.^[16]

In the largest prospective study of plant-based eating patterns to date, Satija, et al.,^[17] evaluated dietary choices and type 2 diabetes incidence in the Nurses' Health Study, Nurses' Health Study 2, and the Health Professionals Follow-up Study. Eating patterns were stratified by an overall plant-based diet index, in which plant foods received positive scores while animal foods (including animal fats, dairy, eggs, fish/seafood, poultry, and red meat) received reverse scores. In the “healthful” version of this plant-based index, fruit juices, refined grains, and added sugars also received reverse scores. Analysis of data from 4.1 million person-years of follow up revealed that those most adherent to the healthful plant-based dietary index had a 34% lower risk of developing diabetes compared with those least adherent. These associations were independent of body mass index and other diabetes risk factors.

2.2. Food and nutrient components of plant-based diets

A whole-foods, plant-based eating pattern generally includes legumes, whole grains, fruits, vegetables, and nuts, and is high in fiber. All of these elements have been found to be protective against diabetes. Whole grains, including whole-grain bread, whole-grain cereals, and brown rice, have been associated with reduced risk of developing diabetes;^[18],[19] a recent systematic review and meta-analysis of 16 cohort studies found a summary relative risk of 0.68 for three daily servings of whole grains.^[20] Specific fruits and vegetables, including root vegetables, green leafy vegetables, blueberries, grapes, and apples, have been linked to lower diabetes rates.^[21],[22] Legumes have also been shown to ameliorate insulin resistance and protect against metabolic syndrome,^[23]–[26] and greater nut consumption has been associated with lower diabetes risk.^[7] Cereal fiber appears to be especially protective against type 2 diabetes.^[27]–[29]

Diets based on whole plant foods not only maximize protective foods, but they also exclude key animal-based foods that tend to promote insulin resistance, particularly processed and unprocessed red meat.^{[7],[30]–[38]} Risk estimates from recent meta-analyses on meat consumption and type 2 diabetes range from 1.13 to 1.19 per 100 g of total red meat per day and from 1.19 to 1.51 per 50 g of processed meat per day.^[39] Animal protein and animal fats have also been linked in both metabolic as well as large cohort studies to worsening insulin resistance and increased incidence of type 2 diabetes.^{[17],[39]–[48]} In the EPIC-interact cohort, for example, van Nielen et al.,^[40] observed a 22% higher type 2 diabetes incidence over 12 years in the highest versus lowest quintile of animal protein consumption, as well as a 5% higher incidence per 10 g increment of animal protein intake (multivariate-adjusted model, including body mass index).

Similarly, during 4.1 million person-years of follow up of participants in the Nurses' Health Study, Nurses' Health Study II, and Health Professionals Follow-up Study, Malik et al.,^[47] found that individuals in the highest quintile of animal protein consumption had a 13% increased risk of type 2 diabetes (95% CI: 6–21) compared with those in the lowest quintiles (pooled multivariate model including body mass index). These authors also found that substituting 5% of energy intake from animal protein with vegetable protein was associated with a 23% reduced risk of type 2 diabetes (95% CI: 16–30). In a geriatric population (ages 65 to 100 years) in Greece, a 5% increase in protein intake from meat and meat products was associated with a 34% greater likelihood of type 2 diabetes even after adjustments for age, gender, obesity, history of hypertension, hyperlipidemia, and other dietary habits.^[49] In contrast, protein intake from plant sources offered protection against diabetes.

4.1. Cardiovascular disease and risk factors

Cardiovascular disease is the major cause of premature mortality in the diabetic population and many trials have demonstrated the benefits of plant-based diets in preventing and treating cardiovascular disease. In large cohort studies, vegetarian diets have been associated with 24%–32% reductions in ischemic heart disease incidence and mortality relative to omnivorous diets.^[62]–[64] Intervention trials of plant-based diets have also documented angiographic and clinical reversal of coronary artery disease. Ornish, et al.,^[56] randomized individuals with cardiovascular disease to usual care or lifestyle treatment that included a low-fat vegetarian diet in combination with moderate exercise, stress management, and smoking cessation. After 5 years, LDL levels in the lifestyle intervention group decreased 20% from baseline without lipid-lowering medications—levels similar to that of the usual care group, 60% of whom were on lipid-lowering medications. In the lifestyle group, the average degree of coronary artery stenosis decreased over five years with a 7.9% relative improvement by year 5, compared to a 27.7% worsening in the usual care group. There was a 60% reduction in cardiac events in the lifestyle group compared with the usual care group. Other studies have demonstrated the significant cardiovascular benefits of using this plant-based lifestyle approach,^[65] and as a result, in 2010 Medicare began to reimburse the Ornish lifestyle intervention as part of an intensive cardiac rehabilitation program.^[66]

