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Impact of a high dietary fiber
cereal meal intervention on body
weight, adipose distribution, and
cardiovascular risk among
individuals with type 2 diabetes
Xiaofeng Li
1
,YuShi
1
*, Dongqin Wei
1
, Wenyu Ni
1
,
Na Zhu
2
and Xinyi Yan
1
1
Department of Endocrinology, Metabolic Management Center, Qidong People’s Hospital, Qidong
Liver Cancer Institute, Affiliated Qidong Hospital of Nantong University, Jiangsu, China,
2
Department
of Remote ECG Diagnostic Center, Qidong People’s Hospital, Qidong Liver Cancer Institute, Affiliated
Qidong Hospital of Nantong University, Jiangsu, China
Objective: This study sought to examine the impacts of a high dietary fiber cereal
meal in comparison to conventional dietary management for diabetes on body
weight, distribution of adipose tissue, and cardiovascular risk among individuals
diagnosed with type 2 diabetes (T2DM).
Methods: A cohort of 120 patients diagnosed with T2DM was enlisted as the
study population and divided into two groups using a ratio of 2:1—namely, the W
group (n=80) and the U group (n=40). The U group (control) received usual diet,
while the W group (intervention) incorporated a high dietary fiber cereal meal in
place of their regular staple food in addition to adhering to conventional diabetes
dietary recommendations. The high dietary fiber cereal meal was based on whole
grains, traditional Chinese medicinal foods, and prebiotics. A subsequent follow-
up period of 3 months ensued, during which diverse parameters such as body
mass index (BMI),waist-hip ratio (WHR), glycated hemoglobin (HbA1c),fasting
blood glucose(FBG),C-peptide levels, blood pressure, blood lipids, high-
sensitivity C-reactive protein (hsCRP),10-year cardiovascular disease (CVD) risk,
and Lifetime CVD risk were assessed before and after the intervention.
Results: Among the participants, a total of 107 successfully completed the
intervention and follow-up, including 72 individuals from the W group and 35
from the U group. Following the intervention, both cohorts exhibited decrease in
BMI, WHR, HbA1c, FBG, blood pressure, and blood lipid levels in contrast to their
initial measurements. Remarkably, the improvements in BMI, WHR, HbA1c, FBG,
total cholesterol (TC), triglycerides(TG), low-density lipoprotein cholesterol
(LDL-C), the ratio of triglyceride to high-density lipoprotein cholesterol (TG/
HDL-C), and the ratio of 2-hour C-peptide (2hCP) to fasting C-peptide (FCP)
were more marked within the W group, exhibiting statistically significant
disparities (P<0.05) in comparison to the U group. Furthermore, the levels of
hsCRP declined among individuals in the W group, while the U group
experienced an elevation.10-year CVD risk reduction were similar in the two
groups. While, Lifetime CVD risk only decreased significantly in the W group.
Frontiers in Endocrinology frontiersin.org01
OPEN ACCESS
EDITED BY
Yuhang Ma,
Shanghai General Hospital, China
REVIEWED BY
Feng Zhang,
Affiliated Hospital of Jiangnan University,
China
Xueqin Wang,
Nantong First People’s Hospital, China
Hongzhuan Sheng,
Nantong University, China
*CORRESPONDENCE
Yu Shi
2383994147@qq.com
RECEIVED 26 August 2023
ACCEPTED 17 October 2023
PUBLISHED 30 October 2023
CITATION
Li X, Shi Y, Wei D, Ni W, Zhu N and Yan X
(2023) Impact of a high dietary fiber cereal
meal intervention on body weight, adipose
distribution, and cardiovascular risk among
individuals with type 2 diabetes.
Front. Endocrinol. 14:1283626.
doi: 10.3389/fendo.2023.1283626
COPYRIGHT
© 2023 Li, Shi, Wei, Ni, Zhu and Yan. This is
an open-access article distributed under the
terms of the Creative Commons Attribution
License (CC BY). The use, distribution or
reproduction in other forums is permitted,
provided the original author(s) and the
copyright owner(s) are credited and that
the original publication in this journal is
cited, in accordance with accepted
academic practice. No use, distribution or
reproduction is permitted which does not
comply with these terms.
TYPE Original Research
PUBLISHED 30 October 2023
DOI 10.3389/fendo.2023.1283626
Conclusion: The intervention centred on a cereal-based dietary approach
showcased favourable outcomes with regard to body weight, adipose
distribution, and cardiovascular risk in overweight individuals grappling with
T2DM.
