





































Clinical Medicine Insights
Received 20 Jul 2021 | Revised 22 Aug 2021 | Accepted 18 Sep 2021 | Published Online 01 Oct 2021

DOI: https://doi.org/10.52845/CMI/2021-2-4-2 
CMI JOURNAL 2 (4), 224−243 (2021) ISSN (O) 2694-4626 

REVIEW ARTICLE

DIET AND NON-COMMUNICABLE DISEASES: PART II Cancer,
Diabetes Mellitus, Kidney Diseases, Alzheimer’s Disease, Arthritis

Shashi K. Agarwal, MD ∗
 

12227 US Highway 1, #309 North
Brunswick, NJ 08902 USA

Abstract
Several global studies have shown that diet plays an important role
as a modifiable lifestyle factor in the development and progression of
non-communicable diseases. A proper diet with a balanced percentage
of macronutrients, viz. carbohydrates, proteins, and fats. It is also
selective in the choice of macronutrients, preferring those that are plant-
based, and avoiding refined carbohydrates, animal-based proteins, and
saturated fats and trans-fats. It is also rich in needed micronutrients viz.
vitamins and minerals, and adequate intake of water. This manuscript
deals with the important role of a prudent diet in five major non-
communicable diseases.
Keywords: diet, non-communicable diseases, cancer, diabetes mellitus,
kidney diseases, Alzheimer’s disease, arthritis

Copyright : © 2021 The Authors. Published by Medical Editor and
Educational Research Publishers Ltd. This is an open access article
under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).

1 INTRODUCTION

Homo sapiens are natural omnivores1. Our
guts resemble those of gorillas and chim-
panzees and are accustomed to handling

a mostly plant-based diet with occasional meat
intake2. In humans, the amount of caloric intake is
important3. Since overweight and obesity have a sig-
nificant negative impact on chronic diseases, proper
weight is an extremely important health issue4. An
ideal body mass index (BMI) is calculated as the
weight in kilograms divided by the height in meters
squared and should be between 18.5 to 24.9 kg/m25.

Many other anthropometric measurements are often
used, primarily because visceral or central obesity
appears to be more hazardous than measurement
of BMI alone6. These include waist circumference,
waist to hip ratio, and waist to height ratio7. Besides
excess body weight, the quality of diet is also im-
portant for good health8−10. A healthy diet should
provide appropriate proportions of macronutrients
(carbohydrates, proteins, and fats) for the energy and
physiologic needs8, sufficient micronutrients (vita-
mins and minerals) for normal growth, develop-
ment, metabolism, and physiologic functioning9, and
adequate water for hydration10. Carbohydrates are

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DIET AND NON-COMMUNICABLE DISEASES: PART II CANCER, DIABETES MELLITUS, KIDNEY 
DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS
abundant in grains, fruits, vegetables, and legumes11.
Whole grains have a higher amount of fiber and mi-
cronutrients than processed grains and are therefore
healthier12,13. Legumes and nuts are also healthy14,15
– except that nuts are energy-dense and may increase
body weight if not consumed judiciously16. Fresh
fruits and vegetables are good sources of phyto-
chemicals (polyphenols, phytosterols, carotenoids),
and dietary fiber – all healthy17−19. Dietary proteins
may be of animal origin (meat, dairy, fish, and eggs)
or plant origin (legumes, soy products, grains, nuts,
and seeds)20. Proteins are good sources of energy
and help maintain lean body mass21,22. Animal-
based sources of protein contain saturated fatty acids,
which are unhealthy23,24. Fats (or lipids), besides
providing energy, also help make up the cellular
membranes25. Dietary fats may be monounsaturated
fats, polyunsaturated fats, saturated fats, and trans
fats26. Unsaturated fats are found in a variety of
foods, including fish, many plant-derived oils, nuts,
and seeds, and are healthy27. Monounsaturated fats
(MUFA) include oleic acid, canola oil, and olive oil
and are heart healthy28. Polyunsaturated fats (PUFA)
include omega 3 fatty acids (Eicosapentaenoic acid
or EPA and docosahexaenoic acid or DHA) and have
positive health effects29−31. EPA andDHA are found
primarily in oily fish32, whereas animal products
(and some plant-derived oils) are rich in saturated
fats and should be only consumed infrequently33−35.
Processed meats are carcinogenic (they are also low
in micronutrients) and should be avoided36,37. Trans
fats found in foods are predominantly the result
of processing vegetable oils but are also present
in small quantities in animal products - they are
health harmful and should not be consumed32,38.
Micronutrients are required in trace amounts and
include vitamins, sodium, potassium, magnesium,
zinc, selenium, copper, and calcium39,40. These are
low in processed and refined foods41. Water is
also a principal component of the body42. Besides
hydration, water also provides several micronutri-
ents, including trace elements and electrolytes43,44.
Sugar-sweetened beverages, although water-based,
are harmful, especially due to the high fructose
content, and should be avoided45. Coffee46, tea47,
chocolate48, and olive oil49 are all plant-based and
healthy. Diabetics should watch their egg intake

but in general, one egg a day14 and low dairy
foods are safe50. Dietary patterns and dietary in-
gredients strongly affect chronic noncommunicable
diseases51.

