CME INDIA Presentation by Dr. Manohar K. N., MD, DNB, Triple FRCP (Edinburg, Glasgow & London) Consultant Physician & Diabetologist – Manipal Hospital, Bangalore; Dr. N. K. Singh, MD, FICP, FACP, Editor: www.cmeindia.in.

“Fruits can be excellent components of the diet in diabetic patients. Fruits have high nutritional values (particularly in respect of micronutrients) and for their palatability which increases patient compliance. The substitution of calories and other nutrients may be done on the basis of patient choice, socioeconomic capability and availability of fruits. These days diabetologists do not advice to avoid fruits.”

Quick Take-Aways

• Higher fresh fruit consumption looks associated with lower risk of diabetes and diabetic vascular complications.
• Indian’s common belief that fresh fruit consumption can raise sugar markedly has not been true in many studies.
• Even in people with diabetes fruit intake in moderation has no significant impact on Hb1ac.
• Studies favour current dietary guidelines that fresh fruit consumption should be recommended for all, including those with diabetes.
• It is not true that all sweet-tasting (or sugar-containing) foods, including fresh fruit, are to be restricted or avoided in diabetics.

Good Diabetics take good fruits in moderation

• Diet and Exercise are cornerstones of treatment. Fruits are an integral part of our diet.
• Choice of Fruits are driven by size, ripeness – just ripe or slightly unripe / Sweetness of fruit and size of the fruit.
• Consume slices rather than juices or milkshakes.
• Avoid Juice – if you take 2/3 fruits per juice, it contains less fiber and leads to faster glucose absorption.
• Diabetics with Kidney disease need to be careful due to potassium content of the fruit.

Are fruits suitable for people who have diabetes?

• A large prospective study has showed that in those individuals who already had diabetes prior to the start of the study, consuming fresh fruit more than three days a week was associated with very important effects. (1)
• There was   17% lower relative risk of dying from any cause.
• There was 13%–28% lower risk of developing diabetes-related both macrovascular and microvascular complications.

Which Fruits?

• Fruits with relatively lower glycaemic index (i.e., apples, oranges, pears, and berries) may have larger beneficial effects on diabetes than those with a higher glycaemic index (i.e., bananas, grapes, and tropical fruits) (2)
• Some studies do show that both higher and lower glycaemic index fruits to be associated with lower risk of diabetes (3)

Do Fruits raise sugar?

• Fruit contains sugars (i.e., glucose and fructose), which may have negative impacts on glycaemic control (4)
• However, the natural sugars in fruit may not be metabolised in the same way as refined sugars (5)
• Fruit consumption had a weak inverse, instead of positive, association with levels of blood glucose, overall and in those with previously diagnosed diabetes. (1)
•  This is largely consistent with many studies   showings that fresh fruit consumption had no significant negative impact on glycaemic control, even in people with diabetes (2,6,7,8)
• Guidelines on healthy eating encourage fruit consumption, and fruit.
• Some meta-analyses of controlled feeding trials indicate a net metabolic benefit, with no harmful effects, from fructose if intake is obtainable from fruit.

How fruits boost positive effects in diabetics

• Fruit is a good source of dietary fibre, minerals (e.g., potassium, and antioxidants (e.g., vitamins and polyphenols (9-13).
• These synergistically confer several benefits on metabolism.
• Fruits are anti-oxidative, anti-inflammatory, anti-proliferative, anti-platelet, anti-hypertensive, anti-dyslipidaemia, anti-hyperglycaemic, and anti-atherogenic effects
• Fruits also modulate the composition and metabolic activity of gut microbiota (14).

Glycaemic Index

• Glycaemic Index is a relative ranking of carbohydrate in foods according to how they affect blood glucose levels. Carbohydrates with a low GI value (55 or less) are more slowly digested, absorbed and metabolised and cause a lower and slower rise in blood glucose and, therefore usually, insulin levels.