Esselstyn, et al.,^[67] examined the effects of making dietary changes alone, without other lifestyle interventions, on patients with established cardiovascular disease. The authors reported that in 11 patients with severe coronary artery disease who were compliant with a low-fat plant-based diet, 8 (73%) had documented regression of coronary artery disease on repeat angiogram after five years on the diet. In a subsequent review, outcomes were reported on 198 consecutive patients with cardiovascular disease who voluntarily came to the Esselstyn program.^[68] A total of 89% were adherent to the diet, consuming a whole-foods, plant-based diet without any meat (including poultry and fish), dairy, eggs, or added oils. The cardiovascular event rate was extraordinarily low: 0.6% among the adherent patients versus 62% among the non-adherent group.

A large body of evidence also supports the use of plant-based diets for the reduction of cardiovascular risk factors. It is well known that the prevalence and incidence of hypertension are significantly lower in those following plant-based diets compared with omnivores.^[69]–[72] In the Adventist Health Study 2 cohort, vegans had approximately half the odds of having hypertension as omnivores, even after adjustment for body mass index.^[69] Animal protein has been shown in several prospective studies to increase the risk of hypertension,^[73]–[75] while plant protein tends to lower blood pressure, even in elderly patients.^[76],[77] Interventional trials of vegetarian diets have been shown to lower blood pressure when compared to omnivorous control diets.^[78]

A literature review of plasma lipids and plant-based diets found that among different plant-based diets (i.e., lacto-ovo vegetarian, lactovegetarian, and vegan), populations following vegan diets had the lowest cholesterol concentrations.^[79] This review also found that plant-based diets are associated with up to a 35% reduction in serum LDL cholesterol, whereas interventions allowing small amounts of lean meat demonstrated less dramatic reductions in total cholesterol and LDL levels. In the EPIC-Oxford cohort, those following vegan diets had lower levels of apolipoprotein B, reflecting lower levels of circulating atherogenic particles.^[80]

Chronic inflammation, as measured by serum biomarkers such as C-reactive protein, has been linked to risk of cardiovascular events,^[81] and is closely tied to dietary choices; those following Western, or ‘meat-based’ diets, tend to have higher levels of biomarkers of inflammation, whereas those following ‘vegetable-and-fruit’ based patterns tend to have lower levels of these biomarkers.^[82] Among intervention trials of plant-based diets, a recent systematic review and meta-analysis found that those adopting a fully or mostly plant-based diet had significant reductions in C-reactive protein and other obesity-related inflammatory biomarkers compared to those following control, non-plant-based diets.^[83]

4.2. Renal disease

Chronic kidney disease rates increase with age, and among those older than 60 years, renal impairment is more common in diabetic versus nondiabetic patients (60% vs. 41%).^[3] Using NHANES 3 data, Chen, et al.,^[84] found that in individuals with chronic kidney disease, defined as a glomerular filtration rate < 60 mL/min, every 33% increase in plant to total protein consumption was associated with a significant 23% lower mortality risk.To evaluate which foods may be associated with worsening renal disease in diabetic patients, Almeida, et al.,^[85] obtained a detailed diet history in diabetic patients with and without micro-albuminuria. High intake of protein from animal sources and low intake of polyunsaturated fatty acids, particularly from plant oils, was associated with the presence of micro-albuminuria.

