Diabetes Research and Clinical Practice 77 (2007) 327–332

www.elsevier.com/locate/diabres

Metabolic improvement of male prisoners with type 2

diabetes in Fukushima Prison, Japan
Masamitsu Hinata a,*, Masami Ono a, Sanae Midorikawa b, Koji Nakanishi c
a
Medical Affairs Section, Fukushima Prison, 1 Uehara, Minamisawamata, Fukushima 960-8254, Japan
b
Department of Internal Medicine III, Fukushima Medical University, School of Medicine, Fukushima 960-1295, Japan
c
Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo 105-0001, Japan
Received 25 May 2006; received in revised form 4 September 2006; accepted 3 October 2006
Available online 8 January 2007

Abstract
Imprisonment often improves metabolic control in prisoners with type 2 diabetes; however, the reasons for this remain unclear.
Here, we investigated the metabolic control of male prisoners with type 2 diabetes in Japan. Retrospective analysis of 4385 medical
charts of male prisoners in Fukushima Prison from 1998 to 2004 revealed 109 prisoners (all Asian) with type 2 diabetes
(mean  S.D.: 51  10 years). All were followed up during their imprisonment (14  10 months). During imprisonment, mean
fasting plasma glucose and hemoglobin Alc (HbA1c) levels dramatically decreased from 184  74 to 113  38 mg/dl ( p < 0.001)
and 8.4  2.1 to 5.9  1.2% ( p < 0.001), respectively. In addition, 5 of 18 prisoners (28%) treated with insulin and 17 of 34 (50%)
treated with oral hypoglycemic agents were able to discontinue their treatment and maintain good metabolic control. Most prisoners
in Japanese prisons work 8 h a day 5 days a week, consuming a high dietary fiber diet including boiled rice with barley,
‘‘Mugimeshi’’. These findings suggest that a well-regulated lifestyle and long-term intake of high dietary fiber may have beneficial
effects on metabolic control in patients with type 2 diabetes.
# 2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Type 2 diabetes; Prison; Lifestyle; Dietary fiber; Barley

1. Introduction America where correctional institutions are provided

The number of patients with type 2 diabetes is on the
increase in Japan [1] and western countries [2], with
changing lifestyles and western dietary habits thought
to be the most important contributing factors [3]. These
factors have also lead to an increase in prisoners with
type 2 diabetes [4]. The state of diabetes in Japanese
prisons is unclear because of the lack of diabetes
specialists in Japanese correctional institutions, unlike
* Corresponding author. Tel.: +81 24 557 2222;
fax: +81 24 555 2039.
E-mail address: mhinata@hotmail.com (M. Hinata).
with a manual for diabetes management [4], In Britain,
it was reported that good diabetic control was achieved
in prisoners with diabetes possibly because most of
these individuals probably led chaotic life-styles before
imprisonment [5]. However, the exact reasons remain
unknown because levels of fasting plasma glucose and/
or HbA1c have not been evaluated, and analysis of the
effect of diet and exercise has not been described.
We recently noted that metabolic control of male
prisoners with type 2 diabetes often shows a dramatic
improvement during imprisonment [6]. In the present
study, we document the metabolic control of male
prisoners with type 2 diabetes in Fukushima Prison,
Japan, and evaluate the factors involved.

0168-8227/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.diabres.2006.10.008
328 M. Hinata et al. / Diabetes Research and Clinical Practice 77 (2007) 327–332

2. Patients and methods
With about 650 inmates, Fukushima Prison is one of
the smallest male prisons in Japan. Most prisoners of
Fukushima Prison are repeat offenders mainly charged
with theft, drug abuse, fraud, intrusion, bodily harm,
robbery, blackmail, and so on. Sentences of subjects
varied from a few days to 8 years but were usually
between 6 months and 4 years. Medical records were
only investigated by the two prison medical officers
after obtaining permission from Fukushima Prison
Ethics Committee, and anonymity and confidentiality
were maintained throughout by assigning each prisoner
a number. Retrospective analysis of 4385 medical charts
between January 1998 and December 2004 identified
157 prisoners (3.6%) with type 2 diabetes at the
beginning of imprisonment according to the criteria of
the National Diabetes Data Group [7]. Of these, 109 (all
Asian) were followed up and included in this study.