2 DISCUSSION

Chronic noncommunicable diseases (NCD) are com-
mon conditions affecting humans52. According to the
World Health Organization, in 2020, the common
cases of cancer were related to the breast, lung,
colon and rectum, prostate, skin (non-melanoma),
and stomach53. Cancer accounted for nearly 10 mil-
lion deaths in 202053. It is on its way to replace
cardiovascular diseases (CVD) as the number one
killer in the world54. Diabetes mellitus is approach-
ing epidemic proportions worldwide55. According to
the International Diabetes Federation, it affected 425
million people globally in 2017, and these numbers
are expected to increase to 629 million by 204556.
Type 2 diabetes mellitus (T2DM) is responsible for
90% of all diabetes cases57 and is caused by a combi-
nation of defective insulin secretion by pancreatic β-
cells and/or the inability of insulin-sensitive tissues
to respond to insulin58. T2DM results in considerable
morbidity and mortality59. Diabetics live approxi-
mately six years less than non-diabetics60. It is an
expensive disease, with the economic burden being
approximately 12% of global health expenditure61.
Chronic kidney disease (CKD) is defined as the
presence of kidney damage or an estimated glomeru-
lar filtration rate (eGFR) less than 60 ml/min/1.73
mt2, persisting for 3 months or more, irrespective
of the cause62. It affects an estimated 10% to 15%
of people around the world63. It is a progressive
disease, and sufferers ultimately need dialysis or

Supplementary information The online version 
of this article (10.52845/CMI/2021-2-4-2) contains 
supplementary material, which is available to autho-
rized users.

Corresponding Author: Shashi K. Agarwal, MD 
Shashi K. Agarwal, MD 2227 US Highway 1, #309 
North Brunswick, NJ 08902,USA
Email: usacardiologist@gmail.com

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mailto:usacardiologist@gmail.com


MEERP LTD
SHASHI K. AGARWAL, MD

kidney transplantation64. CKD patients experience
considerable cardiovascular complications65, poor
cognitive function66, and a lower quality of life67.
They also face an early death68. Dementia is com-
mon globally69. A recent report estimated that 50
million people in the world are living with demen-
tia, and this number is projected to increase to 82
million by 2030 and to 152 million by 205070.
The most common cause is Alzheimer’s disease
(AD)71, which is characterized by amyloid plaques
and neurofibrillary tangles in the brain72. Symp-
toms include cognitive impairment and functional
decline, loss of independence, poor quality of life,
and premature institutionalization73,74. There is no
cure for AD, and treatment remains symptomatic75.
AD is also a major cause of death76. The main
types of arthritis encountered in clinical practice are
osteoarthritis (OA), rheumatoid arthritis (RA), and
gout77. OA is characterized by progressive cartilage
degradation, synovitis, osteophyte formation, and
subchondral bone sclerosis78. Treatment is largely
symptom based79−81, and many patients may end up
needing total joint replacement82. It is the fastest-
growing cause of disability worldwide83. Rheuma-
toid arthritis is an autoimmune disease and presents
as a symmetrical polyarthritis often with systemic
manifestations84. Gout is autoinflammatory joint
arthritis and is associated with hyperuricemia85. It is
induced by monosodium urate crystal deposition in
joints and soft tissues86.

2.1 CANCER

A healthy diet is associated with lower cancer mor-
bidity and mortality87−93. Steinmetz et al. reviewed
of 206 human epidemiologic studies and 22 ani-
mal studies and found that consumption of fruits
and vegetables was protective for cancers of the
stomach, esophagus, lung, oral cavity and pharynx,
endometrium, pancreas, and colon94. Islami et al
reported that low fruit and vegetable consumption
was associated with the development of 17.6% of
oral cavity/pharyngeal cancers, 17.4% of laryngeal
cancers, and 8.9% of lung cancers while low di-
etary fiber accounted for 10.3% of colorectal cancer
cases95. Red meat and processed meat are cancer
provoking96,97. Their consumption has been associ-

ated with an increased incidence of cancers of the
breast, colon, stomach, and prostate95,98. A healthy
diet improves cancer-related symptomology99, the
efficacy of treatment100, and raises the quality of
life101. Cancer patients decrease their risk of get-
ting a second primary tumor102 and improve their
survival103,104. A healthy diet also helps mitigate
against other chronic ailments like obesity, diabetes,
osteoporosis, and cardiovascular disease, which are
often present in cancer patients105−109.Processed and
red meat increases the exposure to carcinogens such
as N-nitroso compounds, polycyclic aromatic hy-
drocarbons, and heterocyclic amines110−113. Plant-
based diets are rich in phytochemicals and fiber that
diversify gut microbiomes, resulting in lower inflam-
mation, decreased oxidative damage, better immu-
nity, decreased tumorigenesis, and improved levels
of circulating sex and growth hormones114−116.

