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A Low-Fat Vegan Diet Elicits Greater Macronutrient Changes, but Is Comparable in Adherence and Acceptability, Compared with a More Conventional Diabetes Diet among Individuals with Type 2 Diabetes
Open accessAbstract
Background Although therapeutic diets are critical to diabetes management, their acceptability to patients is largely unstudied.Objective To quantify adherence and acceptability for two types of diets for diabetes.Design Controlled trial conducted between 2004 and 2006.Subjects/setting Individuals with type 2 diabetes (n=99) at a community-based research facility. Participants were randomly assigned to a diet following 2003 American Diabetes Association guidelines or a low-fat, vegan diet for 74 weeks.Main outcome measures Attrition, adherence, dietary behavior, diet acceptability, and cravings.Statistical analyses For nutrient intake and questionnaire scores, t tests determined between-group differences. For diet-acceptability measures, the related samples Wilcoxon sum rank test assessed within-group changes; the independent samples Mann-Whitney U test compared the diet groups. Changes in reported symptoms among the groups was compared using chi(2) for independent samples.Results All participants completed the initial 22 weeks; 90% (45/50) of American Diabetes Association guidelines diet group and 86% (42/49) of the vegan diet group participants completed 74 weeks. Fat and cholesterol intake fell more and carbohydrate and fiber intake increased more in the vegan group. At 22 weeks, group-specific diet adherence criteria were met by 44% (22/50) of members of the American Diabetes Association diet group and 67% (33/49) of vegan-group participants (P=0.019); the American Diabetes Association guidelines diet group reported a greater increase in dietary restraint; this difference was not significant at 74 weeks. Both groups reported reduced hunger and reduced disinhibition. Questionnaire responses rated both diets as satisfactory, with no significant differences between groups, except for ease of preparation, for which the 22-week ratings marginally favored the American Diabetes Association guideline group. Cravings for fatty foods diminished more in the vegan group at 22 weeks, with no significant difference at 74 weeks.Conclusions Despite its greater influence on macronutrient intake, a low-fat, vegan diet has an acceptability similar to that of a more conventional diabetes diet. Acceptability appears to be no barrier to its use in medical nutrition therapy.
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“Very low-fat patterns are characterized predominantly by having ≤10% energy from fat. 37,[39][40][41]57,58”
From Popular dietary patterns: alignment with American Heart Association 2021 dietary guidance: a scientific statement from the American Heart Association. (2023) · cites this paper as [57]
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Rosenfeld, R. M., Grega, M. L., Karlsen, M. C., Dabrh, A. M. A., Aurora, R. N., Bonnet, J. P., Donnell, L., Fitzpatrick, S. L., Frates, E. P., Joy, E. A., et al. (2025) · American Journal of Lifestyle Medicine · doi:10.1177/15598276251325488 · Cited by 31
Acharya, S. D., Brooks, M. M., Evans, R. G., Linkov, F. Y., & Burke, L. E. (2013) · Journal of the American College of Nutrition · doi:10.1080/07315724.2013.816607 · Cited by 26
“[20] reported similar acceptability between a low-fat vegan diet and a more conventional diabetes management diet.”
BackgroundDorling, J. L., Bhapkar, M. V., Das, S. K., Racette, S. B., Apolzan, J. W., Fearnbach, S. N., Redman, L. M., Myers, C. A., Stewart, T. M., & Martin, C. K. (2019) · Appetite · doi:10.1016/j.appet.2019.104397 · Cited by 25
“, 2011), though others have found certain cravings are elevated (Jakubowicz, Froy, Wainstein, & Boaz, 2012) or unchanged (Barnard et al., 2009) in response to changes in diet.”
BackgroundFrugé, A. D., Smith, K. S., Riviere, A. J., Demark‐Wahnefried, W., Arthur, A. E., Murrah, W. M., Morrow, C. D., Arnold, R. D., & Lloyd, K. B. (2019) · Nutrients · doi:10.3390/nu11102349 · Cited by 25
“Diet acceptability was assessed with the Food Acceptability Questionnaire (FAQ) [14,15] after each intervention period to investigate differences in acceptability between control and intervention diets.”