KEYWORDS
cereal-based nutritional intervention, overweight, type 2 diabetes, cardiovascular risk,
metabolic syndrome
1 Introduction
Cardiovascular disease is the leading cause of death among
individuals with diabetes. Diabetes itself is an independent risk
factor for cardiovascular disease, increasing the risk by 2 to 4 times
compared to those without diabetes. It is worth noting that diabetes
often coexists with other significant cardiovascular risk factors, such
as hypertension and lipid abnormalities (1). The combination of
clinical manifestations, including obesity, hyperglycemia,
hypertension, and dyslipidemia, is referred to as metabolic
syndrome. This collection of factors significantly contributes to the
development of atherosclerotic cardiovascular diseases (ASCVD).
Research has shown that among diabetes patients, those with
uncontrolled metabolic syndrome components face higher risks of
adverse cardiovascular outcomes compared to those with well-
managed components (2). Comprehensive interventions that
address multiple risk factors have the potential to significantly
reduce the incidence and mortality associated with cardiovascular
diseases in individuals with diabetes (3). The management of body
weight is an essential aspect of type 2 diabetes (T2DM) therapy.
Achieving optimal weight not only improves glycemic control and
reduces the need for hypoglycemic medications but also leads to
improvements in other metabolic parameters among diabetic
patients, including blood pressure and lipid profiles.
Obese T2DM patients often exceed their daily caloric intake,
primarily attributed to disproportionate carbohydrate consumption
(4). A multitude of investigations on ketogenic diets have exhibited
that stringent carbohydrate reduction substantively facilitates
weight management and heightens the state of metabolic
syndrome constituents. However, sustaining steadfast adherence
over prolonged periods remains a formidable task for patients (5).
Within the context of Chinese diabetic patients’dietary habits, it is
advocated that carbohydrates constitute 50% to 65% of the overall
energy intake. For individuals grappling with suboptimal
postprandial blood glucose control, a modest curtailment in
energy sourced from carbohydrates is deemed advisable.
Nevertheless, the enduring adoption of an extremely low-
carbohydrate diet is not recommended on a protracted basis (6).
The findings from the Atherosclerosis Risk in Communities (ARIC)
study underscore that the nadir of mortality risk is attained when
carbohydrates contribute to 50% to 55% of the overall energy intake
(7). The consumption of whole grains exhibits an inverse
correlation with the hazards associated with all-cause mortality,
coronary heart disease,T2DM, and colorectal cancer. Similarly,
dietary fiber intake manifests a negative correlation with the
perils linked to all-cause mortality, coronary heart disease, T2DM,
and colorectal cancer (8). Consequently, transcending the mere
oversight of total carbohydrate intake, due attention ought to be
devoted to the caliber of carbohydrates, with a pronounced focus on
augmenting dietary fiber intake. Adults are advised to incorporate
over 14 g of dietary fiber per 1,000 kcal daily (9).
In the management of diabetes patients, continuous
cardiovascular risk assessment is necessary in order to timely
identify individuals at high risk of cardiovascular events, and
facilitate the development of personalized treatment plans by
clinical doctors. The cardiovascular disease prediction model
evaluates the probability of an individual developing
cardiovascular disease in the future based on the levels and
combinations of multiple cardiovascular risk factors. They can be
divided into short-term risk prediction and long-term risk
prediction. Short-term risk generally refers to a ten-year risk,
while long-term risk generally refers to a risk beyond ten years or
lifetime risk. There are various types of cardiovascular disease
prediction models. The main cardiovascular risk assessment
models in Europe and the United States include the Systematic
Coronary Risk Estimation (SCORE) model (10), the QRISK score
model in the UK (11,12), and the Pooled Cohorts Equations (PCE)
model (13) for ASCVD risk assessment. Chinese scholars have used
large sample cohort data from the Prediction for ASCVD Risk in
China (China-PAR) study to establish the China-PAR model for
10-year and lifetime cardiovascular risk assessment (14).
Nutritional therapy has burgeoned as a pivotal stratagem in the
prevention and management of diabetes and its complications (15).
The dietary intervention chosen for this inquiry, namely the high
dietary fiber cereal meal, is rooted in whole grains, traditional
Chinese sustenance, and prebiotics(WTP). The crux of this study
resides in delving into the repercussions of the high dietary fiber
cereal meal on metabolic markers among individuals grappling with
T2DM.Use the China-PAR model to assess the impact of this
intervention on the cardiovascular disease risk in those patients.