The first step is Portion control

Fruit Exchange

Fruit Exchange

How much Fruit?

• Most guidelines recommend to eat 5 servings of fruits and vegetables each day in diabetes.

Diabetics should take Mango or not?

• Mangos (Mangifera indica L.) may offer unique health promoting properties beyond their vitamin, mineral, and fiber content.
• Mangos contain many bioactive compounds including mangiferin, gallic acid, gallotannins, quercetin, isoquercetin, ellagic acid, and b-glucogallin
• Mangos are a rich source of antioxidants. It may help to reduce the damage to proteins, lipids, and DNA.
• One of the antioxidants present in mangos is mangiferin reduces oxidative stress through a variety of pathways including prevention of increased levels of glucocorticoids, interleukin-1b, lipid peroxidation, and other pro-inflammatory mediators.
• The sugar in mangos is accompanied by both fiber and polyphenols which may both independently contribute to glucose control.
• Fiber, particularly soluble fiber, has been shown to improve glycemic control by increasing viscosity in the gastrointestinal tract thereby slowing the absorption of carbohydrates in the small intestine.
• One research has shown that certain fruit polyphenols can inhibit intestinal uptake and transport of glucose independent of fiber.
• The Mangiferin, a polyphenolic antioxidant which in extract form has been shown to lower fasting plasma glucose levels in animal models.
• Remember, mango is a fruit with good nutritive value, low glycemic load as well as with acceptable glycemic index.
• Mangoes can be enjoyed, in moderation in diabetes.
• Depending on the glycemic control, people may consume small portions of the fruit approx. 100–150 g of edible portion/day or 50 g mango slice thrice a day which is friendlier to glucose metabolism than a larger portion of it consumed with the heaviest meal.
• The glycemic index of mango may be further lowered by taking after consumption of high fiber food such as salads or beans or whole grains
• Mangoes score 51–56 on the glycemic index (GI) chart, similar to orange juice.
• The glycemic load of mango is 51, which is classified as low.
• Human studies suggest that mango consumption may improve postprandial glucose and markers of atherosclerosis.
• Mango and Papaya have equivalent GI.

CME INDIA Tail Piece

• Listen Dr. Manohar K. N. on fruits and diabetes:

• Mango leaves are valuable anti-diabetic (19)
  • The anti-diabetic and anti-oxidant potentials of aqueous Mangifera indica leaves have been shown in recent studies.
  • One recent study showed that mangiferin even at a lower concentration of 50 μg/mL produced good results as an anti-diabetic agent when compared to the standard drug (Acarbose) and aqueous mango leaves extract at 500 μg/mL.This study suggested  that the mangiferin in crude extract has less potential as an anti-diabetic drug compared to mangiferin in pure form.

References:

