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Is the Indian Dietary Pattern Associated WithType 2 Diabetes? A Pan-India Randomized Cluster Sample Study

Is the Indian Dietary Pattern Associated WithType 2 Diabetes? A Pan-India Randomized Cluster... Background: Diabetes is associated strongly with many neurodegenerative diseases and is also a lifestyle disorder. A good glycemic status depends on diet management and physical activity. There are several studies available on the relationship between diet habits and impact on diabetes. Purpose: The objective of this study was to check the association of different dietary factors with glucose levels and lipid values in type 2 diabetes from a part of a large nationwide trial. Methods: This was the data fromapan-India multicentered cluster randomized controlled study covering 60 states and 4 union territories; 17,285 individuals were surveyed for dietary factors. Amongst them, data of 12,500 individuals were analyzed. Males were 54% and 60% individuals were from urban areas. Results: The analysis of the results showed that consumption (usual/often) of milk(odds ratio, OR = 7.180), meat (OR = 6.81), less fiber (OR = 17.77), and less fruits (OR = 14.71) was strongly and positively associated with fasting blood glucose (P<.001). The postprandial blood glucose (PPBG) in diabetes individuals also had a strong positive association (P<.001) with consumption (usual/often) of meat (OR = 22.82) and milk (OR = 17.19). In prediabetes individuals, milk was significantly (P<.001) associated with fasting blood glucose (OR = 2.74). In nondiabetes individuals also, milk was significantly associated with postprandial blood glucose (OR = 2.56). Consumption of meat was associated with high cholesterol (OR = 1.465). Consumption of junk food was associated significantly (P <.001)with the status of known diabetes (OR = 1.345) and known hypertension (OR = 1.247). Conclusion: Consumption of milk, meat, less vegetables, less fruits, and junk food has a significant effect on the glycemic status and cholesterol levels, and also on the status of known diabetes and hypertension. Keywords Diabetes, Milk, Meat, Junk food, Indian population Received 2 October 2020; revised 7 October 2020; accepted 7 October 2020 Introduction Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), Kempegowda Nagar, Bengaluru, Karnataka, India Neuroscience Research Lab, Postgraduate Institute of Medical Education Diabetes mellitus is a metabolic disorder, and lifestyle and Research (PGIMER), Chandigarh, India behaviors including dietary patterns, physical activity, bad Centre for Mind Body Medicine, PGIMER, Chandigarh, India habits, and stress are the known etiological factors. Its 4 Panjab University, Chandigarh, India Department of Yoga and Physical Science, SVYASA Yoga University, increasing prevalence in developing countries such as India is Bangalore, India closely associated with the structure of the population, age Corresponding author: 1,2 factors, and urbanized lifestyle. Raghuram Nagarathna, Director, Arogyadhama, VYASA, 19, Eknath Bhavan, The accurate etiology of diabetes mellitus has remained Gavipuram Circle, Kempegowda Nagar, Bengaluru, Karnataka 560019, India. uncertain in spite of the advancement in research and E-mail: rnagaratna@gmail.com Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https:// us.sagepub.com/en-us/nam/open-access-at-sage). 176 Annals of Neurosciences 27(3-4) treatment facilities around the globe. Genetics, age, exercise, amount of vitamin D and calcium may lead to hyperglycemia, physical fitness, dietary patterns, medications, obesity, and while intakes of a diet containing vitamin D and calcium may waist circumference are the high-risk factors contributing to regularize glucose metabolism. Various observational studies the development of causes of diabetes—reduced insulin have been carried out on the relation of the intake of milk absorption and beta-cell destruction. products and insulin absorption, and most of them have 4 10,11 In a review study, it is reported that the quality of the diet revealed an opposite relation. was the important factor for reduced insulin absorption rather A prospective study established that excessive consumption than the components of the diet. In general, a greater intake of red meat was associated with an increased risk of of milk products is not associated with reduced absorption of developing type 2 diabetes in middle-aged and older people. insulin. This is in contrast to the traditional belief that milk Also it was observed that there were significantly positive products, which are associated with higher levels of associations of cholesterol-, protein-, and iron-rich diet foods, 11,12 cholesterol, saturated fat, and protein, are the risk factors for for example red meat, with a risk of developing diabetes. cardio-vascular diseases (CVD). However, the fact that a A study on personalized diet habits and counseling on more protein intake increases the risk of ischemic heart exercise hypothesized thatthese result in improving the 5 13 disease has not been established. function of the nervous system and reduction in pain. But the evidence of the study was not conclusive. The Globally, various studies are available on single dietary study also suggested that several factors related to components factors (e.g., milk, meat, or fiber diet), but no comprehensive in milk products and constitutional variation, genetic study had been conducted in India including all dietary variability in populations may have an impact on insulin factors. Hence, the present study has been conducted to check absorption. For example, the type of milk products they the effect of different diet components on blood sugar and consume and the amount of fat and mineral may influence the lipid values in type 2 diabetes all over India. absorption of insulin. Another study performed in Sweden, observed the Methodology relationship between diet habits and risk of metabolic syndrome, including a diet rich in milk fat compared to Study Design regular milk and cheese. It revealed that excessive consumption of glucose, bakery products, and alcohol