Almost all of the 48 prisoners excluded could not be
included because of transfer to another prison, parole or
release. The following information was obtained for all
diabetes prisoners: age, height, weight, body mass index
(BMI), duration of diabetes history or imprisonment,
fasting plasma glucose (FPG), hemoglobin A1c
(HbA1c), total cholesterol (TC), triglyceride (TG)
and high density lipoprotein cholesterol (HDL-C)
levels, the mode of treatment of diabetes, daily calorific
intake, diabetic complications, and past medical history
and treatments. These items were measured every 1–6
months. Administration of oral hypoglycemic agents
and insulin injections were supervised by prison
medical officers; none of the subjects were administered
oral hypolipidemic agents during imprisonment.
2.1. Statistical analysis
Results are expressed as the mean  S.D. Statistical
significance was determined using the student’s paired,
unpaired t-test or x2 analysis for independence tests (x2-
test), and comparisons between groups were conducted
using one-way analysis of variance (ANOVA). A p-level
of less than 0.05 was considered statistically significance;
all tests were two-tailed. All statistical analyses were
performed on a personal computer using Dr. SPSS II for
Windows (SPSS Japan Inc., Tokyo, Japan). The non-
diabetic reference range for the FPG and HbA1c assays
were 70–109 mg/dl and 4.3–5.8%, respectively.
3. Results
Among the prison inmates, 109 prisoners with type 2
diabetes were followed-up for determination of the
clinical course (Table 1). Subjects were aged 51  10
years, and were followed-up for 14  10 months (range:
1–44, median: 12). Most were within the normal BMI
range. Diabetes treatments were usually the same as
those before imprisonment. All 18 prisoners treated
with insulin had been undergoing insulin therapy for
several years before imprisonment. Thirty-four prison-
ers were treated with glibenclamide (1.25–7.5 mg/day),
and of these, 25 had been undergoing this treatment for
several years before imprisonment. The remaining 57
prisoners were treated with diet alone.

Table 1
Characteristics of the 109 male prisoners with type 2 diabetes in Fukushima Prison
Initial assessment Final assessment p-Value
Age (years) 51  10
Duration of diabetes (years) 77
Follow-up period (months) 14  10
Height (cm) 165  7
Body weight (kg) 65  13 62  10 <0.001
BMI (kg/m2) 23.7  3.7 22.7  2.6 <0.001
FPG (mg/dl) 184  74 113  38 <0.001
HbA1c (%) 8.4  2.1 5.9  1.2 <0.001
TC (mg/dl)a 165  40 149  39 <0.001
TG (mg/dl)a 140  100 119  78 0.099
HDL-C (mg/dl)a 40  13 38  11 0.144
Treatment
Insulin 18 (17%) 13 (12%)
Glibenclamide 34 (31%) 17 (16%) 0.007
Diet 57 (52%) 79 (72%)
Values represent the mean  S.D. BMI: body mass index, FPG: fasting plasma glucose, HbA1c: hemoglobin A1c, TC: total cholesterol, TG:
triglycerides, HDL-C: high-density lipoprotein cholesterol; an = 52 samples.
 M. Hinata et al. / Diabetes Research and Clinical Practice 77 (2007) 327–332 329

Table 2
Metabolic control and treatment changes during imprisonment for each therapy group
Insulin (n = 18) Glibenclamide (n = 34) Diet (n = 57)
FPG (mg/dl)
Initial assessment 161  80 190  87 182  62
Final assessment 102  26* 118  47y 115  35y
HbA1c (%)
Initial assessment 7.7  2.0 8.6  2.5 8.4  1.8
Final assessment 5.7  1.2y 6.1  1.5y 5.9  1.0y
Changes to the treatment profile
Increase 1 (6%) 2 (6%) –
No change 6 (33%) 11 (32%) –
Reduction 6 (33%) 4 (12%) –
Discontinued 5 (28%) 17 (50%) –
Values represent the mean  S.D.; *p = 0.012; yp < 0.001, initial vs. final assessment.

