Fruit and vegetable intake and incidence of type 2 diabetes mellitus,diabetes treatment by operation,gbf release opleiding - Videos Download

Our New BMJ website does not support IE6 please upgrade your browser to the latest version or use alternative browsers suggested below. India continues to suffer from consequences of poverty and underdevelopment, such as malnutrition and huge numbers of child and maternal deaths.
By the year 2020, mortality from communicable, maternal and perinatal conditions, and nutritional deficiencies is expected to fall from almost 5 million to below 3 million a year in India, according to the 1996 Global Burden of Disease series issued jointly by the World Health Organization (WHO), the World Bank and the Harvard School of Public Health. India’s urban population has increased more than threefold in the last 40 years to more than 250 million, and the United Nations projects that by 2025, 50 percent of Indians will live in urban areas, a breeding ground for NCDs and their lifestyle-related triggers.
At the same time, physical activity and energy expenditure continue to decline, as more and more of India’s agricultural society evolves into industrialized communities.
Such diets and lifestyle have exacerbated the incidence of abdominal obesity, insulin resistance, Type II diabetes, hypertension, cardiovascular disease and Syndrome X in India.
In short, India exemplifies the double jeopardy facing many developing countries and the challenges facing international and national policy-makers: halting escalating NCD epidemics worldwide, while confronting NCDs alongside infectious diseases, childhood and maternal mortality, and undernutrition in developing countries. National nutrition policy in India encompasses a multifaceted approach, including chronic-disease prevention, but its overwhelming focus remains the prevention of childhood and maternal malnutrition and infectious diseases.
The vast majority of Indians now have access to radio, and, even in villages, they view TV programs. One way that the Ministry of Health, Door Darshan and the health sector could outsmart the industry and advertising agencies is to beat them at their own game by using visual media effectively. To succeed would require a massive and sustained national campaign, especially targeting children, because childhood is when food habits are formed.
A mass media approach has worked well for tobacco control in the United States and Australia. Dietary fiber, also known as roughage, is the general term of the non-digestible parts of the fruit and vegetable products we eat. Vikas Rana of the Rain Forest Research Institute, in Assam, India, and colleagues point out that research has shown that modern food habits have, it seems, led to an increase in the incidence of obesity, cardiovascular diseases, and type 2 diabetes.
Given that dietary fiber has physiological actions such as reducing cholesterol and attenuating blood glucose, maintaining gastrointestinal health, and positively affecting calcium bioavailability and immune function, it is important for the current generation and future generations that this component of our diets be reasserted through education and information. Steady declines in the rates have been observed everywhere in the last few decades, but the absolute number of new cases per year is increasing mainly because of ageing of the population. However, major economic and social changes in recent decades have brought a new brand of health problems – non-communicable lifestyle diseases among the rich, the middle class and the poor.
A 2003 WHO survey of more than 10,000 urban and rural Indian adults shows a high prevalence of physical inactivity, especially among middle-aged and older adults (see chart).
Ramachandran and colleagues showed that 35 to 45 percent of middle-aged Indians had a body mass index (BMI) that exceeded 25 (see chart). Furthermore, it appears that the nation has yet to take full advantage of its television and other mass media to reach the masses.
In fact, television is the most effective medium for health communications, according to data collected during CECHE’s PSA Testing and Health Beliefs Program in 2000 in South India.
This means outsourcing the production of public service announcements (PSAs), television series, musicals and ads to the very ad agencies that are producing them for the fast-food industry. Such a campaign would need to be supported by training more health professionals and educators in public health and in the use of mass media for health promotion.
And CECHE’s experience in 1997 and 2000 in producing and testing PSAs in Punjab and South India tells us that it is likely to have a similar, positive impact in India, especially with support from the Nutrition Foundation of India, Lady Irwin College and other in-country organizations with health and nutrition expertise.
The team has looked at research conducted into dietary fiber during the last few decades across the globe and now suggests that to avoid initial problems, such as intestinal gas and loose stool, it is best to increase intake gradually and to spread high-fiber foods out throughout the day, at meals and snacks.