was This study is part of a pan-India multicentred cluster associated with the risk of metabolic syndrome. However, in randomized controlled trial covering all populous states and women, consumption of excessive milk products was found 14 union territories. Details of the methodology have been to be having a guarding effect with respect to type 2 diabetes. published earlier.In brief, the study was planned in two phases Further, a diet with excessive milk fat was associated with a with the goal of preventing further development of prediabetes reduced risk of hyperinsulinemia in women, but not in case of into diabetes. In step 1 of phase I, screening was done on Indian men. The authors also noted that there may be a gender Diabetes Risk Score (IDRS) to identify high-diabetes-risk and difference in how different foods affect the metabolic known diabetes individuals. In step 2 of phase I,detailed data consequences with respect to diabetes. including blood test data were acquired for fasting blood In a prospective analysis of 7,731 men and women over 15 glucose (FBG), postprandial blood glucose (PPBG), and years of follow-up, Brunner et al. found that a “healthy” glycated hemoglobin (HbA1c) only in those subjects who had eating pattern characterized by a diet richin fruits, vegetables, attained high IDRS scores (IDRS >60). Phase II was a two- wholemeal bread, and breakfast cereals, low-fat dairy, and armed translational randomized controlled trial on yoga-based little alcohol reduced the risk of diabetes and coronary death lifestyle changes. Figure 1 provides the structure of the project. or nonfatal myocardial infarction as compared to an In step 1, samples from seven geographical zones, i.e., “unhealthy” eating pattern (white bread, processed meat, Jammu & Kashmir, Northeast, North, West, Central, East, and fries, and full-cream milk). Compared with the “unhealthy” South were included. A stratified, multistage cluster sampling pattern, the “healthy pattern” was almost two-fold higher in design was adopted. In rural areas, a two-stage village– fruit and vegetable intake and three-fold higher in bakery household design, and in urban areas, a four-stage town/city– product and milk product intake. ward–block–household design wereadopted. Both rural and Numerous studies on milk products have shown negative urban areas were stratified at three levels based on the associations with the risk of type 2 diabetes. This study 15,16 geographical distribution and population size (Figure 1). examined the different facts that (a) milk products were suggested to have an insulinotropic effect in single meals, (b) Assessments fatty acids were found to improve insulin sensitivity, and (c) diets rich in protein, calcium, and other minerals were found The assessments in step 1 for all participants included four to reduce blood pressure and body weight/fat and also found factors: IDRS, sociodemographic variables, blood pressure, to have an effect on blood cholesterol. and self-reported diabetes. Further assessments of known An earlier systematic review study which observed diabetes and high-diabetes-risk groups (IDRS>60) included outcomes related to glucose homeostasis concluded that less HbA1c, FBG, PPBG, and lipid profiles (in venous blood). Nagarathna et al. 177 Figure 1. Four-Level Sampling Design. Source: Nagendra et al. Table 1. Questions Asked in the Survey. Details of dietary patterns were documented for the high-risk group (Table 1). Skip breakfast? Usually/Often 1 Sometimes 2 Rarely/Never 3 Statistical Analysis Eat less than two servings of fruit Usually/Often 1 Data were uploaded via mobile apps by trained yoga a day? Sometimes 2 Serving = ½cup or 1 medium-sized Rarely/Never 3 volunteers for diabetes mellitus (YVDMs) under supervision fruit or ¾ cup 100% fruit juice. of senior research fellows. Uploaded data from screening Eat less than two servings of veg- Usually/Often 1 forms (about 4, <0.001 per district), registration forms, and etables a day? Sometimes 2 laboratory data (about 50, <0.001) were checked for perfect Serving = ½ cup vegetables, or 1 Rarely/Never 3 matching of coding. After cleaning on Excel, the dataset was cup leafy raw vegetables. analyzed using R software for biostatistical analyses. Linear Eat or drink two servings of milk, Usually/Often 1 regression and binomial regression were adopted for checking yogurt, or cheese a day? Serving = Sometimes 2 the association between dietary factors and sugar levels and 1 cup milk or yogurt; 60 g cheese. Rarely/Never 3 status of diabetes. Eat more than 250 g (see sizes Usually/Often 1 below) of meat, chicken, turkey, or Sometimes 2 fish per day? Rarely/Never 3 Results Note: 100 g of meat or chicken is the size of a deck of cards or one of The survey was conducted on 17,285 individuals for dietary the following: 1 regular hamburger, factors. Sample data of 12,500 individuals were analyzed. In 1 chicken breast or leg (thigh and those, males were 54%, and 60% individuals were from drumstick), or 1 pork chop. urban areas. Burger/Chips How many times in a week? Table 2 shows the regression values for the association Fried items, e.g., Samosa/Kachori/ How many times in a week? between different dietary factors and the blood glucose values Bonda, etc. (FBG and PPBG) in individuals with diabetes, prediabetes, Pizza How many times in a week? and normoglycemia. As seen from the table, usual/often Cake/Pastry How many times in a week? intake of meat, milk, less fiber, and less fruits was significantly Fizzy cold drinks How many times in a week? associated with raised PPBG and FBG in the diabetes group. Chat/Masala puri How many times in a week? 178 Annals of Neurosciences 27(3-4) However, among the prediabetes group, these were Increased consumption of burger, cake, and fizzy per week significantly associated with FBG only, except for the less was associated with hypertension stage 2. fruit group which has a significant association with both FBG Table 5 reveals the odds ratio of the association between and PPBG. The normoglycemia group also revealed various dietary factors consumed usually and peripheral significant associations of PPBG with