DIABETESRESEARCHANDCLINICALPRACTICE 86S (2009) S41 – S48 Dietary strategies for patients with type 2 diabetes in the era of multi-approaches; review and results from the Dietary Intervention Randomized Controlled Trial (DIRECT) Sivan Ben-Avraham a , Ilana Harman-Boehm b , Dan Schwarzfuchs c , Iris Shai a, * a The S. Daniel Abraham Center for Health and Nutrition, Department of Epidemilogy, Ben-Gurion University of the Negev, Beer-Sheva, Israel b Department of Internal Unit C and Diabetes Unit, Soroka University Medical Center, Beer-Sheva, Israel c Nuclear Research Center Negev, Dimona, Israel ARTICLE INFO ABSTRACT Keywords: Type 2 diabetes Glycemic control Low-carbohydrate diet Mediterranean diet Low-fat diet Dietary intervention is recognized as a key component in prevention and management of type 2 diabetes (T2DM) and the debate persists: which dietary strategy is most effective. In the Dietary Intervention Randomized Controlled Trial (DIRECT) 322 moderately obese participants were randomized for 2 years to one of three diet groups: low-fat, Mediter- ranean and low-carbohydrate. Differential effects were observed in the sub-group of pa- tients with T2DM at 24 months: participants randomized to the Mediterranean diet, which had the highest intake of dietary fibers and unsaturated to saturated fat ratio, achieved greater significant improvements in fasting plasma glucose and insulin levels. Patients who were randomized to the low-carbohydrate diet, which had the minimal intake of carbohy- drates, achieved a significant reduction of hemoglobin A1C. Although improvements were observed in all groups, the low-fat diet was likely to be less beneficial in terms of glycemic control and lipid metabolism. Interpretation of results from different studies on dietary strategies may be complex since there is often no consistency in diet compositions, calo- rie restriction, intensity of intervention, dietary assessment or extent of adherence in the trial. Nevertheless, it seems that low fat restricted calorie diets are effective for weight loss and are associated with some metabolic benefits; however, some recent trials have shown that low carbohydrate diets are as efficient in inducing weight loss and in some metabolic measures such as serum triglycerides and HDL-cholesterol may be even superior to low fat diets. When addressing the issue of diet quality rather than quantity applying the glycemic index may have some added benefits. Furthermore special features of the Mediterranean diet have apparent additional favorable effects for patients with T2DM. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction “Diabesity” is a term that describes the joint occurrence of T2DM and obesity [1]. T2DM constitutes 85–95% of all dia- * Address for correspondence: Dr. Iris Shai, The S. Daniel Abraham International Center for Health and Nutrition, Department of Epi- demiology and Health Systems Evaluation, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva 84105, Israel. E-mail address: irish@bgu.ac.il (I. Shai). 0168-8227/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. betes in developed countries, and an even higher percent in developing countries, with 50 to 90% of all cases result- ing from weight gain [2,3]. According to the World Health Organization it is estimated that the worldwide prevalence of diabetes will rise from 171 million in 2000 to 366 million in 2030 [4]. Data from the International Diabetes Federa- tion indicate that in people aged 20–79 years the worldwide prevalence will rise from 5.9% in 2007 to 7.1% in 2025 [2]. Diabetes and related complications are major causes of morbidity and mortality; it is among the leading causes of