2.2 DIABETES MELLITUS

The obesity epidemic is giving rise to an increased
number of diabetics worldwide117. Weight loss in
individuals who are obese is effective in the pre-
vention and management of T2DM118. A calorie
restriction-induced weight loss of about 15 kg, can
lead to remission of T2DM in about 80% of obese
diabetics119. Certain dietary ingredients also im-
pact T2DM120−125. Plant-based diets help reduce
HbA1c more when compared to HbAIc in patients
on a conventional diet120,121. High consumption of
whole grains, low-fat dairy products, yogurt, olive
oil, chocolate, fiber, magnesium, and flavonoid also
significantly reduces the risk of T2DM122−125. In-
take of olive oil126 and coffee127 lowers the risk
of T2DM. Nut and legume intake does not appear
to affect T2DM122. In contrast, a high consumption
of red and processed meat, and sugar or sugar-
sweetened beverages significantly increases the risk
of T2DM124,128,129. No association has been noted
between fish intake and T2DM130. Schwingshackl
et al found that 1 serving/day of eggs (55 g/day) in-
creases the risk of T2DM by threefold122. However,
a recent review and meta-analysis of 82,750 women
from the Nurses’ Health Study, 89,636 women from
the NHS II, and 41,412 men from the Health Pro-
fessionals Follow-up Study found no overall associ-

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ation between moderate egg consumption and risk
of T2DM131. Schwingshackl et al calculated that
risk-decreasing foods are associated with a 42% re-
duction, while consumption of risk-increasing foods
resulted in a threefold increase in T2DM risk, com-
pared to non-consumption122. The Mediterranean
diet may result in a 30% relative risk reduction in
type 2 diabetes over a 20-year period132. The DASH
diet, along with the Alternate Mediterranean Diet
Index, Healthy Eating Index 2010, and Alternate
Healthy Eating Index 2010, has also shown an in-
verse association with T2DM133. A prudent diet is
more effective in decreasing the risk of T2DM if it is
combined with increased physical activity134.

2.3 KIDNEY DISEASES

Diet plays an important role in CKD135. A proper
diet, primarily plant-based, leads to a higher eGFR
and better serum albumin levels136. The prospective
observational Northern Manhattan Study with 900
participants found that plant-based diets resulted in
a 12% lower risk of eGFR decline when compared
with meat-based diets137. A dietary pattern rich in
whole grains, fruit, and low-fat dairy foods is as-
sociated with lower urinary albumin to creatinine
ratio138. Plant-based diets also are associated with
decreased mortality in adults with CKD139. Mor-
tality is high is CKD, primarily from cardiovascu-
lar complications140,141. Individual dietary compo-
nents influence blood pressure, lipid levels, oxidative
stress, insulin sensitivity, systemic inflammatory re-
sponses, pro-fibrotic processes, thrombosis risk, and
endothelial function in these patients and thereby
modify CVD and clinical outcomes142−144. CKD
patients may be advised to reduce their fluid and salt
intake145.A low protein diet is CKD friendly146. It
helps delay the progression of CKD147. A diet rich
in animal protein is potentially harmful and results
in deleterious outcomes148. Animal protein (red and
processed meat), results in higher BP, vasodilation
of afferent renal arterioles, glomerular hypertension,
hyperfiltration, metabolic acidosis, mitochondrial
oxidative stress, DNA damage, and increased accu-
mulation of the end-products of protein catabolism
– all harmful to the kidneys149. A diet high in fruits
and vegetables results in a slower CKD progression

and reduces complications and is associated with de-
creased mortality146. Patients adhering to a Mediter-
ranean diet for six years showed a 50% lower risk
of developing CKD150. An analysis of several large
RCTs also showed that compliance with theMediter-
ranean diet reduced CVD in these patients151. DASH
diet is also CKD protective152−154. A recent German
study also found that the Dietary Approaches to Stop
Hypertension diet (DASH)
adherence was associated with better eGFR
numbers152. Poor adherence to the DASH diet
results in a 16% higher risk of CKD (study of
15,000 Atherosclerosis Risk in Communities
participants)153. An inverse association between
the DASH diet and the risk of developing CKD
can therefore be inferred154. Healthy dietary
patterns (higher in fruit and vegetables, fish,
legumes, cereals, whole grains, and fiber, and lower
in red meat, salt, and refined sugars also lead to
better health quality of life in CKD patients144.