usual milk intake and neuropathy in diabetes individuals. It was found that usual FBG with meat, and less fiber, less fruit intake with raised consumption of meat was significantly associated with PPBG and FBG. In the diabetes group, no significant peripheral neuropathy in diabetes individuals. association was noticed for either FBG or PPBG with skipping Table 6 shows the odds ratio of the association between of breakfast, whereas in the normal group FBG and PPBG various dietary factors consumed usually and cholesterol. It showed a significant association with skipping of breakfast. was found that usual/often consumption of meat and less Furthermore, in the prediabetic group, a significant association vegetables was significantly associated with high cholesterol. was observed only for FBG. Table 3 reveals the odds ratio of the association between Discussion various junk foods and self-reported known diabetes. It was found that consumption of cake and fizzy drinks per week The present study has been conducted across seven zones of was significantly associated with the status of known India. In this study, an association of dietary factors such as diabetes mellitus. milk products, meat, and junk foods with FBG and PPBG Table 4 depicts the odds ratio of various dietary factors for was appraised. the incidence of prehypertension, hypertension stage 1, and The findings of the present study revealed that regular hypertension stage 2. It was found that an increased consumption of pizza and fizzy per week was associated with ingestion of excessive milk, meat, and junk foods has a prehypertension. Increased consumption of pizza, fizzy, and substantiated effect on the blood glucose levels of the cake per week was associated with hypertension stage 1. individuals, particularly in case of diabetes mellitus. These Table 2. Association Between Dietary Factors With Diabetes Categories of Diabetes, Prediabetes, and Normoglycemia (Regression Analysis). Dietary Factor Consumes usually/Often Blood Variables Diabetes Odds Ratio Prediabetes Odds Ratio Normoglycemia Odds Ratio Milk PPBG 17.19* 3.44 2.56* FBG 7.18* 2.74* 2.31 Meat PPBG 22.82* 3.90 1.64 FBG 6.81* 2.63* 1.51* Less fiber PPBG 17.77* 2.78 2.80* FBG 9.17* 2.87* 1.95* Less fruit PPBG 14.71* 3.51* 1.21* FBG 8.99* 1.95* 1.18* Skipping of breakfast PPBG 5.63 1.33 1.72* FBG 4.14 1.69* 1.45* Abbreviations: FBG, fasting blood glucose; PPBG, postprandial blood glucose. Notes: There was a highly significant association between blood glucose (FBG and PPBG) values and consumption of milk, meat, less fruits, and less fiber, but not with skipping of breakfast in diabetes individuals.*significance P< .001. Table 3. Association Between Self-Reported Diabetes and Different Junk Foods (Regression Analysis). 95% Confidence Interval Junk Foods Sig. Odds Ratio Lower Bound Upper Bound Burger/Week .165 1.234 0.917 1.660 Fried food/Week .662 1.053 0.835 1.329 Cake/Week .044 1.345 1.009 1.795 Fizzy drinks/Week .008 1.344 1.079 1.674 Chats/Week .331 0.909 0.749 1.102 Fish/Week .754 0.984 0.888 1.090 Note: There is a significant association between diabetes and consumption of cake and fizzy drinks. Nagarathna et al. 179 Table 4. Association Between Different Categories of Hypertension and Different Junk Foods (Regression Analysis). 95% Confidence Interval Hypertension Factor Sig. Odds Ratio Lower Bound Upper Bound Prehypertension Burger/Week .413 0.968 0.413 1.046 Pizza/Week .006 1.233 0.006 1.432 Cake/Week .803 1.018 0.803 1.176 Fizzy drinks/Week .000 1.335 0.000 1.452 Chats/Week .786 0.991 0.786 1.056 Hypertension stage Burger .429 0.957 0.429 1.067 Pizza .026 1.207 0.026 1.426 Cake .005 1.236 0.005 1.433 Fizzy drinks .002 1.181 0.002 1.310 Chat .991 1.000 0.991 1.069 Hypertension stage Burger .044 0.756 0.044 0.992 Pizza .755 1.048 0.755 1.410 Cake .043 1.247 0.043 1.543 Fizzy drinks .009 1.215 0.009 1.406 Chat .854 0.989 0.854 1.113 Table 5. Association Between Peripheral Neuropathy in Diabetes and Consumption of Different Foods (Regression Analysis). 95% Confidence Interval Dietary Factors Sig. Odds Ratio Lower Bound Upper Bound Milk usually .088 1.143 0.980 1.332 Milk sometimes .598 1.037 0.905 1.128 Meat usually .031 1.198 1.016 1.412 Meat sometimes .157 1.124 0.956 1.323 Less vegetable usually .569 0.953 0.807 1.125 Less vegetable sometimes .778 1.019 0.895 1.161 Less fruit usually .498 0.943 0.797 1.117 Less fruit sometimes .850 0.986 0.857 1.136 Skip breakfast usually .544 1.042 0.913 1.188 Skip breakfast sometimes .736 0.977 0.855 1.117 results establish the role of the frequency and the type of association between intakes of red meat and poultry with a food an individual consumes in healthy and unhealthy risk of developing diabetes. conditions. Ayurveda recommends avoiding milk products Gittelsohn et al. have shown that excessive consumption to control diabetes. of junk foods and bakery products was associated with a Findings of another study also suggested that excessive substantial increase in the risk of developing diabetes and consumption of milk products reduces the insulin sensitivity impaired glucose tolerance. These foods tend to be high in as compared to red meat in overweight and obese subjects simple glucose, low in fiber, and high in fat. The with glucose intolerance. Another study is also in line with authorsobserved a close relationship between dietary patterns the findings of the present study signifying the positive and the incidence of diabetes mellitus. 