Increased consumption has also been associated with increased satiety and weight loss,” the team concludes. The association with gastric cancer was significant for both intestinal and diffuse types of gastric cancer, and it became stronger with increasing antibody titers and with increasing time between serum collection and cancer diagnosis. Writing in the International Journal of Food Safety, Nutrition and Public Health, the team offers fruit, vegetables, whole-grain foods, such as muesli and porridge, beans and pulses, as readily available foods rich in dietary fiber. Soluble (prebiotic, viscous) fiber that is readily broken down or fermented in the colon into physiologically active byproducts and gases. The team suggests that evidence points to a loss of dietary fiber in the diet as being a major risk factor for health problems but one of the simplest to remedy without recourse to major changes in diet or the addition of supplements or so-called functional foods and nutraceuticals to the diet. Given the ready availability particularly in the West and in the relatively richer parts of the developing world of vegetables, fruit and other foods high in dietary fiber it is a matter of recommending that people eat more dietary fiber rather than consistently taking the unhealthy low-fiber option throughout their lives. Dietary modifications and, possibly, vitamin supplements remain one of the most important tool for the prevention of gastric cancer. Thus, given India’s low literacy rates in several areas, visual media offer a special channel to mold public opinion on nutrition and health issues.
The second form is insoluble fiber, which is metabolically inert, but absorbs water as it passes through the digestive system, providing bulk for the intestinal muscles to work against and easing defecation.
There has been a focus on the role of carbohydrates and fibre,2 3 but the relation between fruit and vegetable intake and incidence of type 2 diabetes is not fully understood. As with obesity, Type II diabetes among middle-class adults and children in India is growing rapidly and is now six to 10 times more prevalent in India’s urban than its rural populations (see chart). The food industry is already using TV, radio and the print media to push fast foods; they know how to attract attention, and they are making significant headway. They were compared with an equal number of controls matched by age at serum donation, sex, race, date of serum donation, and site of recruitment. The exact mechanisms by which fruit and vegetables reduce the risk of these chronic diseases are not precisely known. The mean interval between serum collection and the diagnosis of gastric cancer was 14.2 years.
A combination of antioxidants and phytochemicals found in fruit and vegetables might promote health by combating free radicals, which are linked with early phase development of some chronic diseases.16 High intakes of fruit and vegetables have been shown to increase concentration of plasma carotenoids and vitamin C,17 18 both of which have antioxidant properties. The association was stronger in women and blacks and it was not confounded by either blood group or smoking history. In addition, recent studies have been published that could further contribute to the pooled data and allow further investigation into any association.MethodsSearch strategyIn consultation with the research team we used the Cochrane handbook21 and the guide to systematic reviews from the Centre for Reviews and Dissemination22 to develop a systematic review protocol.

A history of peptic ulcer was negatively associated with subsequent gastric carcinoma in this study. To ensure a broad search, the search strategy included the medical subject headings (type 2 diabetes, prediabetes, impaired glucose tolerance, impaired fasting glucose, fruits, vegetables, citrus, follow-up, and prospective studies). There were no language restrictions.Study selectionTo be included, studies had to be prospective cohort studies that included an individual measure of intake of fruits, vegetables, or fruit and vegetable and an assessment of the development of type 2 diabetes. The association was weak, possibly on account of the short time interval between serum collection and cancer diagnosis (mean= 3.1 years).
Some years before diagnosis, many of the cases would have been likely to have severe atrophic gastritis or intestinal metaplasia. Two reviewers (PC and JT) independently assessed all potentially relevant studies and resolved any uncertainty through discussion. These conditions favour the loss of HP colonization, thus leading to false-negative findings in cases more frequently than in controls.
No relevant papers were found in languages other than English.Validity assessmentTwo authors (PC and JT) independently assessed all studies for quality. With respect to the aetiology, priority will be given to the findings concerning dietary habits and HP and their implications for the prevention of this malignancy will be assessed. A fifth prospective study is currently being conducted in Shanghai, China,61 including a cohort of 18 244 men aged 45-64 years who provided serum samples between 1986 and 1989. A scoring system was created to account for participants (1 point if any justification was given for the cohort and 1 point for appropriate inclusion and exclusion criteria), outcome (1 point if diagnosis of type 2 diabetes was confirmed according to accepted clinical criteria23 24 and not based on self report), intervention (1 point if participants’ usual fruit and vegetable consumption was assessed with a validated tool25), and statistical analysis (1 point was given if adjustments were made for age, body mass index (BMI) and family history of type 2 diabetes, these being proven risk factors for type 2 diabetes). The 87 cases of gastric cancer identified by September 1992 were compared with four to five controls per case, matched by year of birth, month of sample collection and residence. We assumed relative risks to be a valid approximation of hazard ratio,21 enabling the use of one consistent measure. The studies used various measurements for intake—for example, servings per week, grams per day.
We standardised all data into servings per day, using a standard portion size of 106 g.29 Any disagreement was resolved through discussion. From the review of the formal epidemiological studies carried out so far, the strongest evidence for a causal association is provided by case-control studies carried out in low-risk populations for gastric cancer and from the nested case-control studies in which it could be demonstrated that the HP infection preceded the gastric cancer development.
