This study compared the effects of three diets - a low carbohydrate Mediterranean (LCM) diet, a traditional Mediterranean (TM) diet, and the 2003 American Diabetes Association (ADA) diet - on 259 overweight patients with type 2 diabetes over 12 months. The LCM diet resulted in greater reductions in HbA1c and triglyceride levels compared to the other diets. Only the LCM diet improved HDL cholesterol levels. All diets resulted in weight loss and improvements in cardiovascular risk factors, but the LCM diet was superior for improving glycemic control.
2. DIABETES, OBESITY AND METABOLISM original article
Given the unclear data, and the lack of community-based diets included only LGI carbohydrates whereas the ADA
long-term clinical trials, our group conducted a large diet included mixed glycaemic index carbohydrates. TM
community-centered interventional study comparing three and ADA included the same percentages of carbohydrates
types of isocaloric diets in overweight DM2 patients. (50–55%), fat (30%) and protein (15–20%); LCM included
We compared the 2003 ADA diet (50–55% carbohydrates, 35% carbohydrates and 45% fat (50% MUFA). Participants
30% fats and 20% proteins) with a traditional Mediterranean were counselled to eat 4–6 meals/day according to their
(TM) diet (50–55% LGI carbohydrates, 30% fats–high lifestyle.
in monounsaturated fat content, 15–20% proteins) and
a low carbohydrate Mediterranean (LCM) diet (35% LGI Dietary Questionnaires
carbohydrates, 45% fats–high in monounsaturated fat content,
15–20% proteins). The main outcome measures were Participants completed a 24-h food recall questionnaire, a
glycaemic control and biomarkers for cardiovascular risk. validated food frequency questionnaire (FFQ) and a physical
activity questionnaire that included quality of life measures, at
baseline, 3 and 6 months [19,20]. Before the study, the dietitians
Methods participated in a training workshop to ensure standardization
The study population has been described elsewhere [18]. in questionnaire administration.
Briefly, 259 eligible patients with DM2 were enrolled between
March 2003 and April 2004. Eligible patients were recruited
Outcome Measures
from 10 urban primary care clinics in Israel’s central region
using the electronic medical records of Clalit Health Services, a Clinical Measurements
Health Maintenance Organization. Weight, height, waist and hip circumferences were measured
Inclusion criteria were: (i) age 30–65 years; (ii) DM2 at every visit. Blood pressure was obtained monthly as a mean
diagnosed within 1–10 years; (iii) body mass index (BMI) of three readings.
27–34 kg/m2 ; (iv) last HbA1c measurement 7–10%; (v) last
plasma TG level 1.8–4.5 mmol/l; (vi) last serum creatinine
<123.2 μmol/l; and (vii) no change in diabetes medication for Laboratory Measurements
at least 3 months before entering the study. All tests were performed in the Clalit Health Services Central
Exclusion criteria were: (i) proliferative diabetic retinopathy; District laboratory. Fasting blood glucose, plasma insulin levels,
(ii) current insulin treatment; (iii) active oncologic or HbA1c, total cholesterol, HDL-C, TGs, liver enzymes, serum
psychiatric disease; and (iv) uncontrolled hypothyroidism or creatinine and urea were measured at baseline and every
hyperthyroidism. 3 months.
We identified 2486 patients with DM2, 1063 (42.8%) of
whom met the inclusion criteria and 644 (60.6%) of those were
willing to participate. Before the study entry, patients were Statistical Analysis
asked to repeat laboratory tests and to undergo fundoscopy: To compare the differences between diets and changes from
244 patients did not comply and an additional 141 were baseline, t-test, one way ANOVA, chi-square or Fisher’s exact
excluded as a result of new findings, thus 259 patients were tests were used as appropriate. To evaluate the effect of the
enrolled (figure 1). diets and examine the changes over time, as well as the
interaction between diet and time, we examined the repeated
Intervention measures using generalized linear models. Measurements taken
at baseline, 3, 6, 9 and 12 months were used in the analyses,
Prior to randomization, the 259 eligible patients entered a 2-
and TG levels were examined after log transformation. Post
week maintenance period. During this time, the patients were
hoc Scheffe test was used to identify the statistically different
asked to continue their usual diet and keep a food intake diary.
diets. All p values were two-sided; p < 0.05 was considered
The patients were then randomly assigned to one of three
statistically significant. All analyses were conducted using SPSS-
isocaloric diets: TM, LCM or ADA.