Mean FPG and HbA1c values were 184  74 mg/dl different between groups, and all decreased dramatically
and 8.4  2.1%, respectively, at the initial assessment. during imprisonment. Five of 18 diabetic prisoners (28%)
Repeated measurements of FPG and HbA1c were treated with insulin therapy and 17 of 34 (50%) treated
made after at least 1 month revealing a dramatic with glibenclamide therapy were able to discontinue
decrease to 113  38 mg/dl ( p < 0.001) and 5.9  treatment and maintain normal metabolic control until
1.2% ( p < 0.001), respectively. Ninety-two (84%) of release. There was no statistically significant relationship
the 109 prisoners with type 2 diabetes showed improved between the improved metabolic control and age, daily
FPG and HbA1c values. In addition, the number of calorific intake, duration of diabetes, diabetic complica-
prisoners who achieved FPG and HbA1c values of less tions, and past medical history and treatments.
than 130 mg/dl and 7.0%, respectively, satisfying the
values recommended by the American Diabetes
Association for adults with diabetes mellitus [4],
dramatically increased from 11 (10%) to 82 (75%)
during imprisonment. Furthermore, body weights and
BMI also significantly decreased from 65  13 to
62  10 kg ( p < 0.001) to 23.7  3.7 to 22.6  2.6
( p < 0.001), respectively, between the initial and final
assessments. TC levels also significantly decreased
from 165  40 to 149  39 mg/dl ( p < 0.001); how-
ever, TG levels tended to decrease but not significantly
( p = 0.078). HDL-C levels showed no difference
between initial and final assessments ( p = 0.144).
The ratio expressing the number of prisoners with type
2 diabetes in each treatment group was significantly
changed between initial and final assessments
( p = 0.007).
The time courses of FPG and HbA1c are shown in
Fig. 1. Levels of both significantly decreased after 1
month. FPG levels then stabilized after 4 months, while
levels of HbA1c stabilized after about 6 months. Both
remained close to their upper normal limit until release.
In addition, FPG and HbA1c levels were also analyzed
according to the three treatment groups, insulin, Fig. 1. Time course of fasting plasma glucose and HbA1c levels in 109
glibenclamide and diet therapy, respectively (Table 2). male prisoners with type 2 diabetes after the initial assessment. Values
Initial levels of FPG and HbA1c were not significantly represent the mean  S.D. *p < 0.01, yp < 0.05, vs. the control.
330 M. Hinata et al. / Diabetes Research and Clinical Practice 77 (2007) 327–332
4. Discussion
In the present study, overall metabolic control of
prisoners with type 2 diabetes was shown to be good
during imprisonment. These findings were perhaps
related to the specific lifestyles and nutrition of
Japanese prisoners. First, almost all prisoners were
shown to lead well-regulated lifestyles during their
imprisonment in Fukushima Prison (Table 3). More-
over, many probably led irregular lifestyles before
imprisonment with, for example, excessive eating,
alcohol and/or sweetened beverage consumption, little
exercise, poor compliance with treatment regimens, and
so on. In Japanese prisons, on the other hand, there is no
access to alcohol, sweetened drinks or fast food, and
smoking, eating between meals and night time snacks
are prohibited. Excessive alcohol [8], junk food [9], and
sugar-sweetened drinks [10] are all risk factors of type 2
diabetes.
In addition, prisoners experience limited but regular
periods of work and exercise. Almost all prisoners work
for 8 h a day 5 days a week while in prison, although this
work is not particularly strenuous; for example, cooking
meals, washing clothes, cleaning inside and outside,
setting the tables at mealtimes, sewing, woodworking,
wiring, handicrafts, and so on. There is little physical
labor in Japanese prisons and exercise, for example,
walking, push-ups, and so on, is usually limited to
30 min in a narrow area twice or three times a week.