In a crossover trial testing whether albuminuria can be improved in diabetic patients with advanced kidney disease simply by replacing the source of protein, red meat in the usual diet was replaced by either chicken as the major source of protein or a low-protein lacto-ovo vegetarian diet. At the end of four weeks, albuminuria on the vegetarian and chicken diets (330 mg/day and 387 mg/day, respectively) was significantly less than after four weeks on the red meat diet (449 mg/day), strongly suggesting that the protein source impacts the degree of albuminuria.^[86] Similarly, Azadbakht, et al.,^[87] performed a randomized controlled trial in diabetic adults with macro-albuminuria (300–1000 mg total protein excretion/day), substituting half of the animal protein for soy protein in the intervention group and following them for four years. They found that the soy protein intervention group had a significant improvement in proteinuria (−150 mg/day vs. +502 mg/day), along with significant decreases in total cholesterol (−23 mg/dL vs. +10 mg/dL, P = 0.01), LDL cholesterol (−20 mg/dL vs. +6 mg/dL, P = 0.01) and fasting glucose (−18 mg/dL vs. +11 mg/dL, P = 0.03).

A recent review outlined how a Western-style diet, characterized by high intake of red meat, animal fat, highly processed food and low intake of fruits and vegetables, is associated with kidney disease.^[88] A variety of mechanisms were proposed for this association, including increased animal protein leading to decreased renal blood flow and glomerular filtration rate, an increased acid load from animal protein that must be excreted by the kidneys, and lower fruit and vegetable ingestion leading to lower alkali levels and a net high endogenous acid load, which increases nephron workload. Taken together, these observational and interventional studies support the use of a plant-based diet in treating diabetic nephropathy by both reducing animal-based foods and increasing plant foods.

4.3. Diabetic neuropathy

Diabetic neuropathy is a microvascular complication of diabetes that can be debilitating. At least two small studies have shown that a plant-based diet can ameliorate diabetic neuropathic pain. One study demonstrated a remarkable resolution of burning neuropathy in 81% of participants during a 25-day residential lifestyle program in which plant-based meals were provided, including a sustained response in the participants who adhered to the diet after returning home.^[89] A recent randomized controlled pilot study also demonstrated how a plant-based diet can effectively treat diabetic neuropathy: among community-dwelling patients with painful diabetic neuropathy, pain scores were significantly improved at 20 weeks on a plant-based diet compared with a control diet.^[90]

5.1. Protein

While the 2015 United States Dietary Guidelines emphasize “lean” sources of protein,^[93] the evidence does not support turning to animal sources for protein, particularly for individuals with diabetes. Plant sources of protein have the benefit of being truly low fat in many cases (e.g., most legumes). In addition, they supply fiber and many beneficial phytonutrients, all of which are lacking in animal foods and are deficient in the average American diet.^[94] In terms of treating type 2 diabetes, a recent systematic review and meta-analysis of 13 randomized controlled trials evaluated the effect of replacing animal protein with plant protein on glycemic control.^[45] Among participants, whose average age was 62 years, there was a significant decrease in hemoglobin A1c (−0.15%), fasting glucose (−0.53 mmol/L) and fasting insulin (−10 pmol/L) in diets that replaced animal protein with plant sources of protein at a median level of about 35% of total protein/day, compared with control diets. Another study carried out among 6107 diabetes patients from 15 European cohorts demonstrated that replacing 10 g of dietary carbohydrate with total and animal protein was associated with a mean 5-year weight gain, whereas replacement with plant protein was not significantly associated with weight change.^[95] Moreover, substitution with plant protein conferred a significant 21% decrease in all-cause mortality risk. Similarly, a recent large cohort study of 131,342 adults found that in participants with at least one unhealthy lifestyle factor, substitution of 3% of energy from plant protein in lieu of animal protein was associated with a 10% decrease in all-cause mortality and a 12% decrease in cardiovascular mortality.^[96] The mortality benefit of plant protein over animal protein was evident across the board, for all major types of animal protein sources (processed meat, red meat, eggs, dairy, poultry, and fish). These studies point to the importance of specifying the type of protein recommended for the management of diabetes and for overall mortality reduction.

