Mediterranean Diet for Effective Management of Diabetes: A Literature Review

This literature review focuses on the effectiveness of Mediterranean diet in managing diabetes. It includes a systematic review of research studies and their evaluation. The review also provides recommendations for nursing practice and patient care.

Running head: EVIDENCE BASED NURSING
Evidence Based Nursing
Name of the Student
Name of the University
Author Note

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Introduction
According to the Australian Institute of Health and Welfare [AIHW] (2018), chronic
diseases are long lasting conditions which are characterised with persistent effects. The social
and the economic consequences of chronic health conditions hamper the health-related
quality of life of the affected individuals. AIHW reports 8 major chronic health conditions
namely asthma, arthritis, cancer, back pain, cardiovascular disease, chronic obstructive
pulmonary disease, diabetes and mental health conditions. This paper will mainly structure its
literature review framework via focusing on the diabetes as a chronic health condition
Research Question
PICOT
P Population Individuals with Diabetes
I Intervention Mediterranean Diet
C Comparison Normal Diet
O Outcome Reduction in glycemic index and effective disease control
Systematic Review
Research Question (100 words)
According to Ryanet al. (2013)diabetes especially type 2 diabetes mellitus is a major
health related problem worldwide. Numerous compelling evidences showed that diabetes can
be prevented by lifestyle changes. The lifestyle modification mainly encompasses
modification of diet which promotes weight loss through restricted calorie intake. Ryanet al.

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(2013) highlighted that Mediterranean diet is moderately rich in fat (fat from vegetable
source) and relatively low in dairy products. This energy is found to promote decreased
incidence of diabetes in comparison to other crash diet or sugar-free diet pattern.
The main research question is how Mediterranean diet plan helps in effective
management of diabetes in comparison to other diet.
Evaluation of the research
Espositoet al. (2014)conducted a primary research in relation to the role of the diet in
controlling type 2 diabetes mellitus. The main aim of the study is to assess the long-term
effects of the dietary interventions on the glycemic control and the requirement of the
diabetes medications and subsequent remission of type 2 diabetes. Espositoet al. (2014) used
two-arm trial design over middle-aged men and women who are over-weight and has recently
been diagnosed with diabetes. The authors randomly allocated the focus group into two
different groups. One in low-carbohydrate Mediterranean diet (LMD) and another group to
low fat diet. This is the main strength of the study design as it allocated randomly the selected
focus groups in to two different groups and accordingly to Brannen(2017), this helps to
decrease the chances of obtaining biased results arising from allocation bias. The two-arm
trial study design further helped to improve the quality of the study (Brannen, 2017).
However, they selected only over-weight men and women in order to check the efficacy of
the Mediterranean diet over the glycemic level and this again stood out for bias selection of
the focus group.The research paradigm selected by the author is positivism research
paradigm. According to Brannen(2017), positivism research paradigm is best suited for the
quantitative research. Espositoet al. (2014) mainly conducted quantitative research as they
used statistical analysis in order to compare the efficacy of LCMD and low fat diet. One

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limitations of the study is, Espositoet al. (2014) used 4 years of follow-up and this lead to the
decrease in the overall sample size which might lead to biased outcome.
Research topic
According to the objective 1of National Strategic Framework for Chronic Conditions,
primary focus should be given on prevention for the promotion of a healthier Australia. The
health promotion and prevention strategies mainly promote minimization or prevention of the
disease progression among the vulnerable population with chronic conditions. Another
implication of objective one is reduction of the risk developing additional conditions and
associated complications along with an improvement of the overall quality of life. According
to Georgoulis, Kontogianni and Yiannakouris(2014),Mediterranean diet helps to minimize
the severity of diabetes mellitus and at the same time helps in the reduction of the glycemic
index of the body. This decreases the overall disease progression. The research conducted by
Sleiman, Al-Badri andAzar(2015) highlighted that observance of Mediterranean diet helps in
the reduction of the development of cardiovascular risk associated with diabetes.
Cardiovascular risk is defined as the macro and microvascular complications which are
associated with diabetes and thus reduction in the risk of developing cardiovascular helps to
decrease the chances of getting affected with the additional disease complications. Thus it can
be said that the research topic mainly aims at the prevention of the disease outcome along
with reduction in the associated health related complication. Thus providing a comprehensive
disease prevention approach.
Literature Review
In relation to the Mediterranean diet Salas-Salvadóet al. (2014)conducted a
multicenter randomised control trial under primary care centres in Spain. The principal aim of
the study is to evaluate whether dietary changes without any strict calorie restriction helps to