PC version 15.
Patients were followed up by the same dietitian every 2
weeks for 1 year. All dieticians followed a structured protocol
for the 24 scheduled meetings and treated patients from each Results
of the three diet groups. All patients were advised to engage in
30–45 min of aerobic activity at least 3 days a week. Of the 259 patients enrolled in the study, 85 were randomly
assigned to the ADA diet, 89 to TM, and 85 to the LCM
diet. There were no significant differences at baseline in
Dietary Intervention demographic, clinical or laboratory measurements among
Table A1 (Appendix) outlines the composition of each diet. the three groups (table 1). Cumulative dropouts were 43,
The daily recommended intake of calories, protein, sodium 56 and 65 patients at 3, 6 and 9 months respectively. The
(up to 3000 mg), potassium (more than 3000 mg), calcium discontinuation rates in the three diet groups were similar
(approximately 1300 mg) and magnesium (more than 800 mg) (figure 1). The 80 individuals who did not complete the 12-
were similar in the three diet programs. The TM and LCM month follow-up had, at baseline, statistically significant higher
Volume 12 No. 3 March 2010 doi:10.1111/j.1463-1326.2009.01151.x 205
3. original article DIABETES, OBESITY AND METABOLISM
Assessed for eligibility
n =2486
Enrollment Not meeting inclusion criteria
n =1423
Refused to participate n=419
Agreed to participate Other reasons (unable to contact,
and randomized moved, changed to another HMO)
n=259 n=385
Total exclusions n=2227
ENROLLMENT
ADA diet n=85 TM diet n=89 LCM diet n=85
FOLLOW-UP
Lost to follow-up Lost to follow-up Lost to follow-up
Up to 3 months n=15 Up to 3 months n=13 Up to 3 months n=14
Up to 6 months n= 11 Up to 6 months n= 8 Up to 6 months n= 6
6 to 12 months n= 4 6 to 12 months n= 5 6 to 12 months n= 4
Due to: Due to: Due to:
Noncompliance n= 10 Noncompliance n= 11 Noncompliance n=13
Changed residence n=2 Unrelated health Changed residence n=3
Domestic problems n=3 problems n=5 Domestic problems n=4
Unrelated health Other n=1 Unrelated health
problems n=7 Incomplete 12-month problems n=2
Other n=2 follow up data n=9 Other n=2
Incomplete 12-month
follow up data n=6
Completed 12-month follow-up
n=55 n=63 n=61
Figure 1. Flow chart of the study population.
fasting plasma glucose, total cholesterol and LDL-C levels than blood lipids and HOMA decreased in all three groups, while
patients who completed the study. No differences were observed fasting insulin levels increased over time. Differences between
in HbA1c, weight, waist circumference, systolic and diastolic diets were found for HbA1c, TGs and HDL-C as well as for
blood pressures, HDL-C and TG levels. LDL-C. The reduction in HbA1c was significantly greater for
To determine patient adherence to the recommended diets, patients on the LCM than for patients on the ADA diet. The
we evaluated the results of the FFQ administered at 6 months. decrease in TGs was greater for the LCM and TM than for
The mean reported energy intake was similar in the three diets the ADA group (p = 0.001). Patients on the LCM achieved a
(2221.6 calories ± 1086.6). There was a statistically significant significant increase in HDL-C levels compared to the ADA, but
trend in the percentage of polyunsaturated fat intake of total did not differ significantly from those on the TM diet. LDL-C
energy, from highest (12.9%) in LCM, to 11.5% in TM, and levels were reduced for all three diets after a year; we found that
lowest in ADA 11.2% (p = 0.002). The same significant trend the decrease was greatest in LCM, but not significantly greater
was observed for monounsaturated fat intake (14.6, 12.8, and than the TM diet.
12.6% for LCM, TM, and ADA, respectively, p < 0.001). The Additional analysis was performed including the 80
opposite trend was observed for the percentage of carbohydrate individuals without 12-month data using the latest available of
intake, being highest in the ADA, and lowest in the LCM 3-, 6- or 9-month follow-up data. The results were comparable
diet (45.4, 45.2, 41.9 for ADA, TM and LCM, respectively, to the analysis of those who completed the study.
p = 0.011).