Li et al. 10.3389/fendo.2023.1283626
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2 Materials and methods
2.1 Inclusion of patients and
general information
During the period spanning March 2015 to April 2015, a
comprehensive total of 120 patients who had received a diagnosis
of T2DM were enlisted from the outpatient clinic of the
Endocrinology Department at our institution. Through
employment of a random allocation table, these participants were
categorically divided into two distinct groups: the W group
(intervention) and the U group (control), adhering to a
proportion of 2:1. The inclusive criteria incorporated the
following requisites: Adherence to the diabetes diagnostic
parameters as stipulated by the World Health Organization
(WHO). An age range of 35 to 70 years. The values of HbA1c
ranged from 6.0% to 12.0%. Demonstrable compliance, indicated by
negligible occurrences of travel, outdoor dining, and consistent
adherence to daily routines. Weight stability within a variance of 2
kg over the course of the preceding 3 months. The exclusion criteria
encompassed the following conditions: Patients diagnosed with
type 1 diabetes. Individuals with intentions of pregnancy,
presently pregnant, or engaged in breastfeeding during the study
period. Patients afflicted by severe diabetes complications, such as
diabetic nephropathy and diabetic foot. Individuals who had
experienced acute episodes of mental illness within the preceding
3 months. Patients with recent history of acute occurrences of
ailments like cholecystitis, gastrointestinal ulcers, and upper and
lower urinary tract infections within the past three months.
Uncontrolled hyperthyroidism, adrenal, or pituitary disorders.
Individuals who underwent gastrointestinal surgery within the
last year, with the exception of appendectomy and hernia surgery.
Patients contending with severe liver ailments like chronic hepatitis
and cirrhosis, or possessing abnormal liver function (serum alanine
amino transferase and aspartate amino transferase levels exceeding
2.5 times the norm). Those with non-specificinflammatory
conditions of the intestines. Patients suffering from acute or
chronic renal insufficiency. Individuals afflicted with significant
cardiovascular conditions such as tumors, coronary heart disease,
and stroke. Those with infectious disorders such as tuberculosis and
HIV/AIDS. Anemia indicated by hemoglobin levels below 10 g/dL.
Individuals who had resorted to medication-based interventions
(inclusive of appetite suppressants like fluoxetine, thyroid
medications, progesterone, laxatives, and various traditional
Chinese weight-loss remedies) or surgical methods for weight loss
within the preceding three months. Participants unable to allocate
adequate time for project involvement. Systolic blood pressure
equal to or exceeding 180 mmHg, or diastolic blood pressure
equal to or exceeding 110 mmHg.
The individuals participating in the study, as well as their family
members, were adequately informed about the intricacies of the
study and accorded their informed consent through signature. The
medical ethics committee affiliated with the hospital was apprised of
the study’s design and granted their approval for its execution. The
trial was registered in the Chinese Clinical Trial Registry (ChiCTR-
IPC-14005346).
2.2 Methods and implementation
Throughout the entirety of the experimental process, all
patients diligently adhered to their existing antihypertensive and
lipid-lowering therapeutic regimens. As a measure to uphold
patient well-being during the study, endocrinologists cautiously
adjusted glucose-lowering medications when patients encountered
extreme blood glucose values. Considering that glucagon-like
peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose co-
transporter-2 (SGLT-2) inhibitors have a more significant impact
on patient weight, these two types of medications were not initiated
during the follow-up period.
Patients assigned to the U group received conventional diabetes
dietary guidance, aligned with the tenets outlined in the Chinese
Diabetes Dietary Guidelines. Conversely, participants in the W
group were furnished with a high dietary fibre cereal meal,
intended to supplant their routine daily staple foods. This cereal
meal, presented as a prepackaged product, was fashioned from two
integral components: pre-packaged porridge (Component 1) and
blending agents (Component 2 and 3), provided by Perfect (China)
Co., Ltd. Component 1, encompassing the pre-packaged porridge,
was formulated through the amalgamation of nine precooked
constituents sourced from whole grains and traditional Chinese
food crops. Abounding in dietary fibre, its composition
encompassed ingredients such as barley, buckwheat, oats, Chinese
yam, lentils, red beans, soybeans, corn, red dates, goji berries, lotus
seeds, and peanuts. Each canister weighed 360 grams when wet.