Therefore, their work and exercise schedules do not
consume a lot of calories, usually less than 800 kcal/
day, and as a result, the body weights and BMI of only
24 (22%) of 109 prisoners with type 2 diabetes
increased during imprisonment; nevertheless, most
achieved good metabolic control. Overall, mean body
weights and BMI values significantly decreased by 3 kg
and 1 kg/m2 over 14 months, respectively. It has been
reported that exercise training improves metabolic
control regardless of body weight loss in patients with
Table 3
Typical daily schedules of prisoners in Fukushima Prison
Weekday Weekend and holiday
Get up 6:40 7:30
Breakfast 7:10 8:00
On duty 7:50–9:30 –
9:45–12:00 –
Lunch 12:00 12:00
On duty 12:40–14:30 –
14:45–16:30 – Dietary fiber (g/day)
Supper 17:00 16:20
Free time 18:30–21:00 17:30–21:00
Bedtime 21:00 21:00
type 2 diabetes [11], suggesting that work and exercise
improve glucose tolerance with or without weight loss,
possibly highlighting one of the most important
contributions to improved metabolic control among
prisoners with type 2 diabetes.
The second factor specific to Japanese prisons that
might have affected the findings is that meals are taken
regularly and tend to be healthy. Standard nutrition
values of Japanese males (2003) [12] and male prisoners
with type 2 diabetes in Fukushima Prison are shown in
Table 4. The prisoners with type 2 diabetes tend to
consume a 2518  226 kcal/day diet including boiled
rice with barley, known as ‘‘Mugimeshi’’, a traditional
Japanese food, as do most prisoners in Fukushima
Prison. The calorific intake of prisoners, however, is
higher than that of the average Japanese male, as is the
energy ratio between carbohydrates and fat. The
composition of these two nutrients is close to that of
high-carbohydrate low fat diets in western countries,
which reportedly lead to high postprandial glucose and
insulin levels in patients with type 2 diabetes [13].
However, in this study, good metabolic control was
achieved despite this. This is possibly because the
prisoners consume a high amount of dietary fiber, about
twice the intake of Japanese males. Insoluble dietary
fiber intake was not so different between Japanese males
and the male prisoners; however, the soluble dietary
fiber intake of the prisoners was 5.5-fold more.
One possible reason for this is that in the 1950s most
Japanese tended to eat ‘‘Mugimeshi’’ as a staple food
because rice was expensive, unlike barley, which was
relatively cheap as well as filling. However, recently,
people tend to eat boiled polished rice without barley.
As a result, daily intake of high dietary fiber in Japan
decreased from 20.5 g in 1952 [14] to 14.3 g in 2003
[12]. All prisoners of Fukushima Prison, as well as other
Table 4
Comparison of the nutritional intake of Japanese men (2003) [12] and
male prisoners with type 2 diabetes in Fukushima Prison
Japanese men Prisoners
with diabetes
Calorific intake (kcal/day) 2138 2518  226
Constituents (% of total energy)
Carbohydrate 56 66–61
Protein 15 13–14
Fat 24 21–25
Others 5 0
Total 14.5 28.4  2.1
Soluble 3.4 18.7  1.2
Insoluble 11.1 9.7  0.9
 M. Hinata et al. / Diabetes Research and Clinical Practice 77 (2007) 327–332
Japanese prisons, tend to eat ‘‘Mugimeshi’’ daily (rice:
barley = 7:3) as a staple food. Barley is known to
contain an abundance of soluble and insoluble fiber and
its endosperm cell walls are rich in b-glucan, a
polysaccharide formed by linear chains with b-1,3
and b-1,4 linkages. b-Glucan is partially soluble and
highly viscous in a soluble condition [15]. As a result,
b-glucan probably reduces glucose and insulin levels by
increasing the viscosity of the stomach and small
intestine contents, decreasing the absorption of digested
nutrients from the small intestine [16]. Moreover,
glucose transport in the intestinal wall is inhibited partly
by increased resistance of the mucosal diffusion barrier
as a result of increased viscosity of the intestinal bolus
[15]. Thus, delayed carbohydrate digestion and absorp-
tion appears to be a major factor responsible for
reductions in the plasma glucose response [17]. The
prison diet also includes vegetables and other high
dietary fiber foods such as beans, mushrooms, and
seaweeds. Carbohydrates with a high dietary fiber
content might delay the absorption of glucose, thereby
permitting a better match between the timing of insulin
release and blood glucose peaks [18].
