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 CMI JOURNAL 2 (4), 224−243 MEERP LTD 224 Open Access Journal https://doi.org/10.52845/CMI/2021-2-3-8 https://orcid.org/0000-0003-0007-5582 https://creativecommons.org/licenses/by-nc-nd/4.0/ https://medicineinsights.info/index.php/cmi 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 CMI JOURNAL 2 (4), 224−243 (2021) MEERP LTD 225 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- MEERP LTD CMI JOURNAL 2 (4), 224−243 (2021) 226 DIET AND NON-COMMUNICABLE DISEASES: PART II CANCER, DIABETES MELLITUS, KIDNEY DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS 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. CMI JOURNAL 2 (4), 224−243 (2021) MEERP LTD 227 MEERP LTD SHASHI K. AGARWAL, MD 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 REFERENCES 1. https://www.nationalgeographic.org/encyclope dia/omnivore/. 2. L. Cordain, S.B. Eaton, A. Sebastian, et al. 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