Component 2, with a content of 10 grams per packet,
predominantly featured bitter melon powder and a blend of low-
molecular-weight oligosaccharides. Component 3, amounting to 15
grams per packet, contained kudzu starch, inulin, and resistant
dextrin. Individuals allocated to the W group were instructed to
consume a minimum of 360 grams of pre-packaged porridge from
Component 1 during each meal, in conjunction with one packet
each of Component 2 and Component 3. In addition, a suitable
quantity of vegetables, legumes, and fruits could be integrated as
accompaniments. Table 1 shows the nutritional composition of
high dietary fibre cereal meal. Figure 1 shows flow chart of the study
population. Both groups of patients were asked to record their daily
diet and medication usage in a logbook. Patients in Group W
exchanged empty packaging bags of intervention food at the end of
each month for the next month’s intervention food.
3 Observation parameters
Prior to and after the 3-month treatment interval, an
assortment of vital metrics were meticulously observed and
Li et al. 10.3389/fendo.2023.1283626
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documented. These included the patients’stature, mass, blood
pressure readings, waist circumference(WC), hip circumference,
comprehensive blood count, HbA1c levels, FBG, FCP, liver and
kidney functionality, blood lipid profiles (TG, TC, LDL-C, HDL-C),
oral glucose tolerance test (OGTT) 2hCP, and levels of hsCRP.
The China-PAR risk assessment model includes gender, age,
place of residence (urban or rural), region (north or south, with the
Yangtze River as the boundary), WC,TC,HDL-C, current blood
pressure level, use of antihypertensive medication, presence of
diabetes, current smoking status, and family history of
cardiovascular disease.
4 Sample size
The sample size was calculated based on a previous study
conducted by Zhao et al. (16). In Zhao et al.’s study,49
participants were randomly assigned to the intervention or
control group in a 2:1 ratio. There was a mean HbA1cdifference
of 0.61 mmol/L between the intervention group and the control
group.To get 90% of power using a two-tailed hypothesis, the
intervention group would require 26 patients. Considering a 20%
dropout rate, a sample of 49 patients divided into 2 groups would be
necessary in order to detect a difference. The sample size of this
study was sufficient.
5 Statistical analysis
The statistical analysis was executed using SPSS 22.0 software.
Enumeration data were displayed as N/% and subjected to scrutiny
through the x2 test. Continuous data were expressed as
x±sand
analyzed using the t-test, provided they conformed to a normal
distribution. For data that deviated from the normal distribution,
changes observed before and after the study period were presented
as a median (interquartile range) and subsequently compared
across groups using the Wilcoxon rank-sum test. The statistical
significance was defined as a P-Value of less than 0.05.
FIGURE 1
Flow chart of the study population.
TABLE 1 Nutritional composition of high dietary fibre cereal meal.
Component
1
a
Component
2
b
Component
3
b
Carbohydrates
(g/100g)
10.5 61.7 85.7
Protein (g/
100g)
2.95 9.76 <0.1
Fat (g/100g) 1.0 1.2 <0.1
Dietary Fiber
(g/100g)
1.4 18.9 6.6
Soluble
Dietary Fiber
(g/100g)
0.4 5.6 6.6
Insoluble
Dietary Fiber
(g/100g)
1.0 13.3 <0.1
Sodium (mg/
kg)
41 1950 102
Potassium
(mg/kg)
1370 1920 227
a. Component 1 is a pre-cooked food. The concentration of each nutrient is per 100 g wet
weight.
b. Component 2 and 3 are dry powder. The concentration of each nutrient is per100 g dry
weight.
Li et al. 10.3389/fendo.2023.1283626
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6 Results
A total of 107 participants successfully completed the
intervention and the subsequent follow-up phase, with the W
group including 72 individuals and the U group including
35 participants.
6.1 The foundational data of the patients
There were no statistically significant differences between the
two patient groups in terms of average age, BMI, and glycated
hemoglobin levels (P>0.05). The proportion of female patients in
the W group was slightly higher than that in the U group.
Additionally, the W group had slightly higher mean HDL-C
levels compared to the U group Table 2. All patients followed
local dietary habits and consumed relatively stable amounts of
carbohydrates, proteins, and fats daily. Based on the patients’
dietary records and the recycling statistics of empty packaging
bags of intervention food, the compliance of Group W patients
with a high-fiber diet was approximately estimated to be 90%.
Patients in Group W reported feeling fuller and experiencing a
decrease in appetite compared to before the intervention, while
patients in Group U reported no significant changes in appetite
before and after the intervention.