2.4 ALZHEIMER'S DISEASE

There appears to be no strong connection between
diet and the risk or progression of dementia155. There
is some suggestion that plant-based diets, especially
rich in green leafy vegetables may reduce cogni-
tive decline and dementia156. Several studies have
demonstrated that theMediterranean diet may have a
weak protective effect on cognition157−161. A slightly
modified DASH diet also appears to prevent cog-
nitive decline162. The benefits may derive from the
beneficial effects of healthy diets on the cardiovascu-
lar system163. Some studies have noted that the intake
of folate, B vitamins, vitamin C, D, E, and sele-
nium,may beneficially modify cognitive impairment
and dementia164−169. The Lipididiet trial found that
multi-nutrient supplementation slowed the decline
of cognitive, functional, and structural aspects of
dementia, and slowed disease progression, after a
period of 36 months170. In this study, the authors
did not find any difference between groups on the
cumulative incidence of dementia nor the mean time
to dementia diagnosis170. The World Health Organi-
zation does not recommend dietary supplements for
the management of dementia171.

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2.5 ARTHRITIS

A weight losing diet resulting in weight loss shows
a benefit on OA172−175. Obesity increases strain
on weight-bearing joints and aggravates OA172−176.
An association of higher BMI with the develop-
ment of hand OA has also been noted177. Hyper-
glycemia affects the subchondral bone and is also a
predictor of OA178−179. Cholesterol has been found
to accumulate in human OA cartilage180. Higher
intakes of total and saturated fat are associated
with increased knee joint space-width loss, whereas
higher intakes of monounsaturated fatty acids (MU-
FAs) and PUFAs are associated with reduced ra-
diographic progression181. These can be modulated
with dietary interventions. Low levels of vitamin
D and vitamin K have also been implicated in
OA182, although benefit via supplemental remains
unclear183,184. Several diets have been studied in
RA for their inflammation-reducing effects, includ-
ing fasting185, the Mediterranean diet186, the Cretan
Mediterranean diet187, vegetarian diet188,189, and an
anti-inflammatory diet190. Fasting followed by a pe-
riod of the Mediterranean diet, the Cretan Mediter-
ranean diet, a vegetarian diet or an anti-inflammatory
diet have been shown to have a beneficial effect
on RA191. A vegan diet is also useful192. Several
foods are pro-inflammatory, including highly refined
flours, gluten, trans- and saturated fatty acids, dairy
products, and red meat193−196. These may aggravate
RA. Some vegetables may worsen RA and include
tomatoes, eggplants, and potatoes197. Some mi-
cronutrients are anti-inflammatory and include long
chain omega-3 polyunsaturated fatty acids monoun-
saturated fatty acids, antioxidants, phytochemicals,
flavonoids, vitamin D, fruits with enzymatic pro-
teins such as papain and bromelain, ginger, turmeric,
black pepper, green tea, and legumes198−217. How-
ever, it is not clear if supplementation with these
ingredients helps218−223. Gout is related to hyper-
uricemia and dietary factors that increase the lat-
ter are harmful224. Uric acid-raising foods like al-
cohol, fructose (fruit juices), meats, organ meats,
and seafood, and sugar intake (including sugar-
sweetened beverages) should be reduced225−227.
Beneficial products in diet are low-fat dairy products,
soy, and vitamin C228. Coffee consumption may

decrease the risk of gout229. Both the DASH diet230
and the Mediterranean diet231 may help prevent gout
or reduce gout attacks.

3 CONCLUSION

A healthy diet is rich in plant-based foods, including
fresh fruits and vegetables, whole grains, legumes,
seeds, and nuts, and lower in animal-based foods,
particularly saturated fat-laden red meat, and pro-
cessed meats. Sugar-sweetened beverages are health
harmful. Coffee, tea, and olive oil are plant-based
and healthy. Alcohol is a double-edged sword and
is harmful if consumed in more than moderate
amounts. Dietary and other lifestyle modifications
are expected to reduce NCD-relatedmorality by 25%
by the year 2025232.
Acknowledgment: None
Funding: None
Conflict of interest: None
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	Introduction
	Discussion
	CANCER
	DIABETES MELLITUS
	KIDNEY DISEASES
	ALZHEIMER'S DISEASE
	ARTHRITIS

	CONCLUSION