180 Annals of Neurosciences 27(3-4) Table 6. Association Between High Cholesterol and Different with an increased risk of type 2 diabetes. A regular habit of Dietary Factors (Regression Analysis). breakfast eating may help lower the risk of type 2 diabetes. Thus, skipping of breakfast is associated withan increased 95% Confidence Interval risk of type 2 diabetes. Odds Lower Upper In this study, association of dietary factors was also DietaryFactors Sig. Ratio Bound Bound analyzed with peripheral neuropathy, which revealed that milk usually .221 0.871 0.699 1.086 subjects who consumed meat usually had a significant Milk sometimes .076 0.840 0.692 1.019 association with peripheral neuropathy, with symptoms of Meat usually .002 1.465 1.156 1.858 pain and numbness from nerve damage in hands and feet, Meat sometimes .194 1.172 0.922 1.489 majorly in diabetes individuals. However, studies reveal that there are treatments in other Less vegetable .037 0.769 0.602 0.984 usually practices. In general, a healthy lifestyle involving maintaining the body weight, eluding contact with toxins, practicing Less vegetable .124 0.864 0.717 1.041 sometimes physician-supervised exercise program, consuming a balanced diet, rectifying vitamin deficiencies, and evading Less fruit usually .902 0.985 0.776 1.251 alcohol and smoking can reduce the symptoms of peripheral Less fruit .428 0.922 0.755 1.127 neuropathy. sometimes However, the Foundation for Peripheral Neuropathy Skip breakfast .918 0.990 0.818 1.199 endorses increasing omega-3 fatty acids for reducing the risk usually of diabetes. It also suggests consuming one to two tablespoons Skip breakfast .884 1.014 0.836 1.231 of flaxseed oil a day oreating fatty fish, salmon, or three sometimes ounces of walnuts a day. Note: High cholesterol was associated significantly with usual consumption The association between nutritional status and optic or of meat and less vegetables. peripheral neuropathies is well established with tobacco, ethanol, deficiencies in thiamine, vitamin A, B12, B3, and On the contrary, a number of studies have shown the B6, and protein–energy malnutrition, all being causative. negative association with milk consumption. A lipid and The present study also revealed the association of dietary glucose study conducted in Tehran, involving 827 subjects, factors with the cholesterol level that mainly revealed showed that a number of factors were found to be associated nonsignificant results, whereas only subjects who consumed favorably with dairy consumption, including the metabolic usually meat and less vegetables showed a significant syndrome in newly diagnosed diabetes, but significant association with the cholesterol level. After consumption of a associations were not found. meat diet, the plasma cholesterol concentration fell by 8.6% The CARDIA study, which is a prospective study over and low-density-lipoprotein cholesterol by 11%. But the 10 years, demonstrated a negative association between milk present study showed a low significant association between consumption and the development of the disease. In contrast, high cholesterol and meat consumption with odds ratio [OR the present study has depicted a significant association Researchers found that consuming 1.274 (1.018, 1.515)]. between milk intake and glucose levels in diabetes. excessive amounts of saturated fat and meat protein was A prospective study conducted in Finland proposed that associated with an upsurge in blood cholesterol than the the association between processed meat and diabetes was 21 meat-free diets. mostly because of sodium. Another study by Alsabieh etal. A meta-analysis of studies postulates that both fresh red proposed an affirmative association between packed food 22 meat and processed meat may upsurge the risk of stroke. This products and hypertension. is a significant finding because the excessive consumption of With consumption of usually less fiber and fruits showing red meat and the high morbidity and mortality have been a significant association with PPBG and FBG in the diabetes, associated with stroke. In this study, we found the association prediabetes, and normoglycemia groups in the present study, between meat and sugar levels. a study suggested the presence of heterogeneity in the The major asset of the study is that it was the first study to associations between the ingestion of fruits and risk of type 2 analyze the association between different food groups and diabetes. However, consumption of blueberries, grapes, and glucose levels across seven zones of India. Sample size was apples was significantly associated with a lower risk of type 2 also good. diabetes. But excessive consumption of fruit juice was found A limitation of the study is that the sample was not to be associated with a higher risk of diabetes. distributed normally in all zones. Moreover, the data about Moreover, skipping of breakfast showed a nonsignificant the exact quantity offoods was not obtained, and alsoit is association with PPBG and FBG in the diabetes group,only PPBG in the prediabetes group, and a significant association difficult to cull out the effects of physical activity. Furthermore, in the normoglycemia group. A meta-analysis of studies data about diet information was retrospectively obtained, and revealed that skipping of breakfast was found to be associated this is not a prospective supervised monitored diet study. Nagarathna et al. 181 ORCID iD Conclusion Akshay Anand https://orcid.org/0000-0001-7947-5209 Milk, meat, less vegetables, less fruits, and junk foods have a significant effect on the glycemic status and cholesterol levels References and on the status of known diabetes and hypertension as well 1. Ramachandran A, Snehalatha C, Kapur A, et al. High prevalence as peripheral neuropathy. of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001;44(9):1094–1101. 2. King H, Aubert RE, Herman WH., Global burden of diabetes, Acknowledgments 1995–2025: Prevalence, numerical estimates, and projections. Diabetes Care 1998;21: 1414–1431. We are thankful to (a) the funding by the Ministry of Health 3. Kahn SE, The relative contributions of insulin resistance and and Family Welfare and Ministry of AYUSH routed through beta-cell dysfunction to the pathophysiology of Type 2 diabe- Central Council for Research in Yoga and Naturopathy, tes. Diabetologia 2003;46: 1707. Government of India for their timely support for this project; 4. Marshall JA, Hamman RF, Baxter J., High-fat, low-carbohy- (b) the executive committee of Indian Yoga Association for drate diet and the etiology of non-insulin-dependent diabetes conducting Niyantrita Madhumeha Bharatha (NMB); (c) Art mellitus: The San Luis Valley Diabetes Study. Am J Epidemiol 1991;134: 590–603. of Living Institute, Vethathiri Maharishi College of Yoga, 5. Sonestedt E, Wirfält E, Wallström P, et al. Dairy products and its Patanjali Yogpeeth, PGIMER Chandigarh, and SVYASA for association with incidence of cardiovascular disease: The Malmö providing more than 1,200 volunteers; and (d) the members diet and cancer cohort. Eur J Epidemiol 2011;26: 609–618. of the research advisory board of NMB for their inputs at all 6. Brunner EJ, Mosdøl A, Witte DR, et al. Dietary patterns and stages of the study. 