6.2 The comparative evaluation of clinical
efficacy between the two patient groups
It was observed that the improvement in weight, BMI, waist-hip
ratio, glycated hemoglobin, fasting blood glucose, TC, TG, LDL-C,
TG/HDL-C, and 2hC-peptide/fasting C-peptide was better in the W
group compared to the U group, with statistically significant
differences (P<0.05). hsCRP decreased in the W group and
increased in the U group. There were no significant differences in
WC, HDL-C, and blood pressure changes between the two groups
Table 3.
6.3 Both groups of patients used
China-PAR model(the Prediction for
ASCVD Risk in China) for risk prediction
of atherosclerotic cardiovascular
disease, evaluating the 10-year
and lifetime CVD risk
TheresultsareshowninTable 4. Both groups showed a
decrease in 10-year cardiovascular disease (CVD) risk after the
intervention, with the W group experiencing a significant reduction
in lifelong CVD risk, while the U group showed less
noticeable improvement.
7 Discussion
In this investigation, the intervention group experienced a
notable substitution of their primary dietary sources with a grain-
based meal. Upon preliminary computation, the cumulative daily
energy contribution furnished by the grain-based regimen within
Group W approximates 646 kcal, wherein carbohydrates comprise
70% of the energy allotment. This equates to a comprehensive
dietary fiber content of 23.76 g/day, encompassing 8.97 g/day of
soluble dietary fiber and 14.79 g/day of insoluble dietary fiber. This
estimation encompasses the supplementary intake derived from
vegetables, legumes, and fruits. The approximated proportion of
daily energy intake sourced from carbohydrates conveniently
adheres to the range of 50% to 65%.The results elicited from this
approach showcased marked decrease in several crucial parameters,
encompassing BMI, WHR, FBG, HbA1c, TC, LDL-C, and hsCRP,
vis-à-vis the conventional dietary management group. A meticulous
analysis of the nutritional composition characterizing this grain-
TABLE 2 General data of patients.
W Group (n=72) U Group (n=35) t-value/Wilcoxon Rank Sum P-Value
Female n (%) 50(69.4%) 21(60%) 0.94 (c
2
) 0.3320
Mean Age (years) 60.86 ± 7.25 58.51 ± 8.02 1486.00 0.1327
BMI (kg/m
2
) 24.75 ± 4.28 25.40 ± 2.80 1037.00 0.1386
HbA1c (%) 8.15 ± 1.20 8.11 ± 1.20 0.17 0.8678
TC (mmol/L) 5.21 ± 1.57 4.86 ± 1.23 1543.00 0.0602
TG (mmol/L) 1.15 ± 0.71 1.39 ± 0.92 1014.50 0.1030
HDL-C (mmol/L) 1.37 ± 0.31 1.23 ± 0.27 2.34 0.0219*
LDL-C (mmol/L) 2.64 ± 1.07 2.63 ± 0.74 1379.00 0.4294
SBP (mmHg) 127.94 ± 14.89 131.54 ± 14.93 -1.17 0.2459
DBP (mmHg) 70.89 ± 10.22 74.26 ± 11.05 -1.52 0.1346
BMI, body mass index; HbA1c, glycated hemoglobin; TC, total cholesterol; TG, triglycerides; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; SBP,
systolic blood pressure; DBP, diastolic blood pressure.
Li et al. 10.3389/fendo.2023.1283626
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based dietary regimen holds promise for illuminating its influence
on metabolic constituents and conferring cardiovascular benefits.
To commence, the grain-based meal exhibits a notable elevation
in dietary fiber content, a component that remains impervious to
digestion and showcases robust water-absorption attributes. Upon
ingestion, dietary fiber interacts with water, expanding in volume
and eliciting a sensation of satiety, thus curbing food intake (17).
This decline in food consumption leads to a commensurate
reduction in overall energy intake, consequently fostering a
favourable milieu for weight reduction.
Dietary fiber and resistant starch, in their incompletely
hydrolyzed state within the small intestine, undergo subsequent
breakdown by the colonic microbiota. A pivotal outcome of this
fermentation process is the generation of short-chain fatty acids
(SCFAs), encompassing butyrate, propionate, and acetate. SCFAs
are markedly associated with mitigating the impact of T2DM (18).