Animal [19], epidemiologic [20], and human inter-
vention [21] studies have all shown that a high soluble
fiber diet might improve glucose and insulin control and
hence reduce the risk of type 2 diabetes. The high
viscosity of b-glucan might therefore be particularly
effective at reducing postprandial glycemia, causing a
significant reduction in the glycemic response [22]. This
finding is consistent with those of several previous
studies whereby an increase in total dietary fiber intake
(predominantly soluble fiber) was shown to significantly
improve glycemic control and decrease the degree of
hyperinsulinemia in patients with type 2 diabetes [21,23].
Several large-scale prospective studies have shown
that diets high in dietary fiber and low in glycemic load
are inversely related to the incidence of type 2 diabetes in
humans [20,24,25]. However, these studies were short-
term and, until now, no research has investigated the
effect of high dietary fiber intake for more than 1 year in
addition to a well-regulated lifestyle including no alcohol
or eating between meals in patients with type 2 diabetes.
The findings of this research are therefore important in
suggesting appropriate management of type 2 diabetes.
Dietary fiber can significantly alter proglucagon
gene expression and modulate glucagon-like peptide-1
(GLP-1) and insulin secretion [26]. GLP-1 plays an
important role in the disposition of glucose absorbed
from the intestine, and circulating GLP-1 has a
regulatory effect on the basal islet output of glucagons,
and consequently, fasting glycemia [27]. In addition,
331
enhanced consumption of soluble fiber improves blood
glucose disposal by increasing skeletal muscle plasma
membrane GLUT-4 content [28]. These mechanisms
might also explain why high dietary fiber not only
improves postprandial glucose but also lowers FPG
levels and improves glucose tolerance. Thus, high
dietary fiber foods such as ‘‘Mugimeshi’’ might be
beneficial for patients with type 2 diabetes or impaired
glucose tolerance.
In the present study, imprisonment also improved
lipid metabolism in prisoners with type 2 diabetes.
Levels of TC significantly decreased, while TG and
HDL-C values tended to decrease but not significantly.
Several studies have shown that lowered cholesterol can
be attributed to the intake of high soluble fiber
[21,29,30], increased excretion of bile acids or neutral
sterols, increased catabolism of low-density lipoprotein
cholesterol, and reduced fat absorption [31]. Soluble
fibers have also been shown to be fermented in the colon
giving rise to short-chain fatty acids, which can be
absorbed and potentially inhibit hepatic cholesterol
synthesis [29]. It has also been reported that dietary
fiber intake has no effect on plasma TG levels in studies
using normal and hypercholesteromic subjects [28].
Indeed, in the present study, plasma TG concentrations
tended to decrease, but not significantly, with the high
dietary fiber diet followed in Fukushima Prison. One
reason for this is related to the initial TG values varied
widely, and the number of samples used to obtain the
initial TG values; that is, less than the number available
for FPG and HbA1c analysis. In addition, prisoners are
generally detained by police for about 2–3 months
before sentencing, during which time their meals are
also controlled. Thus, we believe that the values of TC,
TG and HDL-C also improved compared to before
imprisonment; improvement of FPG and HbA1c values
takes longer.
Since this research was not a randomized controlled
study, it is unclear whether a well-regulated lifestyle, high
dietary fiber intake or both, predominantly contribute to
good metabolic control in prisoners with type 2 diabetes,
and consequently, further studies are needed.
In conclusion, this study shows that good diabetic
care could be dramatically achieved in a Japanese
prison environment, indicating the importance of a
well-regulated lifestyle and long-term intake of high
dietary fiber in patients with type 2 diabetes.
Acknowledgments
We thank Messrs. Kazuhiro Sugai, Yasunori Kan,
Hirotaka Honda, Manabu Fumoto, Shigeru Denbo,
332 M. Hinata et al. / Diabetes Research and Clinical Practice 77 (2007) 327–332
Michio Saito and Terufumi Takeno in Fukushima Prison
for their assistance.
References
[1] N. Yoshiike, Y. Matsumura, M. Iwaya, M. Sugiyama, M. Yama-
guchi, National nutrition survey in Japan, J. Epidemiol. 6 (1996)
S189–S200.