15-y risks of major coronary events, diabetes, and mortality. Am J Clin Nutr 2008;87(5):1414–1421. doi:10.1093/ajcn/87.5.1414 7. Mensink RP., Dairy products and the risk to develop type 2 Authors Contribution diabetes or cardiovascular disease. Int Dairy J 2006;16: 1001– Raghuram Nagarathna is the primary investigator of the 8. Kuroda M and Sakaue H. Role of vitamin D and calcium in study, is the guarantor of this study and as such has full access obesity and type 2 diabetes. Clin calcium 2016;26: 349–354. to all data in the study, and takes responsibility for the 9. Lawlor DA, Ebrahim S, Timpson N, et al. Avoiding milk is associated with a reduced risk of insulin resistance and the met- integrity of the data and its analysis. Akshay Anand was abolic syndrome: Findings from the British Women’s Heart and involved in overall management of study at the local zonal Health Study. Diabet Med 2005;22:808–811. level. Sapna Nanda wrote the manuscript. Suchitra Patil 10. Snijder MB, Van Dam RM, Stehouwer CDA, et al. 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Is the Indian Dietary Pattern Associated WithType 2 Diabetes? A Pan-India Randomized Cluster Sample Study

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Abstract

Background: Diabetes is associated strongly with many neurodegenerative diseases and is also a lifestyle disorder. A good glycemic status depends on diet management and physical activity. There are several studies available on the relationship between diet habits and impact on diabetes. Purpose: The objective of this study was to check the association of different dietary factors with glucose levels and lipid values in type 2 diabetes from a part of a large nationwide trial. Methods: This was the data fromapan-India multicentered cluster randomized controlled study covering 60 states and 4 union territories; 17,285 individuals were surveyed for dietary factors. Amongst them, data of 12,500 individuals were analyzed. Males were 54% and 60% individuals were from urban areas. Results: The analysis of the results showed that consumption (usual/often) of milk(odds ratio, OR = 7.180), meat (OR = 6.81), less fiber (OR = 17.77), and less fruits (OR = 14.71) was strongly and positively associated with fasting blood glucose (P<.001). The postprandial blood glucose (PPBG) in diabetes individuals also had a strong positive association (P<.001) with consumption (usual/often) of meat (OR = 22.82) and milk (OR = 17.19). In prediabetes individuals, milk was significantly (P<.001) associated with fasting blood glucose (OR = 2.74). In nondiabetes individuals also, milk was significantly associated with postprandial blood glucose (OR = 2.56). Consumption of meat was associated with high cholesterol (OR = 1.465). Consumption of junk food was associated significantly (P <.001)with the status of known diabetes (OR = 1.345) and known hypertension (OR = 1.247). Conclusion: Consumption of milk, meat, less vegetables, less fruits, and junk food has a significant effect on the glycemic status and cholesterol levels, and also on the status of known diabetes and hypertension. Keywords Diabetes, Milk, Meat, Junk food, Indian population Received 2 October 2020; revised 7 October 2020; accepted 7 October 2020 Introduction Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), Kempegowda Nagar, Bengaluru, Karnataka, India Neuroscience Research Lab, Postgraduate Institute of Medical Education Diabetes mellitus is a metabolic disorder, and lifestyle and Research (PGIMER), Chandigarh, India behaviors including dietary patterns, physical activity, bad Centre for Mind Body Medicine, PGIMER, Chandigarh, India habits, and stress are the known etiological factors. Its 4 Panjab University, Chandigarh, India Department of Yoga and Physical Science, SVYASA Yoga University, increasing prevalence in developing countries such as India is Bangalore, India closely associated with the structure of the population, age Corresponding author: 1,2 factors, and urbanized lifestyle. Raghuram Nagarathna, Director, Arogyadhama, VYASA, 19, Eknath Bhavan, The accurate etiology of diabetes mellitus has remained Gavipuram Circle, Kempegowda Nagar, Bengaluru, Karnataka 560019, India. uncertain in spite of the advancement in research and E-mail: rnagaratna@gmail.com Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https:// us.sagepub.com/en-us/nam/open-access-at-sage). 176 Annals of Neurosciences 27(3-4) treatment facilities around the globe. Genetics, age, exercise, amount of vitamin D and calcium may lead to hyperglycemia, physical fitness, dietary patterns, medications, obesity, and while intakes of a diet containing vitamin D and calcium may waist circumference are the high-risk factors contributing to regularize glucose metabolism. Various observational studies the development of causes of diabetes—reduced insulin have been carried out on the relation of the intake of milk absorption and beta-cell destruction. products and insulin absorption, and most of them have 4 10,11 In a review study, it is reported that the quality of the diet revealed an opposite relation. was the important factor for reduced insulin absorption rather A prospective study established that excessive consumption than the components of the diet. In general, a greater intake of red meat was associated with an increased risk of of milk products is not associated with reduced absorption of developing type 2 diabetes in middle-aged and older people. insulin. This is in contrast to the traditional belief that milk Also it was observed that there were significantly positive products, which are associated with higher levels of associations of cholesterol-, protein-, and iron-rich diet foods, 11,12 cholesterol, saturated fat, and protein, are the risk