MethodMartin-McGill, K. J., Marson, A. G., Smith, C. T., & Jenkinson, M. D. (2017) · Pilot and Feasibility Studies · doi:10.1186/s40814-017-0209-9 · Cited by 22
“1 Flow of patients through the KEATING trial or intolerances, level of physical activity (as defined by DH [25]), food or fluid texture modification, use of enteral feeding tube, anthropometry (height, weight, BMI, mid-arm muscle circumference, triceps skinfold, mid-arm muscle circumference, hand grip strength, waist…”
MethodInfluentialPreparing to Prescribe Plant-Based Diets for Diabetes Prevention and Treatment
Trapp, C., & Levin, S. (2012) · Diabetes Spectrum · doi:10.2337/diaspect.25.1.38 · Cited by 24
Crimarco, A., Turner-McGrievy, G. M., Botchway, M., Macauda, M., Adams, S. A., Blake, C. E., & Younginer, N. (2020) · Journal of Black Studies · doi:10.1177/0021934719895575 · Cited by 20
“In addition, one of the barriers for dietary acceptability of PBDs is the perceived difficulty of preparing plant-based meals (Barnard et al., 2009).”
BackgroundSelf-citationKahleová, H., Znayenko‐Miller, T., Uribarri, J., Holubkov, R., & Barnard, N. D. (2022) · Obesity Science & Practice · doi:10.1002/osp4.646 · Cited by 20
“A low attrition rate suggests that the plant‐based diet was sustainable, confirming the results of a prior long‐term study.(30) The study also has important limitations.”
ResultSelf-citationDean, E., Jia, X., JONES, A. Y. M., Vongsirinavarat, M., Lomi, C., Kumar, P. L., Ngeh, E. N., & Storz, M. A. (2024) · Nutrition Journal · doi:10.1186/s12937-024-01018-z · Cited by 23
Crimarco, A. E., Dias, C. H., Turner‐McGrievy, G. M., Wilson, M. J., Adams, S. A., Macauda, M. M., Blake, C. E., & Younginer, N. (2019) · Food Quality and Preference · doi:10.1016/j.foodqual.2019.103788 · Cited by 19
Self-citationFuller, N. R., Lau, N. S., Denyer, G. S., Simpson, A. E., Gerofi, J. A., Wu, M., Holmes, A. J., Markovic, T., Kang, J., & Caterson, I. D. (2011) · Obesity Research & Clinical Practice · doi:10.1016/j.orcp.2011.05.003 · Cited by 17
Trepanowski, J. F., & Varady, K. A. (2014) · Critical Reviews in Food Science and Nutrition · doi:10.1080/10408398.2012.736093 · Cited by 19
“, reducing saturated fat and dietary cholesterol intake) on a vegan diet without needing to limit food consumption (Barnard et al., 2009b).”
BackgroundVegetarianism in Food-Based Dietary Guidelines
Baroni, L. (2015) · International Journal Of Nutrition · doi:10.14302/issn.2379-7835.ijn-14-588 · Cited by 15
Mathieu, S., Hanras, E., & Dorard, G. (2023) · International Journal of Food Sciences and Nutrition · doi:10.1080/09637486.2023.2232953 · Cited by 14
Kahleová, H., Znayenko‐Miller, T., Uribarri, J., Schmidt, N., Kolipaka, S., Hata, E., Holtz, D. N., Sutton, M., Holubkov, R., & Barnard, N. D. (2023) · Maturitas · doi:10.1016/j.maturitas.2023.03.008 · Cited by 13
Self-citationKahathuduwa, C. N., Davis, T. H., O’Boyle, M. W., & Binks, M. (2018) · Physiology & Behavior · doi:10.1016/j.physbeh.2018.01.018 · Cited by 15
Liepinsh, E., Skapare, E., Vavers, E., Konrāde, I., Strēle, I., Grı̄nberga, S., Pugovičs, O., & Dambrova, M. (2012) · Nutrition Research · doi:10.1016/j.nutres.2012.03.010 · Cited by 13
A Randomized, Crossover Trial of a Nutritional Intervention for Rheumatoid Arthritis
Barnard, N. D., Levin, S., Crosby, L., Flores, R., Holubkov, R., & Kahleová, H. (2022) · American Journal of Lifestyle Medicine · doi:10.1177/15598276221081819 · Cited by 12
Self-citationDaly, R. M., Ross, B. D., Gianoudis, J., & Tan, S. (2022) · Journal of Nutrition · doi:10.1093/jn/nxac044 · Cited by 12
“Self-reported time spent in moderate-vigorous physical activity (MVPA) was assessed at baseline and follow-up using the Active Australia survey (21, 22).”