However, the lack of control for potential confounders does not allow to draw definitive conclusions.
Especially elevated risk derived from HP infection in younger subjects, although the rarity of gastric cancer before 40 years of age hampers the study of this age group.54,62 The lack of association found in the case-control studies carried out in high-risk areas for stomach cancer might be due to the use of inappropriate serological assays, since assays were based on HP strains most common in Western countries. We assessed titles and abstracts and obtained full articles of potentially relevant studies. Several articles examined fruit and vegetable intake within a dietary pattern only or were cross sectional in design and therefore could not be included. An important contribution can, however, come from the study of different strains of HP, with, possibly, varying oncogenic potentials. This would provide an essential tool to reassess and, possibly reconcile the aforementioned inconsistencies in the epidemiology of HP world-wide.
Ten of the cohort studies found a positive association between some aspect of tobacco use and gastric carcinoma and two did not find such an association. Papers did not state that a power calculation had been undertaken nor give any justification for the numbers of participants needed to detect an effect of differences in fruit and vegetable intake and the incidence of type 2 diabetes. Eight of the cohort studies examined the presence of a dose-response relationship: three of these found a positive dose- response trend, while five others did not. The meta-analysis did not show any significant reductions in risk of type 2 diabetes incidence for consumption of fruit, vegetables, or vegetables and fruit combined (figs 2?, 3?, and 4?), though the data do suggest a trend towards a benefit of consuming greater quantities (table 2?). All studies that examined intake of green leafy vegetables showed a benefit of consuming greater quantities (fig 5?).
Indirect effects of inhaled tobacco smoke in gastric carcinogenesis may involve both the nitrosamines found in smoke, as well as endogenously formed nitrosamines in smokers. Weights are from random effects analysisFig 3 Hazard ratios for incidence in diabetes type 2 for highest versus lowest intake of fruit. Weights are from random effects analysisFig 4 Hazard ratios for incidence in diabetes type 2 for highest versus lowest intake of fruit and vegetables combined. Weights are from random effects analysisFig 5 Hazard ratios for incidence in diabetes type 2 for highest versus lowest intake of green leafy vegetables. The risk pattern with alcohol drinking is clearly different for gastric cancer,64 but some relation is biologically plausible. Alcohol, in fact, could act as a contributory factor by causing chronic irritation of the gastric mucosa.
We separately analysed quality of articles, sex, length of follow-up, and location as these were assumed to be potential sources of bias. Chronic gastritis, a disease which is thought to predispose to cancer of the stomach, is very common among alcoholics.
We also investigated whether the different ways in which authors had grouped intake (thirds, quarters, or fifths) affected the results. There were no significant interactions between any of these variables that would explain the heterogeneity seen. In addition we re-ran the meta-analysis to include the EPIC study,35 which presented data as odds ratios.
Since occupations are clearly related to socio-economic background, some of the excess risk observed might be attributable to patterns of lifestyle such as dietary habits.
The data did not show any significant relations between the consumption of fruits, vegetables, or fruit and vegetables combined on the incidence of diabetes. As there was significant heterogeneity between studies, however, we carried out a sensitivity analysis. This showed no significant interactions between the outcomes of variables examined, and thus could not identify differences that occurred between the studies.Exploration of heterogeneityWithin the sensitivity analysis we examined location as a possible source of heterogeneity.
48% of individuals with affected mothers were affected as compared to only 7% of those who mother did not have chronic atrophic gastritis.

As traditional Chinese diets are high in fruit and vegetables,42 we would expect that intake would be greater in China than the US or Europe. Only two of the studies included men, both of which showed significant benefits of increasing intake of fruit and vegetables.
Our results might have been different if the studies in our meta-analysis had included more men. Recent population-based survival data show that, even in Western countries, 5-year relative survival rates for stomach cancer are very low (around 20%) and improvement over time is small.70 In the absence of widely available and effective screening programmes, primary prevention by decreasing exposure to the identified risk factors for the disease or by increasing protection against them might be the most effective way of controlling it. Further studies in men are required before firm conclusions can be made.Although the sensitivity analysis could not explain the level of heterogeneity, it could be because of several differences between the studies. Despite clear improvements in the last decades, dietary modifications and, possibly, vitamin supplements remain the most important tool for the prevention of gastric cancer.
However, no intervention trial on diet and stomach cancer is in progress and none is planned.