factors for for example red meat, with a risk of developing diabetes. cardio-vascular diseases (CVD). However, the fact that a A study on personalized diet habits and counseling on more protein intake increases the risk of ischemic heart exercise hypothesized thatthese result in improving the 5 13 disease has not been established. function of the nervous system and reduction in pain. But the evidence of the study was not conclusive. The Globally, various studies are available on single dietary study also suggested that several factors related to components factors (e.g., milk, meat, or fiber diet), but no comprehensive in milk products and constitutional variation, genetic study had been conducted in India including all dietary variability in populations may have an impact on insulin factors. Hence, the present study has been conducted to check absorption. For example, the type of milk products they the effect of different diet components on blood sugar and consume and the amount of fat and mineral may influence the lipid values in type 2 diabetes all over India. absorption of insulin. Another study performed in Sweden, observed the Methodology relationship between diet habits and risk of metabolic syndrome, including a diet rich in milk fat compared to Study Design regular milk and cheese. It revealed that excessive consumption of glucose, bakery products, and alcohol was This study is part of a pan-India multicentred cluster associated with the risk of metabolic syndrome. However, in randomized controlled trial covering all populous states and women, consumption of excessive milk products was found 14 union territories. Details of the methodology have been to be having a guarding effect with respect to type 2 diabetes. published earlier.In brief, the study was planned in two phases Further, a diet with excessive milk fat was associated with a with the goal of preventing further development of prediabetes reduced risk of hyperinsulinemia in women, but not in case of into diabetes. In step 1 of phase I, screening was done on Indian men. The authors also noted that there may be a gender Diabetes Risk Score (IDRS) to identify high-diabetes-risk and difference in how different foods affect the metabolic known diabetes individuals. In step 2 of phase I,detailed data consequences with respect to diabetes. including blood test data were acquired for fasting blood In a prospective analysis of 7,731 men and women over 15 glucose (FBG), postprandial blood glucose (PPBG), and years of follow-up, Brunner et al. found that a “healthy” glycated hemoglobin (HbA1c) only in those subjects who had eating pattern characterized by a diet richin fruits, vegetables, attained high IDRS scores (IDRS >60). Phase II was a two- wholemeal bread, and breakfast cereals, low-fat dairy, and armed translational randomized controlled trial on yoga-based little alcohol reduced the risk of diabetes and coronary death lifestyle changes. Figure 1 provides the structure of the project. or nonfatal myocardial infarction as compared to an In step 1, samples from seven geographical zones, i.e., “unhealthy” eating pattern (white bread, processed meat, Jammu & Kashmir, Northeast, North, West, Central, East, and fries, and full-cream milk). Compared with the “unhealthy” South were included. A stratified, multistage cluster sampling pattern, the “healthy pattern” was almost two-fold higher in design was adopted. In rural areas, a two-stage village– fruit and vegetable intake and three-fold higher in bakery household design, and in urban areas, a four-stage town/city– product and milk product intake. ward–block–household design wereadopted. Both rural and Numerous studies on milk products have shown negative urban areas were stratified at three levels based on the associations with the risk of type 2 diabetes. This study 15,16 geographical distribution and population size (Figure 1). examined the different facts that (a) milk products were suggested to have an insulinotropic effect in single meals, (b) Assessments fatty acids were found to improve insulin sensitivity, and (c) diets rich in protein, calcium, and other minerals were found The assessments in step 1 for all participants included four to reduce blood pressure and body weight/fat and also found factors: IDRS, sociodemographic variables, blood pressure, to have an effect on blood cholesterol. and self-reported diabetes. Further assessments of known An earlier systematic review study which observed diabetes and high-diabetes-risk groups (IDRS>60) included outcomes related to glucose homeostasis concluded that less HbA1c, FBG, PPBG, and lipid profiles (in venous blood). Nagarathna et al. 177 Figure 1. Four-Level Sampling Design. Source: Nagendra et al. Table 1. Questions Asked in the Survey. Details of dietary patterns were documented for the high-risk group (Table 1). Skip breakfast? Usually/Often 1 Sometimes 2 Rarely/Never 3 Statistical Analysis Eat less than two servings of fruit Usually/Often 1 Data were uploaded via mobile apps by trained yoga a day? Sometimes 2 Serving = ½cup or 1 medium-sized Rarely/Never 3 volunteers for diabetes mellitus (YVDMs) under supervision fruit or ¾ cup 100% fruit juice. of senior research fellows. Uploaded data from screening Eat less than two servings of veg- Usually/Often 1 forms (about 4, <0.001 per district), registration forms, and etables a day? Sometimes 2 laboratory data (about 50, <0.001) were checked for perfect Serving = ½ cup vegetables, or 1 Rarely/Never 3 matching of coding. After cleaning on Excel, the dataset was cup leafy raw vegetables. analyzed using R software for biostatistical analyses. Linear Eat or drink two servings of milk, Usually/Often 1 regression and binomial regression were adopted for checking yogurt, or cheese a day? Serving = Sometimes 2 the association between dietary factors and sugar levels and 1 cup milk or yogurt; 60 g cheese. Rarely/Never 3 status of diabetes. Eat more than 250 g (see sizes Usually/Often 1 below) of meat, chicken, turkey, or Sometimes 2 fish per day? Rarely/Never 3 Results Note: 100 g of meat or chicken is the size of a deck of cards or one of The survey was conducted