Numerous investigations have underscored the propensity of
butyrate salts to diminish appetite and weight by interacting with
and activating G-protein-coupled free fatty acid receptors (FFAR)
within intestinal enteroendocrine cells (19). This activation
instigates the release of glucagon-like peptide-1 (GLP-1) and
peptide YY (PYY). GLP-1 augments insulin secretion while
inhibiting glucagon release, whereas PYY curbs appetite and
retards gastric emptying (20). Furthermore, butyrate occupies a
substantial role in modulating the expression of genes pivotal to
adipocyte differentiation. Specifically, it orchestrates the
augmentation of the messenger ribonucleic acid of Sterol
Regulatory Element-Binding Protein-1c (SREBP-1c), a cardinal
regulator of adipogenesis and de novo fatty acid synthesis.
Additionally, it elevates the expression of key adipocyte
TABLE 4 Comparison of CVD Risk Assessment Between the Two Groups Before and After Intervention in China PAR Model.
10-year CVD risk lifetime CVD risk
x±s(%) t-value P-Value
x±s(%) t-value P-Value
Group W Before Intervention 13.47 ± 6.34
-2.34 0.0222*
35.55 ± 14.01
-2.46 0.0208*
After Intervention 12.43 ± 6.22 30.33 ± 15.23
Group U Before Intervention 13.79 ± 7.46
-2.22 0.0331*
33.88 ± 11.91
-1.36 0.1907
After Intervention 12.45 ± 6.52 31.65 ± 9.98
TABLE 3 Comparison of Metabolic Parameters in T2DM Patients with and without High Dietary Fiber Intervention.
Observation
Parameters
Changes Before and After Inter-
vention in Group W
Changes Before and After Inter-
vention in Group U
t-value/Wilcoxon
Rank Sum
P-
Value
Body mass (kg) -2.93 ± 3.24 -1.69 ± 1.23 -2.84 0.0055*
BMI (kg/m
2
) -1.10 ± 1.24 -0.64 ± 0.48 -2.75 0.0071*
WC (cm) -2.38 ± 6.28 -1.65 ± 6.45 -0.56 0.5800
HC (cm) -3.00 ± 6.00 0.00 ± 3.25 654.00 3.686×10
-
5
*
WHR 0.01 ± 0.06 -0.01 ± 0.06 2.04 0.0455*
TC (mmol/L) -0.93 ± 0.93 -0.42 ± 0.72 -3.12 0.0024*
TG (mmol/L) -0.26 ± 0.46 0.02 ± 0.97 900.50 0.0128*
HDL-C (mmol/L) -0.05 ± 0.19 -0.07 ± 0.15 0.46 0.6440
LDL-C (mmol/L) -0.17 ± 0.61 0.08 ± 0.44 -2.43 0.0172*
TG/HDL-C -0.16 ± 0.44 0.05 ± 0.82 842.50 0.0041*
HbA1c (%) -1.31 ± 0.99 -0.43 ± 1.02 -4.25 6.730×10
-
5
*
SBP (mmHg) -3.30 ± 15.67 -4.69 ± 12.76 0.50 0.6217
DBP (mmHg) -4.00 ± 11.50 -2.00 ± 8.75 1174.50 0.4945
FBG (mmol/L) -2.41 ± 2.05 -1.02 ± 2.00 -3.37 0.0012*
hsCRP (mg/L) -0.30 ± 1.10 0.20 ± 1.53 878.00 0.0083*
2hCP/FCP 0.54 ± 1.17 -0.06 ± 1.07 -2.52 0.013
BMI, body mass index; WC, waist circumference; HC, hip circumference; WHR, waist–hip ratio; TC, total cholesterol; TG, triglycerides; HDL-C, high-density lipoprotein cholesterol; LDL-C,
low-density lipoprotein cholesterol; TG/HDL-C, the ratio of triglyceride to high-density lipoprotein cholesterol; HbA1c, glycated hemoglobin; SBP, systolic blood pressure; DBP, diastolic blood
pressure; FBG, Fasting Blood Glucose; hsCRP, high-sensitivity C-reactive protein;2hCP,2hC-peptide;FCP,fasting C-peptide (FCP).
Li et al. 10.3389/fendo.2023.1283626
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differentiation markers, including the peroxisome proliferator-
activated receptor g(PPARg) and CCAAT/enhancer-binding
protein alpha (C/EBPa), within adipocytes (21,22).The soluble
dietary fibers used in this study, such as oligofructose and
oligogalactose, can lead to higher abundance of bifidobacteria and
lactobacilli, as well as increased fecal butyrate levels (23,24).