Clinical Measurements Discussion
At the end of the 12-month study period, weight, BMI and waist In recent years, low carbohydrate diets have been shown to
circumference were reduced in all the dietary interventions with be effective in improving glycaemic control and body weight
no significant difference between the groups (table 2). HbA1c, in type 2 diabetes [21–24] as well as weight loss in obese
206 Elhayany et al. Volume 12 No. 3 March 2010
4. DIABETES, OBESITY AND METABOLISM original article
Table 1. Baseline characteristics of the patients in the three diet groups in part by increased consumption of dietary fat in the LCM
group [29], however, the non-significant differences in caloric
Diet [data presented as mean (±s.d.)] intake between groups may have contributed to this weight
ADA TM LCM loss.
Characteristics (n = 55) (n = 63) (n = 61) p-value The LCM reduced the LDL levels by an extra 8% when
Male/female (n) 27/28 35/28 31/30 0.764
compared to the ADA and TM, which themselves each reduced
Age (year) 56.0 (6.1) 57.4 (6.1) 55.5 (6.5) 0.229 LDL by 20% (LCM reduced 24.8%, TM 20.9% and ADA
Years since DM 5.1 (2.6) 6.2 (9.9) 5.5 (3.8) 0.229 13.8%). This finding is of particular note, as other studies using
diagnosis high MUFA diets have not shown significant reductions in LDL
Weight (kg) 87.9 (13.7) 85.5 (10.6) 86.7 (14.3) 0.544 [16]. These studies had a follow-up between 4 and 6 weeks. It
BMI 31.8 (3.3) 31.1 (2.8) 31.4 (2.8) 0.483 is possible that the reduction of LDL in high MUFA diets takes
Waist circumference 113.4 (10.0) 111.1 (9.1) 112.7 (9.6) 0.401
(cm)
considerably longer to manifest than 4–6 weeks and therefore
HbA1c (%) 8.3 (0.8) 8.3 (1.0) 8.3 (1.0) 0.980 in these earlier studies the full effect of the MUFA diet was not
Fasting plasma 10.3 (1.7) 10.1 (1.8) 10.5 (2.0) 0.454 recorded.
glucose (mmol/l) In our study, LCM was the only diet that led to an increase
Fasting plasma 12.7 (6.2) 12.1 (6.5) 13.5 (5.7) 0.476 in HDL-C levels (12%). Although the ADA recommends
insulin (μU/ml) reducing fat calories to less than 30% of the total daily caloric
HOMA 5.8 (3.3) 5.0 (2.9) 5.9 (4.0) 0.549
intake, several recent studies underlined the superiority of diets
Total cholesterol 5.4 (0.9) 5.5 (0.8) 5.4 (0.9) 0.848
(mmol/l) containing higher amounts of MUFA. Garg et al. [30] found
HDL-C (mmol/l) 1.1 (0.2) 1.1 (0.2) 1.1 (0.2) 0.732 a 7–13% increase in HDL-C levels when comparing a diet
LDL-C (mmol/l) 3.0 (0.9) 3.2 (0.8) 3.1 (0.8) 0.769 rich in MUFA with a diet rich in carbohydrates in diabetic
Triglycerides 3.1 (0.8) 3.0 (0.7) 3.2 (0.8) 0.792 patients. These findings together with our study suggest that a
(mmol/l) low carbohydrate, high MUFA diet might be the best method
to increase HDL-C, while still reducing LDL.
patients [25–27]. Based on this increasing evidence, in 2008 Previous studies were unable to clarify the effect of a high
the ADA included a low carbohydrate diet as a possible MUFA diet on HbA1c. In our study, both TM and LCM diets
intervention. induced a greater decrease in HbA1c than did the ADA. As
We found that an intensive community-based dietary both Mediterranean diets were based on LGI carbohydrates,
intervention reduced cardiovascular risk factors in overweight while the reference diet included mixed glycaemic index
patients with DM2 for all three diets. The LCM group had carbohydrates, this study supports the suggested protective
improved cardiovascular risk factors compared to either the effects of LGI carbohydrates on glycaemic control in patients
ADA or the TM groups. with DM2.