MethodWagenaar, C. A., Toonstra, A., Walrabenstein, W., van Schaardenburg, D., & van Nassau, F. (2024) · BMC Public Health · doi:10.1186/s12889-024-18554-2 · Cited by 11
“These findings are supported by studies who found no difference in acceptance of plant-based diets (i.e. vegan and vegetarian) when compared to diets including meat [36].”
Bethancourt, H. J., Kratz, M., & O’Connor, K. A. (2019) · British Journal Of Nutrition · doi:10.1017/s0007114519001533 · Cited by 10
Marsh, K. A., & Brand-Miller, J. C. (2010) · American Journal of Lifestyle Medicine · doi:10.1177/1559827610387393 · Cited by 8
“However, the vegan diet group had a greater reduction in fat and cholesterol intakes.(87,111) The vegan dieters significantly increased their intake of carbohydrate, dietary fiber, vitamins A, C, and K, b-carotene, folate, magnesium, and potassium, but reduced their intakes of calcium and vitamin B12 whereas the ADA d…”
BackgroundResultTurner‐McGrievy, G. M., Wirth, M. D., Bernhart, J. A., & Aydin, H. Z. (2022) · Appetite · doi:10.1016/j.appet.2022.106135 · Cited by 13
Self-citationHamilton, E. A. A., Nowell, A. K., Harden, A., & Thangaratinam, S. (2018) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2018.05.008 · Cited by 11
Crimarco, A. E., Turner‐McGrievy, G. M., Wirth, M. D., Shivappa, N., Dunn, C. G., Vyas, S., Mandes, T., Hurley, T. G., West, D. S., & Hébert, J. R. (2018) · Nutrition and Health · doi:10.1177/0260106018800645 · Cited by 9
Self-citationRibeiro, R. V., Senior, A. M., Simpson, S. J., Tan, J., Raubenheimer, D., Couteur, D. G. L., Macia, L., Holmes, A. J., Eberhard, J., O’Sullivan, J., et al. (2024) · Aging Cell · doi:10.1111/acel.14276 · Cited by 8
“Previous studies have found adherence and acceptability of PBD of all levels (vegan, vegetarian, pesco-vegetarian, semi-vegetarian) to be similarly good (Barnard et al., 2009 ).”
Legumes and their role in linking nutrition, sustainability and veganism
Gulia, V., Dhull, S. S., Beniwal, D., Deepali, D., Sangwan, A., & Rani, J. (2025) · International Journal of Vegetable Science · doi:10.1080/19315260.2025.2496739 · Cited by 7
“Lower risk of blood pressure and cardiovascular diseases Friedewald et al., (2011); Barnard et al., (2009).”
Marsh, K. A., Saunders, A. V., & Zeuschner, C. L. (2015) · Practice, progress, and proficiency in sustainability · doi:10.4018/978-1-4666-9553-5.ch008 · Cited by 7
Adherence to Low-Fat, Vegan Diets in Individuals With Type 2 Diabetes: A Review
Storz, M. A. (2020) · American Journal of Lifestyle Medicine · doi:10.1177/1559827620964755 · Cited by 7
“%) was found in a small pilot study by Nicholson and colleagues, which included only 7 participants in the intervention group.19 Race and ethnicity were reported in detail in only 4 of the included studies.3,20,24,25 Apart from a 2019 study that specifically investigated the impact of a plant-based diet (coupled with…”
BackgroundResultInfluentialChwyl, C., Wright, N., Turner‐McGrievy, G. M., Butryn, M. L., & Forman, E. M. (2022) · JMIR Formative Research · doi:10.2196/37414 · Cited by 7
“Consistent with past WFPBD interventions and to ensure nutritional adequacy, participants were instructed to consume 50 μg of vitamin B12 supplements daily [47,48].”