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provide protection from diabetes. They randomly assigned participants to three different diet
plans, like Mediterranean diet which is supplemented with extra-virgin olive oil (EVOO),
Mediterranean diet which is supplemented with nuts and another control diet (low-fat diet).
Salas-Salvadóet al. (2014) devised no specific interventions in order to increase the physical
activity in order to lose weight. The analysis of the results highlighted that Mediterranean diet
which is rich with EVOO but without any form of strict energy restriction was successful in
decreasing the overall risk of diabetes among patients upon long term intervention. This
decrease in the threat of diabetes among the older person further helped to reduce the
cardiovascular risk. Salas-Salvadóet al. (2014) are of the opinion that this beneficial effect
was mainly attributed to the overall versatility of the dietary pattern and not on calorie
restriction or increase in the rate of physical activity. In relation to Mediterranean diet and
blood glycaemic load and its association with the type 2 diabetes mellitus, Rossi et al. (2013)
conducted a population based cohort study. Rossi et al. (2013) are of the opinion that effect of
diet in the prevention of diabetes is uncertain. The aim of their study is to investigate the
effect of two different dietary aspects in relation to diabetes control and management. The
two different diets which are taken into consideration include Mediterranean diet and
Glycaemic load. They mainly included 22,295 participants and followed for a median of
11.32 years. Then semi-quantitative food frequency questionnaire is used to analyse the
results and Mediterranean diet score (MDS) was used to calculate the results. The results
highlighted that observance of Mediterranean diet is helpful in reducing the incidence of type
2 diabetes via decreasingthe glycaemic load (Rossi et al., 2013). Rossi et al. (2013) are of the
opinion that the overall rate of absorption and digestion of different carbohydrate sources
increases the risk of diabetes. This increase in the risk of diabetes in narrated in terms of
dietary index and is known as glycaemic index (GI). GI is an indicator of the ability of
carbohydrate to increase the blood sugar levels. It is highlighted that long-term intake of

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high-GI containing food increases the overall insulin demand in the body along with
promotion of insulin resistance or impairment of the pancreatic beat cells in providing insulin
thus leading to the generation of diabetes mellitus. However, the observance of the
Mediterranean diet helps to lower the overall GI and thereby helping to reduce the
susceptibility of developing diabetes (Rossi et al., 2013).Espositoet al. (2014) conducted a
follow-up randomised control trail in order to access the long-term effects of the dietary
interventions on the glycaemic control and subsequent requirement for diabetes medicines
and cure of type 2 diabetes. They mainly used a two-arm trial design over middle-aged men
and women who are over-weight and have recently been diagnosed with type 2 diabetes.
They randomly assigned the participants into different group, one with low-carbohydrate
Mediterranean diet (LCMD) and another group with low-fat diet. The four years of follow up
highlighted that patients who are recently diagnosed with type 2 diabetes, showed greater
reduction in the blood glucose level upon observance of LCMD and required less demand for
pharmacologic medication in comparison to low-fat diet (Esposito et al., 2014).
Thus from the research findings it can be said that the main implications for change in
nursing practice is to take the diet of the patients with diabetes into active consideration for
the effective management of the disease. The Mediterranean diet must be designed in such a
way that it is rich in fat which are derived from the plant source and are low in the
carbohydrate and the sugar content. Such restricted carbohydrate intake will help to lower the
blood glucose level. Reduction in the in-take of the carbohydrate will help to decrease the
calorific value of the diet and will limit the overall calorie intake too. Moreover, proper
regulation of the fat and protein from the natural sources will help to maintain the nutritional
value of the body. However, it is the duty of the nursing professionals to take help from the
professional dietician in devising the Mediterranean diet plan for the patient with diabetes.
The planning of the diet chart should be done on the basis of the body mass index, age and

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the glycemic level of the body. Proper monitoring of the blood glucose level must be
undertaken in order to regulate the calorific intake of the body and thus help in healthy
functioning of the body(Munshi et al., 2016).
Recommendation
According to Bohanny et al. (2013), devising of the proper diet plan in order to
regulate the glycemic level of the blood among the diabetic patient is not comprehensive in
overall reduction of the blood glucose level. Bohanny et al. (2013) proper the proper healthy
literacy promotes proper adherence of the diet plan and thereby helping in the effective self-
management of the disease. This is because there is strong relationship between health
literacy, self-efficacy and self-care behaviour of the individuals with diabetes. Proper
strategies are required to be devised in order to incorporate the concept of self-efficacy in
designing the care plan for the chronic disease like diabetes. The concept of self-efficacy is
promoted via providing health education in self-care behaviours on managing hypoglycaemic
and hyperglycaemic shocks via abiding diet plan and checking the blood sugar levels.Halali
et al. (2016) further highlighted the observance of a strict diet plan for long-term intervention
for the diabetes control can generate a sense of monotony. So in order to bring change in the
taste buds, it is the duty of the nursing professionals to make cyclic rotation of the menus
under the Mediterranean diet plan. This cyclic rotation must be done on weekly basis under
the controlled supervision of the professional dieticians.