The weight loss in the LCM group at 1 year was greater Consumption of MUFA is thought to improve insulin
than in the other dietary intervention groups, although the sensitivity [31–33], an effect that may explain the favourable
difference was not significant. Similar results have been found effect of the Mediterranean diet on glucose and HbA1c levels.
among moderately obese adults [28]. This may be explained Furthermore, both the Mediterranean and low carbohydrate
Table 2. Results from generalized linear model analysis describing changes in clinical and laboratory measurements between baseline and 12-month
follow-up examinations
ADA (n = 55) TM (n = 63) LCM (n = 61)
Baseline 12-month Baseline 12-month Baseline 12-month Change over p value
Variables (± s.d.) (± s.d.) (± s.d.) (± s.d.) (± s.d.) (± s.d.) time p value between diets
Weight (kg) 87.8 (13.7) 80.2 (13.2) 85.5 (10.6) 78.1 (9.9) 86.7 (14.3) 77.8 (13.1) <0.001 0.557
BMI 31.8 (3.2) 29.0 (3.3) 31.1 (2.8) 28.5 (2.9) 31.4 (2.8) 28.1 (2.8) <0.001 0.359
Waist circumference (cm) 113.1 (9.7) 104.0 (10.2) 110.9 (8.9) 101.6 (8.0) 112.6 (9.7) 102.2 (10.2) <0.001 0.388
Fasting plasma glucose (mmol/l) 10.26 (1.69) 7.19 (1.85) 10.07 (1.80) 6.57 (1.34) 10.47 (2.00) 6.18 (0.84) <0.001 0.087
HbA1c (%) 8.3 (0.8) 6.7 (0.9) 8.3 (1.0) 6.5 (0.8) 8.3 (1.0) 6.3 (1.4) <0.001 0.021∗,†
Total cholesterol (mmol/l) 5.36 (0.89) 4.50 (0.71) 5.46 (0.85) 4.50 (0.69) 5.38 (0.97) 4.50 (0.85) <0.001 0.204
LDL-C (mmol/l) 3.05 (0.87) 2.68 (0.83) 3.18 (0.76) 2.63 (0.67) 3.07 (0.81) 2.46 (0.72) <0.001 0.036∗
HDL-C (mmol/l) 1.05 (0.22) 1.00 (0.19) 1.09 (0.17) 1.09 (0.21) 1.08 (0.23) 1.21 (0.21) <0.001 <0.001∗‡
Triglycerides (mmol/l) 3.14 (0.81) 2.26 (1.12) 3.04 (0.68) 1.58 (0.33) 3.18 (0.78) 1.66 (0.36) <0.001 <0.001∗,†
Fasting insulin (μU/ml) 12.8 (6.7) 13.7 (5.3) 11.2 (6.6) 12.4 (6.2) 12.6 (8.4) 14.9 (5.7) 0.007 0.183
HOMA 5.85 (3.32) 4.32 (2.07) 4.96 (2.95) 3.69 (1.90) 5.94 (4.00) 4.20 (1.80) <0.001 0.238
∗ LCM different than ADA.
†
TM different than ADA.
‡
LCM different than TM.
Volume 12 No. 3 March 2010 doi:10.1111/j.1463-1326.2009.01151.x 207
5. original article DIABETES, OBESITY AND METABOLISM
diets have been shown to reduce postprandial hyperglycaemia, 9. Hung T, Sievenpiper JL, Marchie A, Kendall CWC, Jenkins DJA. Fat versus
which likely lowers LDL and TGs [34]. carbohydrate in insulin resistance, obesity, diabetes and cardiovascular
Some limitations in our study must be underlined. disease. Curr Opin Clin Nutr Metab Care 2003; 6: 165–176.
Potentially eligible patients refused to repeat fundoscopy and 10. Hu FB, van Dam RM, Liu S. Diet and risk of type II diabetes: the role of
blood tests and therefore, were not enrolled. The dropout types of fat and carbohydrates. Diabetologia 2001; 44: 805–817.
rate was relatively high at 31% (80/259), although this was 11. Sargrad KR, Mozzoli M. Effect of high protein vs high carbohydrate intake
in keeping with other nutritional studies [35]. Patients were on insulin sensitivity, body weight, hemoglobin A1c, and blood pressure
in independent living conditions without close supervision of in patients with type 2 diabetes mellitus. J Am Diet Assoc 2005; 105:
their food intake. However, food questionnaires showed a good 573–580.
adherence to the assigned diet and patients were followed up 12. Garg A, Bonamone A, Grundy SM, Zhang ZJ, Unger RH. Comparison of a
every 2 weeks in an urban primary care clinic. high-carbohydrate diet with a high-monounsaturated-fat diet in patients
In conclusion, we found that nutritional therapy in a with non-insulin-dependent diabetes mellitus. N Engl J Med 1988; 319:
829–834.
community-based population of overweight DM2 patients
was effective in reducing BMI, HbA1c, LDL and TG levels for 13. Campbell LV, Marmot PM, Dyer JA, Borkman M, Storlien LH. The high-
all three of the dietary interventions. A low carbohydrate monounsaturated fat as a practical alternative for NIDDM. Diabetes Care
1994; 17: 177–182.
