Open access peer-reviewed chapter - ONLINE FIRST
Abstract
Prevalence of prediabetes is increasing globally and a public health concern because it is transitional stage between normoglycemia and diabetes. Therefore, effective interventions are essential to curb its progression. Consumption of fruits and vegetables is vital for overall health and associated with improved insulin sensitivity, reduced oxidative stress, and regulation of inflammatory pathways. Notably, the interplay between dietary choices and gut microbiota composition has emerged as a novel aspect of metabolic health. Antioxidants present in fruits and vegetables contribute to gut barrier integrity and anti-inflammatory effects. As such, incorporating fruits and vegetables into the diet can enhance gut health, mitigate chronic inflammation, and indirectly influence metabolic health. The dietary fiber present in fruits and vegetables, which is plentiful and serves as a source for gut bacteria to generate SCFAs. Beyond promoting gut health, SCFAs also enhance insulin sensitivity, regulate glucose control, and exert systemic impacts on metabolism. The chapter emphasizes the role of gut microbiota in prediabetes and suggests that low glycemic fruit and vegetable consumption can improve metabolic health. It recommends personalized dietary guidance, monitoring inflammatory markers, and incorporating gut microbiota assessments into patient care to support gut health and slow prediabetes progression to type 2 diabetes.
Keywords
- fruits and vegetables
- gut microbiota
- dietary fiber
- supplementation
- prediabetes
1. Introduction
Prediabetes, marked by elevated blood glucose levels below the diabetes diagnosis threshold, is a pivotal stage between normoglycemia and type 2 diabetes (T2DM), posing significant public health concerns [1, 2]. With a predominant prevalence in low- and middle-income countries (72.2%), proactive intervention becomes imperative to halt or delay the progression to overt T2DM [3]. Approximately, 25% of prediabetic patients progress to overt T2DM within 3–5 years, and up to 70% may eventually develop diabetes [4]. Recognizing the treatable nature of prediabetes, interventions are essential to slow its course and minimize the risk of diabetes development [5, 6]. The landscape of metabolic health is undergoing a paradigm shift with an increasing recognition of the intricate interplay between dietary choices and the microbiota residing in the human gastrointestinal tract.
The term “gut microbiota” refers to the diverse array of microorganisms, including bacteria, viruses, fungi, archaea, and other microbes, residing in the gastrointestinal tract of humans and animals [7]. These microorganisms collaboratively form a sophisticated ecosystem crucial to various physiological processes [8]. While the specific composition varies among individuals due to factors such as genetics, diet, age, and environment, certain essential bacterial groups and species are consistently present in the human gut [9]. Beyond mere composition, the functional capacity of the gut microbiota is of paramount importance. Different bacteria play roles in key metabolic processes such as dietary component fermentation, vitamin synthesis, and inflammatory regulation [10]. The inflammatory markers, such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α), are often elevated in individuals with prediabetes, which is closely linked to insulin resistance and the progression of prediabetes to T2DM [11]. The gut-hepatic-kidney axis, a complex interplay between the gut, liver, and kidneys, plays a significant role in regulating metabolic processes [12].
Dysbiosis, an imbalance in this microbial population, has been linked to various disorders, including immune-related conditions, gastrointestinal issues, and metabolic abnormalities [13, 14]. The composition of the gut microbiota, associated with factors, such as inflammation and insulin sensitivity, holds significance for metabolic health [15]. Understanding the mechanisms by which the gut microbiota influences these metabolic processes is crucial for identifying potential therapeutic targets and interventions to mitigate the burden of diabetes. Given the potential impact on metabolic pathways and gut microbiota composition, fruits and vegetables, as nutrient-dense components of a balanced diet, present an enticing avenue for dietary intervention [16]. This review seeks to explore the potential health effects arising from the connection between a fruit and vegetable-rich diet and the gut microbiota in individuals with prediabetes. This study is not merely an exploration of the scientific unknown; it holds the promise of offering practical insights that could inform personalized interventions and, ultimately, contribute to more effective diabetes prevention strategies. It is anticipated that the findings will not only enhance the understanding of metabolic health but also pave the way for tailored approaches to bridge the gap between dietary choices and optimal gut microbial balance in the context of prediabetes.