Ford and Mokdad estimated servings per week,40 intake from three studies was calculated as servings per day,37 39 41 and the two remaining studies35 36 38 calculated grams per day. This latter tendency occurs mainly in Eastern countries in which a substantial proportion of the population takes vitamin supplements, and in developing countries that are undergoing rapid economic change, such as China, which is influencing the food supply. Three studies examined intake of fruit and vegetables separately and combined,37 39 41 one study examined combined consumption,40 and two examined intake separately.36 38 These two papers both showed significant benefits of greater consumption of fruit, vegetables, and green leafy vegetables. The main features of these trials have been described in detail elsewhere.71 Control of HP infection, by means of eradication or immunization, is also likely to have great potential in the prevention of stomach cancer.
Ford and Mokdad collected data via a single 24 hour recall,40 two studies used dietary assessment interviews,36 38 and the remaining studies used self completed food frequency questionnaires. Indeed studies have previously shown that interactions between diet and disease have been masked by the use of food frequency questionnaires but identified by food diaries and nutritional biomarkers.49 50 51 The use of biomarkers avoids problems associated with self report, and they can be collected for large numbers of participants. Thus there is a need to incorporate more biological markers of fruit and vegetable intake, such as plasma vitamin C concentration, into prospective nutritional assessment studies.In our meta-analysis we included the most fully adjusted hazard ratio presented in the articles.
Not all authors of the primary articles made the same adjustments, and this might have had an impact on our overall dataset. Our results support this as green leafy vegetables, such as spinach, have been shown to contain high concentrations of ? carotene and vitamin C,56 both of which confer antioxidant properties. Green leafy vegetables also contain polyphenols,57 which are known for their antioxidant properties.
Green leafy vegetables might reduce the risk of type 2 diabetes because of their magnesium content. A recent meta-analysis found magnesium intake to be inversely associated with incidence of type 2 diabetes.58 Green leafy vegetables are also good sources of ? linolenic acid,59 which is an omega 3 polyunsaturated fatty acid.
The fatty acid profile of the diet is thought to be important in determining the fatty acid composition of the phospholipid bilayer. The composition of this bilayer is related to insulin sensitivity within skeletal muscle.60 Thus there are several possible mechanisms that could explain the benefit of consuming green leafy vegetables in the diet.
Our results support the evidence that “foods” rather than isolated components such as antioxidants are beneficial for health. The search was conducted on multiple databases and was carried out by two independent authors. In addition we contacted all authors of included articles to request any further information.As with all meta-analysis, several limitations must be considered.
The statistical power of the study might be limited as we included only six studies and only four studies for the examination of green leafy vegetables. In addition the meta-analysis includes only one study from Europe, highlighting a lack of potentially important information.There was significant heterogeneity between the included studies so overall conclusions must be regarded with caution. We did, however, carry out a thorough sensitivity analysis to investigate possible sources of heterogeneity.To further examine the association between intake and risk of type 2 diabetes we investigated the possibility of carrying out a dose-response analysis. Previous studies have also shown that greater intake of fruit and vegetables is linked to other lifestyle factors such as physical activity.52 We cannot rule out the possibility that other variables, which were not adequately controlled for, might have influenced the data from these studies. The results highlight a call for standardisation of nutritional epidemiology, with emphasis on the additional use of biological markers and uniformity of food groups.Conclusions and implicationsResults from our meta-analysis support recommendations to promote the consumption of green leafy vegetables in the diet for reducing the risk of type 2 diabetes. PC performed the literature review, extracted and analysed data, and wrote the first draft of the article.
All authors contributed to the writing of the paper and gave input at all stages of the study. All members of the research team are either employees of the University of Leicester or the University Hospitals of Leicester NHS Trust. Dietary habits and gastro-intestinal cancers: A comparative case-control study of stomach and large intestinal cancers in Nagoya, Japan.
Dietary risk factors in intestinal and diffuse types of stomach cancer: a multicenter case-control study in Poland. Effect of eradication of Helicobacter pylori on gastric juice ascorbic acid concentrations. Anti-Helicobacter pylori antibodies prevalence and gastric adenocarcinoma in Portugal: report of a case-control study.
Helicobacter pylori infection in a randomly selected population, healthy volunteers, and patients with gastric ulcer and gastric adenocarcinoma. Association between infection with Helicobacter pylori and risk of gastric cancer: Evidence from a prospective investigation.
Association between Helicobacter pylori infection, lifestyle and the risk of gastric carcinoma in China. Chemoprevention trial on precancerous lesions of the stomach in Venezuela: summary of study design and baseline data. Difficulty in eradicating helicobacter pylori in a population at high risk for stomach cancer in Venezuela.

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