The ascendancy of insoluble dietary fiber prompts heightened
excretion of bile acids, while its soluble counterpart dissolves within
gastrointestinal fluids to engender a gel-like consistency that
impedes fat absorption (25). Simultaneously, the trajectory
of weight loss precipitates a decrement in plasma free fatty
acid (FFA) concentrations (26,27). This curtailment in free fatty
acid levels consequently instigates a reduction in hepatic
gluconeogenesis. Further alterations materialize in the form of
amplified the phosphatidylinositol-3-kinase (PI3K) activity,
pertaining to insulin receptor substrate-1 (IRS-1), and augmented
type 4 glucose transporter (GLUT-4) translocation to the muscle
surface, culminating in an augmented glucose uptake that serves to
alleviate insulin resistance. This cascade serves to diminish
pancreatic b-cell vulnerability to lipotoxicity, thus forestalling the
deterioration of pancreatic function (28). Plasma FFA reduction can
decrease cholesterol ester and triglyceride (TG) synthesis, reduce
HDL clearance, and increase its concentration (28). In this study,
the intervention group showed a significant decrease in TG/HDL-C
levels and an increase in 2hC-peptide/fasting C-peptide levels
compared to before the intervention, with significant statistical
differences compared to the control group, suggesting that this
grain-based nutritional meal is beneficial for improving insulin
resistance. The inclusion of dietary fiber can restore the vigour of
the phosphoinositide 3-kinase/serine kinase pathway, in turn
normalizing serum leptin levels. This normalization cascade
culminates in an amelioration of insulin resistance and an
augmentation of insulin sensitivity (29).
Chen et al.’s exploration yielded the noteworthy discovery of a
substantial reduction in the levels of serum inflammatory
chemokines (IL-1b, IL-6) among patients grappling with T2DM
subsequent to high-fiber diet intervention (30). Within the present
study, the W group exhibited a palpable decline in hsCRP levels
relative to the baseline, thus unveiling a statistical distinction
relative to the control group. Notably, hsCRP stands as a pivotal
risk indicator for untoward cardiovascular consequences within the
context of coronary artery disease (31). An assemblage of evidence
advances the proposition that in the realm of coronary artery
disease patients following guideline-directed medical therapy, the
embrace of a vegetarian diet can evoke a reduction in hsCRP levels
(32). This outcome underscores the anti-inflammatory potential of
the cereal-based nutritional meal, a facet that bears significant
import within the context of coronary artery disease.
WC persists as an autonomous risk determinant impinging
upon cardiovascular afflictions and all-cause mortality (33).
Simultaneously, WHR assumes the mantle of an efficacious
indicator for evaluating central obesity. In accordance with the
benchmarks stipulated by the World Health Organization, a WHR
surpassing 0.90 for males and 0.85 for females flags the advent of
central obesity (34). A clinical trial was conducted on 64 overweight
and obese adolescents. Half of them were required to supplement
daily with chitosan. Chitosan is a dietary fiber. After 12 weeks of
follow-up, chitosan supplementation had greater improvement in
BMI and WC compared with the placebo group. Differences were
significant(P< 0.05) (35). Within the ambit of this study’sfindings,
both the intervention and control groups evinced post-treatment
reductions in WC relative to the baseline. Nevertheless, no
substantive statistical disparity surfaced between the two groups
on this parameter. However, a conspicuous advantage manifested
withinthechangeinWHRwithintheinterventiongroupas
compared to the control group. This variance could potentially be
ascribed to the demographic composition disparity across the
groups, with the control group skewing slightly towards males
while the intervention group encompassed a higher proportion of
females. Gender exerts a discernible influence upon body fat
distribution. Furthermore, a noteworthy facet arises from the
recognition that the sole reliance on WC measurements might
inadvertently introduce measurement imprecisions. In this regard,
the employment of the WHR proves instrumental in mitigating the
repercussions of measurement discrepancies. Conclusively, it is
believed that grain-based meals have a certain role in improving
central obesity.