2. Method of literature search
A comprehensive literature search was done, with established keywords such as fruit and vegetable consumption, gut microbiota, and prediabetes. The following eligibility criteria were established:
This study includes primary research studies, including clinical trials, observational studies, and experimental studies, that investigate the relationship between fruit and vegetable consumption and gut microbiota among individuals with prediabetes.
Studies involving individuals diagnosed with prediabetes, which may be defined by criteria such as impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or elevated HbA1c levels.
Studies that measure or report outcomes related to gut microbiota composition or function.
Studies with mixed populations of persons with and without prediabetes, and where data for prediabetic individuals cannot be separated.
Exclude studies that do not specifically measure or report fruit and vegetable consumption.
3. Impact of Gut microbiota on metabolic health
In individuals with prediabetes, the gut microbiota has notable effects on metabolic health, affecting the extraction of nutrients and energy from food and potentially impacting weight management [17]. A balanced gut microbiota has been associated with increased insulin sensitivity, a crucial factor for individuals with prediabetes aiming to prevent the progression to type 2 diabetes [3]. Dietary fiber fermentation by gut bacteria produces short-chain fatty acids (SCFAs), particularly butyrate, linked to decreased insulin resistance and improved glucose control [18]. The SCFAs play a crucial role in maintaining gut health, controlling inflammation, and influencing systemic metabolism [19, 20]. Beyond metabolic health, a healthy gut microbiota supports a balanced immune response, reduces chronic inflammation associated with prediabetes, and maintains a robust gut barrier, lowering the risk of systemic inflammation [14]. Moreover, the gut-brain axis demonstrates bidirectional communication, with a healthy gut microbiota positively impacting stress levels, mood, and cognitive abilities, all of which influence metabolic health [21].
4. Link between diet, gut microbiota, and prediabetes
Dietary modifications, including increased consumption of fruits and vegetables, can potentially alter the gut microbiota composition favorably, highlighting the significance of individualized approaches in prediabetes care. Gram-positive (G+) bacteria, a diverse group crucial for gut metabolism, contribute to this microbial balance and can be influenced by dietary choices [22]. In the context of prediabetes, exploring the relationship between a diet rich in fruits and vegetables, gut microbiota composition, and metabolic outcomes becomes clinically significant. Fruits and vegetables, being rich in dietary fiber, vitamins, minerals, and various bioactive substances, serve as excellent food sources [19]. Research suggests that their consumption can enhance insulin sensitivity, reduce oxidative stress, and modulate inflammatory pathways, serving as a preventive measure against diabetes onset [15, 23]. Fruits and vegetables do not only supply critical nutrients to the body but also act as substrates for the gut microbiota.
Studies have associated greater fruit and vegetable consumption with increased microbial diversity and a more balanced microbial profile [24, 25]. Unlike potentially harmful bacteria, beneficial ones, such as Bifidobacteria and Lactobacilli, thrive in diets abundant in these plant-based foods, contributing to a healthier gut environment and improved metabolic outcomes [26]. However, the specific influence of fruit and vegetable consumption on the gut microbiota in the context of prediabetes remains a relatively underexplored area. Understanding how these dietary components shape the gut microbiota in individuals with prediabetes could provide valuable insights into potential dietary interventions aimed at preventing or managing metabolic dysfunction.
5. Importance of fruits and vegetables
Consuming a diet rich in fruits and vegetables is widely acknowledged for its positive impact on gut microbiota and overall gut health. It is important to distinguish between low- and high-glycemic fruits and vegetables, particularly in individuals with prediabetes, as their consumption can influence the gut microbiota differently. Low glycemic options have a minimal impact on blood sugar levels and contribute to a more diverse and beneficial gut microbial community [27]. Conversely, high glycemic fruits and vegetables can lead to rapid blood sugar spikes, potentially causing dysbiosis and inflammation [10]. Personal responses to these foods vary, highlighting the importance of recommending a balanced diet focused on low glycemic options. Increasing the intake of low glycemic fruits and vegetables plays a crucial role in enhancing gut microbiota composition and overall metabolic health in individuals with prediabetes [28]. Research indicates that a diet abundant in these options can alter stomach microbial composition, promoting the growth of beneficial bacterial species associated with the production of SCFAs, such as butyrate. SCFAs, in turn, influence metabolic processes, inflammation regulation, and the integrity of the intestinal barrier [29, 30]. According to some research, people with prediabetes may see improvements in metabolic markers, including insulin resistance, fasting glucose levels, and HbA1c, if they eat a diet rich in fruits and vegetables [30, 31]. These gains are credited, at least in part, to gut microbiota modulation’s advantageous impacts.