[2] S. Liu, J.E. Manson, M.J. Stampfer, F.B. Hu, E. Giovannucci,
G.A. Colditz, et al., A prospective study of whole-grain intake
and risk of type 2 diabetes mellitus in US women, Am. J. Public
Health 90 (2000) 1409–1415.
[3] S. Nakanishi, M. Okubo, M. Yoneda, K. Jitsuiki, K. Yamane, N.
Kohno, A comparison between Japanese-Americans living in
Hawaii and Los Angeles and native Japanese: the impact of
lifestyle westernization on diabetes mellitus, Biomed. Pharmac-
other. 58 (2004) 571–577.
[4] D.L. Lorber, S. Chavez, J. Dorman, L.K. Fisher, S. Guerken,
L.A. Haas, et al., Diabetes management in correctional institu-
tions, Diabetes Care 27 (2004) S114–S121.
[5] L.A. MacFarlane, G.V. Gill, E. Masson, N.H. Tucker, Diabetes in
prison: can good diabetic care be achieved? BMJ 304 (1992)
152–155.
[6] M. Hinata, K. Sugai, M. Ono, K. Nakanishi, S. Midorikawa,
Metabolic improvement of prisoners with type 2 diabetes in
Fukushima Prison, Japan, Diabetes 54 (Suppl. 1) (2005) A425–
A426.
[7] National Diabetes Data Group, Classification and diagnosis of
diabetes mellitus and other categories of glucose intolerance,
Diabetes 28 (1979) 1039–1057.
[8] S. Carlsson, N. Hammar, S. Efendic, P.G. Persson, C.G. Osten-
son, V. Grill, Alcohol consumption, type 2 diabetes mellitus and
impaired glucose tolerance in middle-aged Swedish men, Dia-
betes Med. 17 (2000) 776–781.
[9] J. Gittelsohn, T.M. Wolever, S.B. Harris, R. Harris-Giraldo, A.J.
Hanley, B. Zinman, Specific patterns of food consumption and
preparation are associated with diabetes and obesity in a Native
Canadian community, J. Nutr. 128 (1998) 541–547.
[10] M.B. Schulze, J.E. Manson, D.S. Ludwig, G.A. Colditz, M.J.
Stampfer, W.C. Willett, et al., Sugar-sweetened beverages,
weight gain, and incidence of type 2 diabetes in young and
middle-aged women, JAMA 292 (2004) 927–934.
[11] N.G. Boule, E. Haddad, G.P. Kenny, G.A. Wells, R.J. Sigal,
Effects of exercise on glycemic control and body mass in type 2
diabetes mellitus: a meta-analysis of controlled clinical trials,
JAMA 286 (2001) 1218–1227.
[12] The National Nutrition Survey in Japan (2003), Tokyo: Office for
Life-Style Related Disease Control, General Affairs Division,
Health Service Bureau, Ministry of Health, Labour and Welfare,
(Accessed August 21, 2006, at http://www.mhlw.go.jp/houdou/
2005/04/h0421-1b.html), in Japanese.
[13] Y.D. Chen, A.M. Coulston, M.Y. Zhou, C.B. Hollenbeck, G.M.
Reaven, Why do low-fat high-carbohydrate diets accentuate
postprandial lipemia in patients with NIDDM? Diabetes Care
18 (1995) 10–16.
[14] S. Nakaji, K. Sugawara, D. Saito, Y. Yoshioka, D. MacAuley, T.
Bradley, et al., Trends in dietary fiber intake in Japan over the last
centry, Eur. J. Nutr. 41 (2002) 222–227.
[15] P. Wursch, F.X. Pi-Sunyer, The role of viscous soluble fiber in the
metabolic control of diabetes. A review with special emphasis on
cereals rich in beta-glucan, Diabetes Care 20 (1997) 1774–1780.
[16] J. Adiotomre, M.A. Eastwood, C.A. Edwards, W.G. Brydon,
Dietary fiber: in vitro methods that anticipate nutrition and
metabolic activity in humans, Am. J. Clin. Nutr. 52 (1990)
128–134.