on 17,285 individuals for dietary the following: 1 regular hamburger, factors. Sample data of 12,500 individuals were analyzed. In 1 chicken breast or leg (thigh and those, males were 54%, and 60% individuals were from drumstick), or 1 pork chop. urban areas. Burger/Chips How many times in a week? Table 2 shows the regression values for the association Fried items, e.g., Samosa/Kachori/ How many times in a week? between different dietary factors and the blood glucose values Bonda, etc. (FBG and PPBG) in individuals with diabetes, prediabetes, Pizza How many times in a week? and normoglycemia. As seen from the table, usual/often Cake/Pastry How many times in a week? intake of meat, milk, less fiber, and less fruits was significantly Fizzy cold drinks How many times in a week? associated with raised PPBG and FBG in the diabetes group. Chat/Masala puri How many times in a week? 178 Annals of Neurosciences 27(3-4) However, among the prediabetes group, these were Increased consumption of burger, cake, and fizzy per week significantly associated with FBG only, except for the less was associated with hypertension stage 2. fruit group which has a significant association with both FBG Table 5 reveals the odds ratio of the association between and PPBG. The normoglycemia group also revealed various dietary factors consumed usually and peripheral significant associations of PPBG with usual milk intake and neuropathy in diabetes individuals. It was found that usual FBG with meat, and less fiber, less fruit intake with raised consumption of meat was significantly associated with PPBG and FBG. In the diabetes group, no significant peripheral neuropathy in diabetes individuals. association was noticed for either FBG or PPBG with skipping Table 6 shows the odds ratio of the association between of breakfast, whereas in the normal group FBG and PPBG various dietary factors consumed usually and cholesterol. It showed a significant association with skipping of breakfast. was found that usual/often consumption of meat and less Furthermore, in the prediabetic group, a significant association vegetables was significantly associated with high cholesterol. was observed only for FBG. Table 3 reveals the odds ratio of the association between Discussion various junk foods and self-reported known diabetes. It was found that consumption of cake and fizzy drinks per week The present study has been conducted across seven zones of was significantly associated with the status of known India. In this study, an association of dietary factors such as diabetes mellitus. milk products, meat, and junk foods with FBG and PPBG Table 4 depicts the odds ratio of various dietary factors for was appraised. the incidence of prehypertension, hypertension stage 1, and The findings of the present study revealed that regular hypertension stage 2. It was found that an increased consumption of pizza and fizzy per week was associated with ingestion of excessive milk, meat, and junk foods has a prehypertension. Increased consumption of pizza, fizzy, and substantiated effect on the blood glucose levels of the cake per week was associated with hypertension stage 1. individuals, particularly in case of diabetes mellitus. These Table 2. Association Between Dietary Factors With Diabetes Categories of Diabetes, Prediabetes, and Normoglycemia (Regression Analysis). Dietary Factor Consumes usually/Often Blood Variables Diabetes Odds Ratio Prediabetes Odds Ratio Normoglycemia Odds Ratio Milk PPBG 17.19* 3.44 2.56* FBG 7.18* 2.74* 2.31 Meat PPBG 22.82* 3.90 1.64 FBG 6.81* 2.63* 1.51* Less fiber PPBG 17.77* 2.78 2.80* FBG 9.17* 2.87* 1.95* Less fruit PPBG 14.71* 3.51* 1.21* FBG 8.99* 1.95* 1.18* Skipping of breakfast PPBG 5.63 1.33 1.72* FBG 4.14 1.69* 1.45* Abbreviations: FBG, fasting blood glucose; PPBG, postprandial blood glucose. Notes: There was a highly significant association between blood glucose (FBG and PPBG) values and consumption of milk, meat, less fruits, and less fiber, but not with skipping of breakfast in diabetes individuals.*significance P< .001. Table 3. Association Between Self-Reported Diabetes and Different Junk Foods (Regression Analysis). 95% Confidence Interval Junk Foods Sig. Odds Ratio Lower Bound Upper Bound Burger/Week .165 1.234 0.917 1.660 Fried food/Week .662 1.053 0.835 1.329 Cake/Week .044 1.345 1.009 1.795 Fizzy drinks/Week .008 1.344 1.079 1.674 Chats/Week .331 0.909 0.749 1.102 Fish/Week .754 0.984 0.888 1.090 Note: There is a significant association between diabetes and consumption of cake and fizzy drinks. Nagarathna et al. 179 Table 4. Association Between Different Categories of Hypertension and Different Junk Foods (Regression Analysis). 95% Confidence Interval Hypertension Factor Sig. Odds Ratio Lower Bound Upper Bound Prehypertension Burger/Week .413 0.968 0.413 1.046 Pizza/Week .006 1.233 0.006 1.432 Cake/Week .803 1.018 0.803 1.176 Fizzy drinks/Week .000 1.335 0.000 1.452 Chats/Week .786 0.991 0.786 1.056 Hypertension stage Burger .429 0.957 0.429 1.067 Pizza .026 1.207 0.026 1.426 Cake .005 1.236 0.005 1.433 Fizzy drinks .002 1.181 0.002 1.310 Chat .991 1.000 0.991 1.069 Hypertension stage Burger .044 0.756 0.044 0.992 Pizza .755 1.048 0.755 1.410 Cake .043 1.247 0.043 1.543 Fizzy drinks .009 1.215 0.009 1.406 Chat .854 0.989 0.854 1.113 Table 5. Association Between Peripheral Neuropathy in Diabetes and Consumption of Different Foods (Regression Analysis). 95% Confidence Interval Dietary Factors Sig. Odds Ratio Lower Bound Upper Bound Milk usually .088 1.143 0.980 1.332 Milk sometimes .598 1.037 0.905 1.128 Meat usually .031 1.198 1.016 1.412 Meat sometimes .157 1.124 0.956 1.323 Less vegetable usually .569 0.953 0.807 1.125 Less vegetable sometimes .778 1.019 0.895 1.161 Less fruit usually .498 0.943 0.797 1.117 Less fruit sometimes .850 0.986 0.857 1.136 Skip breakfast usually .544 1.042 0.913 1.188 Skip breakfast sometimes .736 0.977 0.855 1.117 results establish the role of the frequency and the type of association between intakes of red meat and poultry with a food an individual consumes in healthy and unhealthy risk of developing diabetes. conditions. Ayurveda recommends avoiding milk products Gittelsohn et al. have shown that excessive consumption to control diabetes. of junk foods and bakery products was associated with a Findings of another study also suggested that excessive substantial increase in the risk of developing diabetes and consumption of milk products reduces the insulin sensitivity impaired glucose tolerance. These foods tend to be high in as compared to red meat in overweight and obese subjects simple glucose, low in fiber, and high in fat. The with glucose intolerance. Another study is also in line with authorsobserved a close relationship between dietary patterns the findings of the present study signifying the positive and the incidence of diabetes mellitus. 