Chronic inflammation, a significant factor in insulin resistance and prediabetes progression, can be mitigated by the anti-inflammatory activities of phytochemicals found in fruits and vegetables [32]. These bioactive substances, including flavonoids and polyphenols, contribute to a healthy gut microbial habitat and support a robust gut barrier, preventing the entry of harmful compounds into the bloodstream [33]. The gut-brain axis, which connects the brain with gut bacteria, suggests that increased consumption of low glycemic fruits and vegetables may positively influence mood, cognition, and stress responses, ultimately impacting metabolic health [34]. Additionally, the low-calorie and high-fiber nature of many fruits and vegetables indirectly aids in weight management, a crucial aspect of prediabetes control [21].
Dysbiosis, an imbalance in the gut microbiota, is associated with metabolic issues, and consuming a variety of fruits and vegetables helps maintain a healthy microbial environment, reducing the risk of dysbiosis [35]. The vitamins, minerals, and antioxidants present in colorful fruits and vegetables contribute to the integrity of the intestinal barrier, immune system support, and protection against free radicals [36]. Certain fruits and vegetables, such as citrus fruits, may create a slightly acidic gut environment that favors the growth of beneficial bacteria while inhibiting harmful microbes [37]. Despite the general association between fruit and vegetable consumption and improved gut flora, individual responses can vary due to genetic factors, baseline microbiota composition, and dietary practices [38]. To deepen the understanding of the effects of fruit and vegetable consumption on gut microbiota and metabolic health in prediabetes, future research should consider incorporating randomized controlled trials directly manipulating fruit and vegetable intake.
6. The role of fiber
Dietary fiber, abundant in fruits and vegetables, serves as a crucial substrate for gut bacteria, leading to the production of SCFAs. As a form of carbohydrate inherent in plant-based diets, dietary fiber undergoes partial digestion and absorption in the body [39]. Distinguishing between soluble and insoluble forms, dietary fiber assumes a significant role in gut health, with potential implications for prediabetes management. Soluble fiber, prevalent in fruits and vegetables, acts to impede carbohydrate digestion, fostering stable glycemic control and enhancing insulin sensitivity, thereby reducing excess insulin production [35]. Its capacity to form a gel-like substance in the digestive tract, slowing down carbohydrate absorption, further promotes glycemic stability [40]. The association between a diverse gut microbiota, improved gut health, and overall well-being is underscored by the supportive role of soluble fiber. It facilitates the growth of beneficial bacteria, such as Bifidobacteria and Lactobacilli, functioning as a prebiotic that nourishes gut bacteria, yielding short-chain fatty acids that contribute to gut health and inflammation reduction, particularly in prediabetes patients [41]. Studies even suggest that a diet rich in soluble fiber may enhance insulin sensitivity, a pivotal aspect of prediabetes management [42, 43, 44].
In contrast, insoluble fiber, while contributing bulk to stool and preventing constipation by promoting regular bowel movements [45], is less fermentable than its soluble counterpart. However, it remains integral to maintaining gut health, promoting microbial balance, and supporting metabolic well-being. Despite its lesser involvement in microbial fermentation, insoluble fiber’s contribution is manifested through its role in sustaining regular bowel movements. Additionally, its ability to induce a feeling of fullness aids in weight management by reducing overall calorie intake [46]. Given the significance of maintaining a healthy weight in prediabetes prevention and management, insoluble fiber indirectly impacts blood sugar control.
Emphasizing the symbiotic relationship between diet and gut health, a balanced and fiber-rich dietary pattern, coupled with regular physical activity, can exert a positive influence on the gut microbiota. This holistic approach holds the potential to enhance gut health and support overall metabolic well-being in individuals with prediabetes [18].