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References
Australian Health Ministers’ Advisory Council (2017).National Strategic Framework for
Chronic Conditions. Access date: 26th September 2018. Retrieved from:
http://www.health.gov.au/internet/main/publishing.nsf/content/A0F1B6D61796CF3D
CA257E4D001AD4C4/$File/National%20Strategic%20Framework%20for
%20Chronic%20Conditions.pdf
Australian Institute of Health and Welfare.(2018). Chronic Disease Overview. Access date:
25th September 2018. Retrieved from:
https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/
chronic-disease/overview
Bohanny, W., Wu, S. F. V., Liu, C. Y., Yeh, S. H., Tsay, S. L., & Wang, T. J. (2013). Health
literacy, self‐efficacy, and self‐care behaviors in patients with type 2 diabetes
mellitus. Journal of the American Association of Nurse Practitioners, 25(9), 495-502.
Brannen, J. (2017). Mixing methods: Qualitative and quantitative research.Routledge.
Esposito, K., Maiorino, M. I., Petrizzo, M., Bellastella, G., &Giugliano, D. (2014). The
effects of a Mediterranean diet on need for diabetes drugs and remission of newly
diagnosed type 2 diabetes: follow-up of a randomized trial. Diabetes care,
DC_132899.
Georgoulis, M., Kontogianni, M. D., &Yiannakouris, N. (2014).Mediterranean diet and
diabetes: prevention and treatment. Nutrients, 6(4), 1406-1423.

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Halali, F., Mahdavi, R., Mobasseri, M., Jafarabadi, M. A., &Avval, S. K. (2016). Perceived
barriers to recommended dietary adherence in patients with type 2 diabetes in
Iran. Eating behaviors, 21, 205-210.
Munshi, M. N., Florez, H., Huang, E. S., Kalyani, R. R., Mupanomunda, M., Pandya, N., ...&
Haas, L. B. (2016). Management of diabetes in long-term care and skilled nursing
facilities: a position statement of the American Diabetes Association. Diabetes
care, 39(2), 308-318.
Rossi, M., Turati, F., Lagiou, P., Trichopoulos, D., Augustin, L. S., La Vecchia, C.,
&Trichopoulou, A. (2013). Mediterranean diet and glycaemic load in relation to
incidence of type 2 diabetes: results from the Greek cohort of the population-based
European Prospective Investigation into Cancer and Nutrition
(EPIC). Diabetologia, 56(11), 2405-2413.
Ryan, M. C., Itsiopoulos, C., Thodis, T., Ward, G., Trost, N., Hofferberth, S., ...& Wilson, A.
M. (2013). The Mediterranean diet improves hepatic steatosis and insulin sensitivity
in individuals with non-alcoholic fatty liver disease. Journal of hepatology, 59(1),
138-143.
Salas-Salvadó, J., Bulló, M., Estruch, R., Ros, E., Covas, M. I., Ibarrola-Jurado,
N., ...&Romaguera, D. (2014). Prevention of diabetes with Mediterranean diets: a
subgroup analysis of a randomized trial. Annals of internal medicine, 160(1), 1-10.
Sleiman, D., Al-Badri, M. R., &Azar, S. T. (2015).Effect of mediterranean diet in diabetes
control and cardiovascular risk modification: a systematic review. Frontiers in public
health, 3, 69.

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Appendix
Annotated Bibliography
Name and year of
publication
Aim of the study Study Design Results
Salas-Salvadó, J.,
Bulló, M., Estruch, R.,
Ros, E., Covas, M. I.,
Ibarrola-Jurado,
N., ...&Romaguera, D.
(2014).
To access the efficacy
of different
Mediterranean diet in
reducing the incidence
of type 2 diabetes
mellitus
Subgroup analysis of
multicenter randomised
control trial
The analysis of the
results highlighted that
Mediterranean diet
which is rich with
EVOO but without any
form of strict energy
restriction was
successful in
decreasing the overall
risk of diabetes among
patients upon long term
intervention.
Rossi, M., Turati, F.,
Lagiou, P.,
Trichopoulos, D.,
Augustin, L. S., La
Vecchia, C.,
&Trichopoulou, A.
(2013)
The aim of the study
was to investigate two
different dietary
aspects, adherence to
Mediterranean diet and
glycaemic load (GL),
in relation to diabetes
occurrence
Population based
cohort study
The results highlighted
that observance of
Mediterranean diet is
helpful in reducing the
incidence of type 2
diabetes via decreasing
the glycaemic load
Esposito, K., Maiorino,
M. I., Petrizzo, M.,
Comparison between
low-carbohydrate
Follow-up randomised The four years of
follow up highlighted

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Bellastella, G.,
&Giugliano, D. (2014)
Mediterranean diet
(LCMD) and low-fat
diet to access long-
term effects of the
dietary interventions on
the glycaemic control
among type 2 diabetes
individual
control trail that patients who are
recently diagnosed
with type 2 diabetes,
showed greater
reduction in the blood
glucose level upon
observance of LCMD
and required less
demand for
pharmacologic
medication in
comparison to low-fat
diet