180 Annals of Neurosciences 27(3-4) Table 6. Association Between High Cholesterol and Different with an increased risk of type 2 diabetes. A regular habit of Dietary Factors (Regression Analysis). breakfast eating may help lower the risk of type 2 diabetes. Thus, skipping of breakfast is associated withan increased 95% Confidence Interval risk of type 2 diabetes. Odds Lower Upper In this study, association of dietary factors was also DietaryFactors Sig. Ratio Bound Bound analyzed with peripheral neuropathy, which revealed that milk usually .221 0.871 0.699 1.086 subjects who consumed meat usually had a significant Milk sometimes .076 0.840 0.692 1.019 association with peripheral neuropathy, with symptoms of Meat usually .002 1.465 1.156 1.858 pain and numbness from nerve damage in hands and feet, Meat sometimes .194 1.172 0.922 1.489 majorly in diabetes individuals. However, studies reveal that there are treatments in other Less vegetable .037 0.769 0.602 0.984 usually practices. In general, a healthy lifestyle involving maintaining the body weight, eluding contact with toxins, practicing Less vegetable .124 0.864 0.717 1.041 sometimes physician-supervised exercise program, consuming a balanced diet, rectifying vitamin deficiencies, and evading Less fruit usually .902 0.985 0.776 1.251 alcohol and smoking can reduce the symptoms of peripheral Less fruit .428 0.922 0.755 1.127 neuropathy. sometimes However, the Foundation for Peripheral Neuropathy Skip breakfast .918 0.990 0.818 1.199 endorses increasing omega-3 fatty acids for reducing the risk usually of diabetes. It also suggests consuming one to two tablespoons Skip breakfast .884 1.014 0.836 1.231 of flaxseed oil a day oreating fatty fish, salmon, or three sometimes ounces of walnuts a day. Note: High cholesterol was associated significantly with usual consumption The association between nutritional status and optic or of meat and less vegetables. peripheral neuropathies is well established with tobacco, ethanol, deficiencies in thiamine, vitamin A, B12, B3, and On the contrary, a number of studies have shown the B6, and protein–energy malnutrition, all being causative. negative association with milk consumption. A lipid and The present study also revealed the association of dietary glucose study conducted in Tehran, involving 827 subjects, factors with the cholesterol level that mainly revealed showed that a number of factors were found to be associated nonsignificant results, whereas only subjects who consumed favorably with dairy consumption, including the metabolic usually meat and less vegetables showed a significant syndrome in newly diagnosed diabetes, but significant association with the cholesterol level. After consumption of a associations were not found. meat diet, the plasma cholesterol concentration fell by 8.6% The CARDIA study, which is a prospective study over and low-density-lipoprotein cholesterol by 11%. But the 10 years, demonstrated a negative association between milk present study showed a low significant association between consumption and the development of the disease. In contrast, high cholesterol and meat consumption with odds ratio [OR the present study has depicted a significant association Researchers found that consuming 1.274 (1.018, 1.515)]. between milk intake and glucose levels in diabetes. excessive amounts of saturated fat and meat protein was A prospective study conducted in Finland proposed that associated with an upsurge in blood cholesterol than the the association between processed meat and diabetes was 21 meat-free diets. mostly because of sodium. Another study by Alsabieh etal. A meta-analysis of studies postulates that both fresh red proposed an affirmative association between packed food 22 meat and processed meat may upsurge the risk of stroke. This products and hypertension. is a significant finding because the excessive consumption of With consumption of usually less fiber and fruits showing red meat and the high morbidity and mortality have been a significant association with PPBG and FBG in the diabetes, associated with stroke. In this study, we found the association prediabetes, and normoglycemia groups in the present study, between meat and sugar levels. a study suggested the presence of heterogeneity in the The major asset of the study is that it was the first study to associations between the ingestion of fruits and risk of type 2 analyze the association between different food groups and diabetes. However, consumption of blueberries, grapes, and glucose levels across seven zones of India. Sample size was apples was significantly associated with a lower risk of type 2 also good. diabetes. But excessive consumption of fruit juice was found A limitation of the study is that the sample was not to be associated with a higher risk of diabetes. distributed normally in all zones. Moreover, the data about Moreover, skipping of breakfast showed a nonsignificant the exact quantity offoods was not obtained, and alsoit is association with PPBG and FBG in the diabetes group,only PPBG in the prediabetes group, and a significant association difficult to cull out the effects of physical activity. Furthermore, in the normoglycemia group. A meta-analysis of studies data about diet information was retrospectively obtained, and revealed that skipping of breakfast was found to be associated this is not a prospective supervised monitored diet study. 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