Fiber plays a crucial role in supporting the metabolic well-being of children and adults with prediabetes. Incorporating an adequate amount of dietary fiber can be beneficial for both children and adults in managing prediabetes. Soluble fiber regulates blood sugar, improves insulin sensitivity, aids weight management, lowers LDL cholesterol, promotes a healthy gut, and stabilizes energy levels [35, 40, 43]. This is crucial for prediabetic individuals, preventing spikes in blood sugar, reducing insulin resistance, managing weight, supporting cardiovascular health, fostering a healthy gut microbiota, and providing steady energy release [45, 46].
7. Vitamin and minerals
The impact of vitamins found in fruits and vegetables on gut microbiota is particularly significant for individuals dealing with diabetes [47]. Among the key vitamins are Vitamin C (Ascorbic Acid), Vitamin A (Retinol), Vitamin D (with immunomodulatory functions), Vitamin E (Tocopherol), Vitamin K (regulating gut bacteria producing beneficial short-chain fatty acids), and the B vitamins group (including B6, B9-Folate, B12, B3-Niacin, B5-Pantothenic Acid, B7-Biotin, and B1-Thiamine) [48]. Vitamin C, renowned for its antioxidant properties, fosters a healthy gut environment by reducing oxidative stress, promoting the growth of beneficial gut bacteria, and indirectly influencing gut microbiota composition and insulin sensitivity, particularly relevant in prediabetes [49]. Vitamin A plays a crucial role in maintaining gut lining integrity and immune function, indirectly contributing to gut health and inflammatory regulation, with potential implications for prediabetes development [50]. Research suggests that vitamin D may influence gut microbiota composition, immune responses, and inflammation, potentially reducing the risk of prediabetes and impacting immune system function [50]. The antioxidant properties of Vitamin E contribute to gut health by reducing oxidative stress and indirectly affecting gut microbiota composition through anti-inflammatory effects [51]. Vitamin K, vital for blood clotting and bone health, indirectly influences gut health by promoting bacteria producing beneficial short-chain fatty acids [52]. B vitamins, especially folate and B12, are crucial for DNA synthesis and methylation in gut bacteria, ensuring a balanced microbiota [53]. Niacin, involved in energy metabolism, indirectly influences gut health and can affect glucose metabolism and lipid profiles [54]. Biotin and thiamine are essential for gut bacteria growth and metabolism, and deficiencies can lead to glucose dysregulation [55]. These vitamins work in synergy with other dietary components, such as fiber and phytochemicals, to support gut health [48].
In addition to vitamins, minerals found in fruits and vegetables also wield significant influence on the gut microbiota of individuals with prediabetes. These minerals contribute to overall health and indirectly impact gut health by fostering a favorable gut microbiota composition [56]. Essential minerals play a pivotal role in supporting overall health and fostering a balanced gut microbiota. Among these crucial minerals are magnesium, calcium, zinc, iron, potassium, selenium, copper, manganese, phosphorus, and sulfur. Magnesium is instrumental in supporting the growth of beneficial gut bacteria, contributing to a reduced risk of constipation [57]. Calcium emerges as a key player in mitigating the risk of colon cancer and promoting a harmonious balance within the gut microbial community [58]. Zinc, intricately involved in immune function, also lends support to the intestinal barrier, while iron proves indispensable for the growth and metabolism of gut bacteria [59]. Potassium, essential for cardiovascular function, makes a substantial contribution to overall well-being [60]. Selenium, with its potent antioxidant properties, and copper, supporting enzyme activity in gut bacteria metabolism, both play crucial roles in maintaining a healthy gut environment [61]. Manganese is indispensable for the growth and activity of gut bacteria, further highlighting its significance [61]. Lastly, phosphorus plays a vital role in supporting gut microbiota metabolism and contributing to overall digestive health [62]. This comprehensive array of minerals underscores their multifaceted impact on promoting a thriving gut microbiota and, consequently, supporting overall health.
8. Antioxidants and phytochemicals
Fruits and vegetables stand out as rich reservoirs of antioxidants and phytochemicals, wielding essential roles in fostering overall health and acting as protective agents against prediabetes and its progression to Type 2 Diabetes Mellitus (T2DM). Within these nutritional powerhouses, a diverse spectrum of antioxidants is present, encompassing vital vitamins such as C and E, alongside an array of phytochemicals such as flavonoids, polyphenols, and carotenoids [63].