1. Du H, Li L, Bennett D, Guo Y, Turnbull I, Yang L, et al. China Kadoorie Biobank study. Fresh fruit consumption in relation to incident diabetes and diabetic vascular complications: A 7-y prospective study of 0.5 million Chinese adults. PLoS Med. 2017 Apr 11;14(4):e1002279. doi: 10.1371/journal.pmed.1002279. PMID: 28399126; PMCID: PMC5388466.
2. Jenkins DJ, Srichaikul K, Kendall CW, Sievenpiper JL, Abdulnour S, Mirrahimi A, et al. (2011) The relation of low glycaemic index fruit consumption to glycaemic control and risk factors for coronary heart disease in type 2 diabetes. Diabetologia 54: 271–279. 10.1007/s00125-010-1927-1.
3. Muraki I, Imamura F, Manson JE, Hu FB, Willett WC, van Dam RM, et al. (2013) Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies. BMJ 347: f5001 10.1136/bmj.f5001.
4. Lustig RH, Schmidt LA, Brindis CD (2012) Public health: the toxic truth about sugar. Nature 482: 27–29. 10.1038/482027a.
5. Sievenpiper JL, de Souza RJ, Jenkins DJ (2012) Sugar: fruit fructose is still healthy. Nature 482: 470.
6. Christensen AS, Viggers L, Hasselstrom K, Gregersen S (2013) Effect of fruit restriction on glycemic control in patients with type 2 diabetes—a randomized trial. Nutr J 12: 29 10.1186/1475-2891-12-29.
7. Wang B, Liu K, Mi M, Wang J (2014) Effect of fruit juice on glucose control and insulin sensitivity in adults: a meta-analysis of 12 randomized controlled trials. PLoS ONE 9: e95323 10.1371/journal.pone.0095323.
8. Hegde SV, Adhikari P, M N, D’Souza V (2013) Effect of daily supplementation of fruits on oxidative stress indices and glycaemic status in type 2 diabetes mellitus. Complement Ther Clin Pract 19: 97–100. 10.1016/j.ctcp.2012.12.002.
9. Silva FM, Kramer CK, de Almeida JC, Steemburgo T, Gross JL, Azevedo MJ (2013) Fiber intake and glycemic control in patients with type 2 diabetes mellitus: a systematic review with meta-analysis of randomized controlled trials. Nutr Rev 71: 790–801. 10.1111/nure.12076.
10. Harding AH, Wareham NJ, Bingham SA, Khaw K, Luben R, Welch A, et al. (2008) Plasma vitamin C level, fruit and vegetable consumption, and the risk of new-onset type 2 diabetes mellitus: the European prospective investigation of cancer—Norfolk prospective study. Arch Intern Med 168: 1493–1499. 10.1001/archinte.168.14.1493.
11. Weickert MO, Pfeiffer AF (2008) Metabolic effects of dietary fiber consumption and prevention of diabetes. J Nutr 138: 439–442.
12. Chatterjee R, Yeh HC, Edelman D, Brancati F (2011) Potassium and risk of Type 2 diabetes. Expert Rev Endocrinol Metab 6: 665–672. 10.1586/eem.11.
13. Kim Y, Keogh JB, Clifton PM (2016) Polyphenols and glycemic control. Nutrients 8: E17 10.3390/nu8010017.
14. Marchesi JR, Adams DH, Fava F, Hermes GD, Hirschfield GM, Hold G, et al. (2016) The gut microbiota and host health: a new clinical frontier. Gut 65: 330–339. 10.1136/gutjnl-2015-309990.
15. Colles SL, Singh S, Kohli C, Mithal A (2013) Dietary beliefs and eating patterns influence metabolic health in type 2 diabetes: a clinic-based study in urban North India. Indian J Endocrinol Metab 17: 1066–1072. 10.4103/2230-8210.122626.
16. Sargeant LA, Khaw KT, Bingham S, Day NE, Luben RN, Oakes S, et al. (2001) Fruit and vegetable intake and population glycosylated haemoglobin levels: the EPIC-Norfolk Study. Eur J Clin Nutr 55: 342–348. 10.1038/sj.ejcn.1601162.
17. Oboh G, Ademosun AO, Akinleye M, Omojokun OS, Boligon AA, Athayde ML. Starch composition, glycemic indices, phenolic constituents, and antioxidative and antidiabetic properties of some common tropical fruits. J Ethnic Foods 2015;2:64‑73.
18. Kalra B, Gupta L, Khandelwal D, Choubey N. Mango and diabetes. J Soc Health Diabetes 2018;6:56-8.
19. Vrushali M. Kulkarni, Virendra K. Rathod,Exploring the potential of Mangifera indica leaves extract versus mangiferin for therapeutic application,Agriculture and Natural Resources,Volume 52, Issue 2,2018,Pages 155-161,ISSN 2452-316X,https://doi.org/10.1016/j.anres.2018.07.001.
20. Serum glucose and insulin response to mango and papaya in type 2 diabetic subjectsJanuary 2003.Nutrition Research 23(1):9-14.DOI:10.1016/S0271-5317(02)00492-X.

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