Mediterranean diet also increased HDL-C levels and was
superior in reducing LDL, TG and HbA1c levels compared 14. Toobert DJ, Glasgow RE, Strycker LA et al. Biologic and quality-of-life
to ADA and standard Mediterranean diets. It would appear outcomes from the Mediterranean lifestyle program. Diabetes Care 2003;
26: 2288–2293.
that the low carbohydrate Mediterranean diet should be
recommended for overweight diabetic patients. 15. Garg A. High-monounsaturated-fat diets for patients with diabetes
mellitus: a meta-analysis. Am J Clin Nutr 1998; 67: 577S–582S.
16. Rodriguez-Villar C, Perez-Heras A, Mercade I, Casals E, Ros E. Comparison
Acknowledgements of a high-carbohydrate and a high- monounsaturated fat, olive oil-rich
diet on the susceptibility of LDL to oxidative modification in subjects with
This study was registered in Clinical Trials.gov Protocol
type 2 diabetes mellitus. Diabet Med 2004; 21: 142–149.
Registration System: IDNCT00520182. The authors would like
17. Esposito K, Marfella R, Ciotola M et al. Effect of a mediterranean-style diet
to thank S. Daniel Abraham International Center for Health and
on endothelial dysfunction and markers of vascular inflammation in the
Nutrition, Ben Gurion University, for assisting in study design
metabolic syndrome: a randomized trial. JAMA 2004; 292: 1440–1446.
and statistical analysis, Faye Schreiber for editorial assistance
18. Shahar DR, Abel R, Elhayani A, Vardi H, Fraser D. Does calcium intake
and Nava Yelin for helping in statistical analysis.
enhance weight loss among overweight diabetic patients? Diabetes Care
2007; 30: 485–489.
References 19. Shahar DR, Shai I, Vardi H, Brener-Azrad A, Fraser D. Development of a
1. The Israeli Ministry of Health Statistics. Selected health for all indicators semi quantitative food frequency questionnaire (FFQ) to assess dietary
2003. Morbidity, disability and hospital discharges. Available from URL: intake of multiethnic populations. Eur J Epidemiol 2003; 18: 855–861.
http://www.health.gov.il/Download/pages/Morbidity.pdf. Accessed 27 20. Shai I, Rosner BA, Shahar DR et al. DEARR study: dietary evaluation and
January 2009. attenuation of relative risk: multiple comparisons between blood and
2. Centers for Disease Control and Prevention. Crude and age-adjusted urinary biomarkers, food frequency, and 24-hour recall questionnaires:
percentage of civilian, noninstitutionalized population with diagnosed the DEARR study. J Nutr 2005; 135: 573–579.
diabetes, United States, 1980–2006. Available from URL: http://www. 21. Gannon MC, Nuttall FQ. Effect of a high-protein, low-carbohydrate diet on
cdc.gov/diabetes/statistics/prev/national/figage.htm. Last modified blood glucose control in people with type 2 diabetes. Diabetes 2004; 53:
October 8, 2008. Accessed 27 January 2009. 2375–2382.
3. Manco M, Mingrone G. Effects of weight loss and calorie restriction on
22. Boden G, Sargrad K, Homko C, Mozzoli M, Stein TP. Effect of a low-
carbohydrate metabolism. Curr Opin Clin Nutr Metab Care 2005; 8:
carbohydrate diet on appetite, blood glucose levels, and insulin resistance
431–439.
in obese patients with type 2 diabetes. Ann Intern Med 2005; 142:
4. Norris SL, Zhang X, Avenell A et al. Long-term non-pharmacological 403–411.
weight loss interventions for adults with type 2 diabetes mellitus. Cochrane
23. Ma Y, Olendzki BC, Hafner AR et al. Low-carbohydrate and high-fat intake
Database Syst Rev 2005; Issue 2, Art. no.: CD004095. DOI: 10.1002/
among adult patients with poorly controlled type 2 diabetes mellitus.