Antioxidants function as formidable neutralizers of oxidative stress, counteracting detrimental free radicals in the body [64]. While their direct impact on gut microbiota composition may be modest, antioxidants indirectly contribute to gut well-being by mitigating oxidative damage to gut tissues. Moreover, their anti-inflammatory properties play a pivotal role in fostering a healthier gut environment. Persistent inflammation in the gut has been associated with disruptions in the equilibrium of gut microbes, linking it to metabolic diseases like prediabetes [11]. Antioxidants have the potential to influence the balance of gut microbial communities by constraining the growth of specific bacteria. Maintaining optimal gut health relies, in part, on the integrity of the gut barrier, a role in which antioxidants are instrumental [50]. A robust gut barrier serves as a shield, preventing harmful compounds from entering the bloodstream and supporting a diverse community of gut microbes. Antioxidants also modulate immunological responses, impacting gut health by contributing to a balanced immune system, essential for maintaining a favorable intestinal environment. Certain antioxidants found in berries, for instance, have demonstrated associations with enhanced insulin sensitivity, a crucial aspect for individuals grappling with prediabetes [12]. Antioxidants can play a role in regulating blood sugar levels by diminishing oxidative stress and inflammation, potentially leading to more effective glycemic control.
Phytochemicals, abundantly present in fruits and vegetables, wield significant influence on gut microbiota in individuals with prediabetes [65]. Some phytochemicals, such as polyphenols found in foods such as grapes and apples, exhibit prebiotic properties, stimulating the growth and activity of beneficial gut bacteria. Diets rich in phytochemicals correlate with increased diversity among gut microbes, indicative of improved gut health. Additionally, certain phytochemicals harbor antimicrobial properties, assisting in the management of harmful gut bacteria proliferation. Polyphenols and various phytochemicals have been investigated for their potential to enhance insulin sensitivity, a valuable benefit for individuals navigating prediabetes [66]. Many phytochemicals boast anti-inflammatory attributes, contributing to the reduction of systemic inflammation associated with prediabetes. The consumption of phytochemical-rich foods, such as berries, nuts, and leafy greens, holds promise in supporting blood sugar regulation and reducing the risk of progressing to T2DM. Flavonoids, for instance, can modulate gut microbiota composition, reducing inflammation and enhancing gut barrier function [67]. Glucosinolates present in cruciferous vegetables display potential ant-cancer properties [68]. Carotenoids, prevalent in carrots and sweet potatoes, have demonstrated the ability to reduce oxidative stress and inflammation in the gut environment [69]. Resveratrol, found in grapes and red wine, has been linked to potential cardiovascular benefits [70]. Integrating a diverse array of phytochemical-rich foods into one’s diet holds the potential to foster a more balanced gut microbiota, thereby contributing to improved metabolic health.
9. Implications for public health
10. Clinical practice implications
11. Conclusion
The study highlights the importance of gut microbiota in prediabetes and suggests that low glycemic fruit and vegetable consumption can improve metabolic health. It emphasizes the role of dietary fiber, vitamins, minerals, antioxidants, and phytochemicals in supporting gut health. Healthcare professionals should provide personalized dietary guidance and integrate gut microbiota assessments into patient care. The study suggests that healthcare professionals should educate patients about low glycemic fruits and vegetables, considering individual preferences. Long-term dietary changes support gut health, reduce inflammation, and slow prediabetes progression to type 2 diabetes. The gut microbiota significantly impacts prediabetes, affecting metabolic health and nutrient absorption. Consuming low glycemic fruits and vegetables, personalized dietary guidance, monitoring inflammatory markers, and incorporating gut microbiota as assessments into patient care are recommended. In prediabetes patients who are taking low fruits and vegetables, micronutrients and fiber supplementation are recommended, while engaged in behavioral counseling for adoption of intake of low glycemic fruits and vegetables.
Acknowledgments
The author acknowledges the use of Quillbot website, for paraphrasing and language polishing of the manuscript. This tool contributed to improving the quality and clarity of the manuscript’s language.
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