Discussion
T2D, bleeding, inflammation, weight reduction, diabetic, TG, diabetes
INFLAMMATION, BLEEDING, GINGIVAL BLEEDING, DIABETES
The Okinawan-based Nordic diet is consistent with the Nordic official nutrition standards as defined in 2012. The food was well accepted by all the participants. All participants complied with the study requirements (based on assessments of returns and questionnaires). None of the study individuals was lost to follow-up. A strength of the present study was that all daily packages with prepared meals were delivered by dedicated carriers (unaware of what they provided). To ensure compliance and to encourage study completion, those who delivered the food were in regular contact with study participants. To further improve the compliance partners/spouses were also provided the diet and at no costs to them. These individuals were not part of the study. The present study was conducted before the onset of the COVID19 pandemic. The study identified, however, that home deliveries of individually prepared food with daily rations would over a longer time periods be too expensive and with several logistic restrictions. It is possible that the knowledge obtained during the pandemic and the common deliveries of both groceries and prepared food might have given us information that would have facilitated the present study.All study participants had a long track record of supportive diabetic care and had as part of the inclusion requirements stable diabetic conditions. Clinically relevant, and similar improvements were obtained in both study groups. The overall 64% reduction in the extent of gingival bleeding during a one-month study period with no professional oral hygiene instruction or treatment is a clinical important observation. The clinical improvements cannot simply be explained as a Hawthorne or bias effect. The reduction in % BOP as identified was also linked to improvements in serum HbA1c levels as well as for reduced levels of some pro-inflammatory cytokines. The present study also demonstrated that the control diet designed to meet standard of care diet to any individual with a diagnosis of T2D had similar clinical outcome impact as the OBND diet. the improvement in serum HbA1c values were correlated to the improvement in the extent of gingival inflammation. One explanation to the clinical improvements in gingival conditions may be explained by the general sugar restriction by the two diets. Most likely, early bacterial colonization primarily by streptococci species may have had favorable effects on the extent and severity of gingival inflammation [The present study also showed that body weight, waist circumference, BMI scores, blood lipids i.e., cholesterol, LDL and TG were improved in both study groups but significantly more so in the OBND group, which had a lower calorie content. The individuals in the OBND group had, on average, a higher BMI score at baseline. The potential to reduce body weight might have been an advantage for weight reduction. The reduced levels of pro-inflammatory cytokines may be associated with the relative loss of weight especially the OBND group. The statistically significant reductions in the OBND group for Eotaxin Il-17A IFN-γ Il-9 IP10MCP1 and PDFBB and for clinical parameters suggest that the OBND appeared to have relevant advantages over the control diet.The impact of diet as a factor on cardiovascular conditions has been identified among Japanese individuals and people using a Mediterranean dietary [Both the OBND, and the hospital standard of care diet had a proven positive impact on the clinical progress of the clinical conditions. The OBND diet had, in several aspects, better effects on endocrinological parameters and serum cytokine levels than the control hospital diet. To validate the present findings, future studies should monitor the effects of diet over longer time periods. A true control group of individuals with no clinical evidence of T2D should also be included. Indeed, clinical changes regarding both medical and dental parameters may, in fact, require longer periods than 30 days to confirm that clinically relevant changes were obtained. The greater the proportional reduction in serum HbA1c levels, as well as the greater the reduction in the proportion of bleeding on probing, suggests a strong relationship between serum HbA1c and severity of gingival inflammation as defined by clinical bleeding on probing in the present study. This was more pronounced in the OBND test group. Notwithstanding, data suggest that using a ketogenic diet improves both glycemic and lipid profiles in individuals with T2D [The lack of association between changes in serum level for cytokines studied and changes in the extent of BOP is consistent with finding from other studies for the control group [The primary shortcomings of the present study were the limited 30 days study period, and that only 30 study participants were included in the study. Given the fact that serum HBA1c levels routinely are monitored as a method to the get an average estimate of blood sugar levels of longer periods than 30 days we did not expect to show immediate effects on blood sugar levels. Nevertheless, the short-term diet (OBND) for individuals with T2D had an impact on potential diabetes risks such as body weight. Body weight was reduced over this short period. Additional studies over perhaps six months may be required to observe serum Hb A1c level changes. Longer periods may be needed to study sustainable effects of the OBND diet.The present report similar results as two other studies [The concept of receiving “ready to eat” food for a continuous period of 30 days was unfortunately not acceptable to many potential study individuals. The present study was also restricted by the IRB regarding study length and absence of conventional therapy for diagnosed treatment needs beyond the study period of 30 days. It is possible that in the context of the COVID 19 experiences the concept of delivered ready to eat meals would be more appreciated.The Okinawan-based Nordic diet is high in nutrition and fiber, but low in calories. Notwithstanding, the diet provides good satiety for a prolonged time. The Okinawan-based Nordic diet promotes the use of a wide variety of ingredients. The main characteristic is high nutritional value and fiber content which provides long-lasting satiety with a minimum calory amount. It is based on whole intact grains – including oat, barley, rye, wheat, and millet, plenty of vegetables of all colors, root fruits, beans, and legumes, fish, and some poultry, vegetable oils, fruits, berries, nuts, and seeds. The diet is also restrictive in sugar, salt, red meat, processed meat, but also fatty dairy products.The diet complies with the Nordic Nutrition Recommendations as well as many international official dietary recommendations. In comparison with the Nordic nutrition recommendations, the macronutrient profile of the Okinawan based Nordic diet (OBND) used in the present study has a slightly higher protein and fiber contents above the Nordic recommendations. The fat content in the OBND is, however, in accordance with the current recommendations. In contrast, the OBND carbohydrate content is slightly below those recommendations.From a metabolic point of view, the Okinawa diet resembles in the Mediterranean diet with regards to fibers, vegetable oils, fruits, berries. The dietary fibers content is beneficial for the digestion. From a cardiovascular perspective, the unsaturated fat, and the antioxidant content should contribute to lowering levels of inflammation. Furthermore, sugar, salt, processed meat, and saturated fats restrictions of the OBND diet are in accordance with current WHO recommendations, and other established health authorities. The low sugar content and low total caloric diet is also consistent with current efforts to reduce blood sugar levels, and control of insulin needs among individuals with T2D.