14651858.CD004095.pub2.
Nutrition 2006; 22: 1129–1136 [Epub 2006 Oct 4].
5. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-
Parikka P. Prevention of type 2 diabetes mellitus by changes in lifestyle 24. Nielsen JV, Joensson E. Low-carbohydrate diet in type 2 diabetes. Stable
among subjects with impaired glucose tolerance. N Engl J Med 2001; 344: improvement of bodyweight and glycemic control during 22 months
1343–1350. follow-up. Nutr Metab (Lond) 2006; 3: 22–26.
6. Pan XR, Li GW, Hu YH, Wang IX, Yang WY, An ZX. Effects of diet and 25. Foster GD, Wyatt HR, Hill JO et al. A randomized trial of a low-carbohydrate
exercise in preventing NIDDM in people with impaired glucose tolerance. diet for obesity. N Engl J Med 2003; 348: 2082–2090.
The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 26: 537–544. 26. Stern L, Iqbal N, Seshadri P et al. The effects of low-carbohydrate versus
7. American Diabetes Association. Nutrition principles and recommendations conventional weight loss diets in severely obese adults: 1-year follow-up
in diabetes. Diabetes Care 2004; 27 (Suppl. 1): S36–S46. of a randomized trial. Ann Intern Med 2004; 140: 778–785.
8. Chandalia M, Garg A, Lutjohann D, von Bergman K, Grundy SM, Brinkley LJ. 27. American Diabetes Association. Nutrition recommendations and inter-
Beneficial effects of high dietary fiber intake in patients with type 2 ventions for diabetes: a position statement of the American Diabetes
diabetes mellitus. N Engl J Med 2000; 342: 1392–1398. Association. Diabetes Care 2008; 31: S61–S78.
208 Elhayany et al. Volume 12 No. 3 March 2010
6. DIABETES, OBESITY AND METABOLISM original article
28. Shai I, Schwarzfuchs D, Henkin Y et al. Dietary intervention random- 35. Jenkins DJ, Kendall CW, McKeown-Eyssen G et al. Effect of a low-glycemic
ized controlled trial (DIRECT) group. Weight loss with a low- index or a high-cereal fiber diet on type 2 diabetes: a randomized trial.
carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008; 17: JAMA 2008; 300: 2742–2753.
229–241.
29. Tucker LA, Thomas KS. Increasing total fiber intake reduces risk of weight Appendix
and fat gains in women. J Nutr 2009; 139: 576–581.
30. Garg A, Bantle JP, Henry RR, et al. Effects of varying carbohydrate content Table A1. Composition of diets
of diet in patients with NIDDM. JAMA 1994; 271: 1421–1428.
31. Esposito K, Marfella R, Ciotola M et al. Effect of a Mediterranean-style Diet ADA TM LCM
diet on endothelial dysfunction and markers of vascular inflammation Carbohydrates∗ (% of TCI) 50 50 35
in the metabolic syndrome: a randomized trial. JAMA 2004; 292: Fibre (g) 15 30 30
1440–1446. Fat∗ (% of TCI) 30 30 45
32. Schwenke DC. Insulin resistance, low-fat diets, and low-carbohydrate MUFA (% of fat) 10 10 23
diets: time to test new menus. Curr Opin Lipidol 2005; 16: 55–60. PUFA (% of fat) 12 12 15
SFA 7 7 7
33. Lara-Castro C, Garvey WT. Diet, insulin resistance, and obesity: zoning in
Protein∗ (% of TCI) 20 20 20
on data for Atkins dieters living in South Beach. J Clin Endocrinol Metab
Calories/kg body weight 20 20 20
2004; 89: 4197–4205.
34. Gheewala NM. Dietary strategies for improving post-prandial glucose, MUFA, monounsaturated fats; PUFA, polyunsaturated fats; SFA, saturated
lipids, inflammation, and cardiovascular health. J Am Coll Cardiol 2008; fats.
∗
51: 249–255. Carbohydrates, fat and proteins are 100% of total caloric intake (TCI).
Volume 12 No. 3 March 2010 doi:10.1111/j.1463-1326.2009.01151.x 209