[17] J.H. Lavin, N.W. Read, The effect on hunger and satiety of
slowing the absorption of glucose: relationship with gastric
emptying and postprandial blood glucose and insulin responses,
Appetite 25 (1995) 89–96.
[18] M. Rendell, Dietary treatment of diabetes mellitus, N. Engl. J.
Med. 342 (2000) 1440–1441.
[19] J. Li, T. Kaneko, L.Q. Qin, J. Wang, Y. Wang, A. Sato, Long-term
effects of high dietary fiber intake on glucose tolerance and lipid
metabolism in GK rats: comparison among barley, rice, and
cornstarch, Metabolism 52 (2003) 1206–1210.
[20] K.A. Meyer, L.H. Kushi, D.R. Jacobs Jr., J. Slavin, T.A. Sellers,
A.R. Folsom, Carbohydrates, dietary fiber, and incident
type 2 diabetes in older women, Am. J. Clin. Nutr. 71 (2000)
921–930.
[21] M. Chandalia, A. Garg, D. Lutjohann, K. von Bergmann, S.M.
Grundy, L.J. Brinkley, Beneficial effects of high dietary fiber
intake in patients with type 2 diabetes mellitus, N. Engl. J. Med.
342 (2000) 1392–1398.
[22] G.F. Keogh, G.J. Cooper, T.B. Mulvey, B.H. McArdle, G.D.
Coles, J.A. Monro, et al., Randomized controlled crossover study
of the effect of a highly beta-glucan-enriched barley on cardi-
ovascular disease risk factors in mildly hypercholesterolemic
men, Am. J. Clin. Nutr. 78 (2003) 711–718.
[23] R.C. Turner, C.A. Cull, V. Frighi, R.R. Holman, Glycemic
control with diet, sulfonylurea, metformin, or insulin in patients
with type 2 diabetes mellitus: progressive requirement for multi-
ple therapies (UKPDS 49). UK Prospective Diabetes Study
(UKPDS) Group, JAMA 281 (1999) 2005–2012.
[24] J. Salmeron, J.E. Manson, M.J. Stampfer, G.A. Colditz, A.L.
Wing, W.C. Willett, Dietary fiber, glycemic load, and risk of
non-insulin-dependent diabetes mellitus in women, JAMA 277
(1997) 472–477.
[25] J. Salmeron, A. Ascherio, E.B. Rimm, G.A. Colditz, D. Spiegel-
man, D.J. Jenkins, et al., Dietary fiber, glycemic load, and risk of
NIDDM in men, Diabetes Care 20 (1997) 545–550.
[26] R.A. Reimer, M.I. McBurney, Dietary fiber modulates intestinal
proglucagon messenger ribonucleic acid and postprandial secre-
tion of glucagon-like peptide-1 and insulin in rats, Endocrinol-
ogy 137 (1996) 3948–3956.
[27] D.A. D’Alessio, R. Vogel, R. Prigeon, E. Laschansky, D. Koer-
ker, J. Eng, et al., Elimination of the action of glucagon-like
peptide 1 causes an impairment of glucose tolerance after
nutrient ingestion by healthy baboons, J. Clin. Invest. 97
(1996) 133–138.
[28] Y.J. Song, M.M. Sawamura, K. Ikeda, S. Igawa, Y. Yamori,
Soluble dietary fibre improves insulin sensitivity by increasing
muscle GLUT-4 content in stroke-prone spontaneously hyper-
tensive rats, Clin. Exp. Pharmacol. Physiol. 27 (2000) 41–45.
[29] K.M. Behall, D.J. Scholfield, J. Hallfrisch, Effect of beta-glucan
level in oat fiber extracts on blood lipids in men and women, J.
Am. Coll. Nutr. 16 (1997) 46–51.
[30] D.J. Jenkins, T.M. Wolever, A.V. Rao, R.A. Hegele, S.J. Mitch-
ell, T.P. Ransom, et al., Effect on blood lipids of very high intakes
of fiber in diets low in saturated fat and cholesterol, N. Engl. J.
Med. 329 (1993) 21–26.
[31] R.M. Kay, A.S. Traswell, Effect of citrus pectin on blood lipids
and fecal steroid excretion in man, Am. J. Clin. Nutr. 30 (1997)
171–175.