Noteworthy evidence underscores that tailored dietary patterns,
typified by the Dietary Approaches to Stop Hypertension (DASH)
diet, when synergistically married with other lifestyle modifications
like physical exercise and weight reduction, can furnish efficacious
reductions in blood pressure (36). Within the compass of this study,
both the intervention and control cohorts exhibited a decline in
blood pressure levels post-treatment vis-à-vis the baseline, yet
without the emergence of a marked statistical distinction between
the groups. This deficiency in statistical significance in inter-group
juxtaposition might be ascribed to parallel interventions in sodium
salt consumption. Moreover, the mean age bracket of the study
populace approximated 60 years, thereby propelling age-related
vascular degeneration to manifest as an immutable trigger,
delineating a state of decreased responsiveness to blood pressure-
lowering interventions akin to the DASH diet (37). Further
complexity arises from the recognition that around 40% of
patients within both groups had a history of hypertension, a
backdrop that substantiates a more accentuated vascular
impairment in comparison to their counterparts without such a
history. This suggests a noticeable impact of vascular senescence
upon the outcomes of interventions (37).
The Mediterranean diet, revered for its composition abundant
in b-carotene, vitamin C, vitamin E, natural folate, flavonoids,
selenium, and other essential minerals, plays a crucial role. The
antioxidative attributes inherent to these constituents engender
a mitigation of acute cardiac afflictions. Indicative evidence
highlights the capacity of carotenoids to protract the progression
of atherosclerotic plaques (38). Included in this cereal-based meal
is an array of constituents, encompassing lentils, red beans,
soybeans, corn, red dates, goji berries, lotus seeds, and peanuts.
Among these, legumes serve as significant sources of unsaturated
fatty acids, red dates are rich in vitamin C, while goji berries are
endowed with a profusion of goji polysaccharides, b-carotene,
vitamin E, selenium, and flavonoids. Together, they possess
significant antioxidative properties.
Li et al. 10.3389/fendo.2023.1283626
Frontiers in Endocrinology frontiersin.org07
This study utilized the China-PAR risk assessment model to
evaluate changes in 10-year and lifelong CVD risk before and after
intervention in both groups, offering a clearer indication of the
differences in cardiovascular benefits. The results showed a decrease
in 10-year CVD risk for both groups after intervention, with a
significant reduction in lifetime CVD risk for the W group, while
the reduction in the U group was not statistically significant. This
study supports the beneficial effects of the cereal-based nutritional
intervention on cardiovascular disease.
The strengths of this study include a placebo control and a
randomized design. However, some limitations should also be
acknowledged. Firstly, it was not a very large sample study, but
rather a study with a small sample size conducted at a single center.
The gender composition ratio between the two groups and the use
of hypoglycemic drugs were not completely balanced. We hope to
conduct a larger study with a larger sample size in multiple centers
in the future. Secondly, the follow-up period for this study was
relatively short, and there may have been some imbalance in the use
of treatment medications between the two groups, which could have
ledtoalackofsignificant intergroup differences in certain
cardiovascular risk factors at the end of the follow-up. Gong Q
et al. conducted a 30-year follow-up study and found that lifestyle
interventions can reduce the risk of cardiovascular events in
individuals with impaired glucose tolerance (IGT) (39). Therefore,
the current presentation of some negative results does not
necessarily mean that there is no significant difference, but
perhaps our observation time is not sufficient.
8 Conclusions
In conclusion, this study demonstrates the beneficial effects of a
high-fiber grain-based meal on weight, body fat distribution,
various metabolic indicators, and cardiovascular risk in patients
with type 2 diabetes. Embracing a backdrop of myriad targets and
minimal untoward effects, natural food therapy has emerged as an
important area of study for improving cardiovascular health (40).
Encompassing a stratum of society caught up in the fast-paced
nature of modern life, notably the working professionals, the rise in
diabetes among younger people has coincided with an increase in
fast food consumption. There is a need for effective dietary
interventions for this group. Within this spectrum, cereal-based
nutritional meals, offering both convenience and multiple
cardiovascular benefits, have the potential to be a practical
approach in advocating for diabetes dietary management.
Data availability statement
The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation.
Ethics statement
The studies involving humans were approved by Ethics
Committee of Qidong People’s Hospital. The studies were
conducted in accordance with the local legislation and
institutional requirements. The participants provided their written
informed consent to participate in this study.
Author contributions
XL: Writing –original draft. YS: Writing –review & editing.
DW: Investigation, Data curation. WN: Formal Analysis. NZ:
Investigation. XY: Investigation.
Funding
The author(s) declare financial support was received for
the research, authorship, and/or publication of this article.
The study was supported by the National Natural Science
Foundation of China (81870594); Clinical research plan of
SHDC [No.SHDC2020CR1016B].
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be
construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed or
endorsed by the publisher.
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