MethodSelf-citationFuller, N. R., Fong, M., Gerofi, J. A., Leung, L., Leung, C., Denyer, G. S., & Caterson, I. D. (2016) · Clinical Obesity · doi:10.1111/cob.12137 · Cited by 7
“Table 5 Average scores for each group at baseline and 6 weeks for the Food Acceptability Questionnaire (FAQ) Intervention ‘VW’ group (mean ± standard deviation) (n = 33) Control ‘AGHE’ group (mean ± standard deviation) (n = 34) Between group comparison (VW relative to AGHE) mean difference (95% CI) Screening Δ 6 weeks…”
BackgroundInfluentialHu, E. A., Turner‐McGrievy, G. M., Wilson, M. J., Davey, M., Bailey, S., Okpara, N., Frongillo, E. A., & Wilcox, S. (2024) · Nutrition Research · doi:10.1016/j.nutres.2024.01.010 · Cited by 7
Self-citationMarsh, K. A., Saunders, A. V., & Zeuschner, C. L. (2016) · IGI Global eBooks · doi:10.4018/978-1-5225-0549-5.ch007 · Cited by 6
The Physician's Role in Nutrition-Related Disorders: From Bystander to Leader
Barnard, N. D. (2013) · The AMA Journal of Ethic · doi:10.1001/virtualmentor.2013.15.4.oped1-1304 · Cited by 7
Self-citationHou, Y., Chang, Y.-L., Kuo, S.-C., Chiang, C., Chiang, C.-Y., Lin, Y.-F., Weng, P.-C., Hu, F.-C., Wu, J., & Lai, C. (2014) · International Journal of Medical Sciences · doi:10.7150/ijms.8158 · Cited by 5
“These studies all found similar effects of vegetable-related diets in previous studies about vegan diets in type II DM (6, 8, 24).”
ResultNutrient Adequacy of Vegetarian Diets
Turner‐McGrievy, G. M. (2010) · Journal of the American Dietetic Association · doi:10.1016/j.jada.2010.08.015 · Cited by 6
Self-citationThe Health Impact of Eating Foods of Animal Origin
Marsh, K. A., Saunders, A. V., & Zeuschner, C. L. (2018) · Advances in marketing, customer relationship management, and e-services book series · doi:10.4018/978-1-5225-4757-0.ch002 · Cited by 6
Metadata
- Authors
- Barnard, N. D., Gloede, L., Cohen, J., Jenkins, D. J. A., Turner-McGrievy, G., Green, A. A., & Ferdowsian, H.
- Affiliations
- Physicians Committee for Responsible Medicine (US)
- University of North Carolina at Chapel Hill (US)
- Corresponding author
- Barnard, Neal D.
- Venue
- Journal of the American Dietetic Association
- Publisher
- Elsevier BV
- Published
- 2009-02
- Volume
- 109
- Issue
- 2
- Pages
- 263-272
- ISSN
- 0002-8223 (ISSN-L)
- PMC
- PMC2680723
- OpenAlex
- W2153632139
- Cited by
- 154
- References
- 23
- Citations by year
- 2026: 3 · 2025: 7 · 2024: 13 · 2023: 11 · 2022: 10 · 2021: 15 · 2020: 7 · 2019: 13 · 2018: 11 · 2017: 8 · 2016: 5 · 2015: 8 · 2014: 11 · 2013: 6 · 2012: 7
- FWCI
- 8.74
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of the American Dietetic Association (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (5r01dk059362-02)
- National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK059362-01A2, R01 DK059362)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Physiology (medical) › Diet and metabolism studies
- Keywords
- type 2 diabetes, vegan diet, low-fat diet, dietary adherence, diet acceptability, macronutrient intake, dietary restraint, hunger, food cravings, American Diabetes Association guidelines, medical nutrition therapy, dietary fat and cholesterol
- MeSH terms
- Adult, Aged, Aged, 80 and over, Blood Glucose, Cholesterol, Dietary, Diabetes Mellitus, Type 2, Diet, Diabetic, Diet, Reducing, Dietary Carbohydrates, Dietary Fats, Dietary Fiber, Dietary Proteins, Female, Glycated Hemoglobin, Humans, Male, Middle Aged, Obesity, Patient Acceptance of Health Care, Patient Compliance, Surveys and Questionnaires, Diet, Vegetarian, Weight Loss, Chi-Square Distribution, Treatment Outcome, Patient Satisfaction, Diet, Fat-Restricted
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