5.2. Fats

In relation to insulin resistance, the weight of metabolic studies and epidemiologic evidence suggests that the type of fat in the diet (e.g., saturated, polyunsaturated, or monounsaturated) is highly relevant. Saturated and trans fats increase the risk of developing diabetes;^[43] moreover, in diabetic patients, saturated fats are actually associated with increased mortality when they replace carbohydrates in the diet.^[97] A recent systematic review of randomized controlled feeding trials evaluated the effects of saturated, monounsaturated, and polyunsaturated fats, as well as carbohydrates on metrics of glucose insulin homeostasis.^[98] Replacing carbohydrates (mainly refined starches and simple sugars) and saturated fats with monounsaturated and polyunsaturated fats lowered hemoglobin A1cand improved insulin resistance; polyunsaturated fats were also noted to improve insulin secretion. The authors concluded that in comparison to carbohydrates and saturated fats, monounsaturated and polyunsaturated fats had the most favorable effect on glycemia, insulin resistance, and secretion. In terms of foods, these findings support consumption of vegetable fats (e.g., nuts, avocados, olives) in place of animal fats and refined grains.

Furthermore, there may be a threshold beyond which total fat also affects insulin resistance. In an observational study of 1785 European adults aged 50–75 years with type 2diabetes, increasingtotal fatintake from < 25% to ≥ 35% was associated with a significant increase in LDL cholesterol, triglycerides, hemoglobin A1c, and C-reactive protein (P<0.05), whereas increasing carbohydrate intake from < 45 to ≥ 60% was associated with significantly lower triglycerides, hemoglobin A1c, and C-reactive protein (P<0.05).^[99]Similarly, Vessby, et al.,^[100] found that the beneficial impact of monounsaturated fats over saturated fats on insulin sensitivity was absent in individuals with a high total fat intake (> 37% of energy). It is important to note that in key randomized trials of plant-based diets for type 2 diabetes, recommended total fat intake has been low (approximately 10% of energy) for intervention groups.^[53],[55]

5.3. Carbohydrates

It is a common perception that carbohydrate-rich foods should be avoided in people who have, or are at risk for, type 2 diabetes. As with protein and fat, it is essential to distinguish between the types and sources of carbohydrates. Meta-analyses of cohort studies demonstrated that carbohydrates from whole grains and cereal fibers reduce the risk of developing diabetes while refined,^[20],[101] low-fiber carbohydrates can increase the risk of diabetes.^[29] Metabolic studies also confirm benefits of carbohydrates in comparison to animal protein. Sargrad, et al.,^[102] compared high-protein versus high-carbohydrate diets, while keeping fat intake constant at 30%, for a period of eight weeks in patients with type 2 diabetes. The high-carbohydrate group was instructed to eat more bread, cereal, pasta, and starchy vegetables while the high-protein group was instructed to have more fish, chicken, eggs, low fat milk, cheese, and nuts.Although weight loss was equivalent in both groups, the high-carbohydrate group had a decrease in hemoglobin A1c (from 8.2% to 6.9%, P < 0.03) and fasting plasma glucose (from 8.8 to 7.2 mmol/L, P < 0.02), and an increase in insulin sensitivity (from 12.8 to 17.2 mmol/kg per minute, P < 0.03). No significant changes in these parameters occurred in the high-protein group.

Moreover, low-carbohydrate diets have been found in several studies to actually increase the risk of type 2 diabetes. Among more than 40,000 men in the Health Professionals Follow-Up Study, the highest quintile of a low-carbohydrate eating pattern, when based on animal sources, conferred a 37% increased risk of diabetes; interestingly, when the low-carbohydrate diet was based on vegetable sources, it was protective, decreasing risk by 22%.^[103] Halton, et al.,^[104] found a similar protective effect of plant-based low-carbohydrate diets among women in the Nurses' Health Study, although, in this population, the overall low-carbohydrate score did not increase risk. In the Nurses' Health Study II cohort, among 4502 women with a history of gestational diabetes, there was a 36% increased risk of diabetes among women with the highest overall low-carbohydrate diet score, and a 40% increased risk when the low-carbohydrate diet favored animal products.^[105] In the EPIC-Potsdam cohort, Schulze et al.,^[106] noted that a higher carbohydrate intake at the expense of protein might decrease diabetes risk. In the general and geriatric populations, low-carbohydrate diets have been associated with increased all-cause, cardiovascular, and cancer mortality.^{[107]–[110]}

This article is part of a Special Issue “A plant-based diet and cardiovascular disease”.

Guest Editors: Robert J Ostfeld & Kathleen E Allen

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