International Journal of Noncommunicable Diseases

: 2021  |  Volume : 6  |  Issue : 4  |  Page : 159--165

Dietary approaches in management of noncommunicable diseases: A review

Janeline Lunghar, A Thahira Banu 
 Department of Home Science, The Gandhigram Rural Institute-Deemed to be University, Dindigul, Tamil Nadu, India

Correspondence Address:
Ms. Janeline Lunghar
Department of Home Science, The Gandhigram Rural Institute-Deemed to be University, Gandhigram, Dindigul - 624 302, Tamil Nadu


The prevalence of noncommunicable diseases (NCDs) has increased drastically over recent decades, with 41 million deaths each year, equivalent to 71% of all deaths globally. Unhealthy food choices and food habits, excessive calories, and inactivity are apparent factors to NCDs, namely obesity, diabetes mellitus, cancer, and cardiovascular disease. Healthy dietary intake and calorie restrictions have a promising effect on longevity. Eventually, adopting these strategies may delay the onset and decrease the burden of NCDs. Recent findings proved that nutrition has a strong association with the prevalence of NCDs. American Institute for Cancer Research and the World Cancer Research Fund says 30%–40% of cancers are preventable by adopting healthy food choices, dietary restrictions, engaging in physical activity, and maintaining body mass index. This review focuses on dietary intake and dietary restrictions and finally leads to understand the vital role of gut microbiome in managing NCDs.

How to cite this article:
Lunghar J, Banu A T. Dietary approaches in management of noncommunicable diseases: A review.Int J Non-Commun Dis 2021;6:159-165

How to cite this URL:
Lunghar J, Banu A T. Dietary approaches in management of noncommunicable diseases: A review. Int J Non-Commun Dis [serial online] 2021 [cited 2022 Jan 25 ];6:159-165
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The World Health Organization 2018 stated that noncommunicable diseases (NCDs) are the leading cause of death worldwide, with about 71% (41 million) of the 57 million deaths globally.[1] Dietary restriction can be very promising to increase longevity and perhaps, it delays the onset burden of NCDs. Dietary restrictions concerning the portion intake and frequency of meals could potentially prevent and delay the onset of NCDs without the occurrence of malnutrition.[2] For instance, the Mediterranean diet can reduce diabetes and cardiovascular diseases (CVDs)[3] and an effective approach like intermittent fasting can provide many health benefits.[4] Besides, gut microbiota also plays a pivotal role in NCDs.[5]

 Added-Value of This Review Paper

This review paper provides information on various dietary approaches across nations and quantifies to reduce the risk of NCDs through diet management. In addition, this review characterizes the relationship between dietary patterns and the development of various diseases including gut microbiome. The researchers collected the data from PudMed Advanced Search and Google Scholar from 2011 to 2021, and study including human and animal trials.

Dietary approaches in the management of NCDs and restricting calorie intake especially carbohydrate diet, low fat intake, intake of fiber, and Omega 3 fatty acids can prevent NCDs. Other food approaches are the Mediterranean diet and maintaining a good gut microbiome which are discussed below [Figure 1].{Figure 1}

 High-Calorie Intake, Weight Imbalances, and Its Association to Non-Communicable Diseases

Consuming a high-calorie diet is one of the NCDs main risks such as obesity, diabetes, cancer, and others. The worldwide report says that at least 2.8 million people die each year due to overweight or obese. An estimated 35.8 million (2.3%) of global disability-adjusted life years (DALYs) are caused by excess of eating or diet high in calorie rooting to overweight and obesity. Europe region, World Health Organization (2021), revealed that individuals who had body mass index (BMI) of 25.0–29.9 kg/m2 is taken as preobesity.[6] The BMI ranges categorized on excessiveness of body fat leads to obesity or even death. BMI was developed as a risk indicator of the disease and known that, as BMI increases, the risk for diseases increases, including obesity, CVDs, high blood pressure, and diabetes.[6]

In 2016, 18 years and above age with a total number of 1.9 billion populations (39% of the world adult) indicated as overweight “BMI higher to 25 kg/m2” of individual adult and more than 650 million populations are estimated as obese.[1] Numerous reasons including genetic and environmental factors can contribute to weight gain. Furthermore, BMI level can increase due to high energy intake from diet and poor physical activity.[7]

On the other hand, adverse health effects are being overweight and observed during earlier life stages. Children and young adolescents who have obesity are at increased risk of developing health issues such as breathing difficulties, insulin resistance, hypertension, and can even display early CVD markers.[1],[8] It is predicted that if a child is obese, it can impact and lead to obesity when they reach adulthood stage and most likely prone to develop chronic diseases (diabetes, coronary heart disease, and hypertension) and chances causing premature mortality rates.[8]

Lately, overweight and obesity in India are increasing in a fast pace. Besides, overweight has increased from 8.4% to 15.5% in adult women in the years 1998 and 2015, and the majority of obesity increased from 2.2% to 5.1% in the women category over the same period[9] and it keep increasing yearly.[10]

In the late 90s, in India, the DALYs were related to communicable, maternal, neonatal, and nutritional disorders. At present, India is facing a double burden with increase in the prevalence of NCDs.[11] There are other studies in India predicting the increase in weight, obesity, and its relationships with NCDs. Costa-Font and Mas opined that urbanization has increased the intake of energy and decreased physical activity resulting in overview associated with NCDS, Diabetes, Cancer, and CVDs.[12] The WHO, 2018, indicated that dietary intake of five portions focusing on fruits and vegetables for key element to stay fit. Most importantly, addressing calorie intake is vital to the obesity epidemic since energy imbalance results in overweight and obesity.[1]

 Diet and Diabetes

The statistical report on the prevalence of diabetes globally had estimated that 9.3% (463 million people) have diabetes mellitus and it would drastically rise to 10.2% (578 million) by 2030 and even higher with 10.9% (700 million) by 2045. However, the chances are comparatively higher in developed countries (10.8%) than in developing countries (7.2%). One in two (50.1%) people living with diabetes, not aware they are in the diabetic category, (International Diabetes Federation), in 2019, revealed that type 2 diabetes (T2D) is chiefly connected with the sedentary lifestyle that leads to overweight and more serious health issues.[13]

Low carbohydrate, low fat, and Mediterranean diet for type 2 diabetes

Many reports have stated that an unhealthy lifestyle can promote diabetes. Therefore, inculcating exercise and modifying lifestyle are the steps to prevent this chronic illness. A lifestyle modification of healthier diets and calorie restriction can lower the risk of associated T2D incidence. Schwingshackl et al. stated that low carbohydrate diet or low-fat diet, Mediterranean type diets, and vegetarian or vegan diets are considered to be healthy dietary patterns compared[14] to western-based diet.[15] The traditional Mediterranean diet is distinguished by using abundance of vegetables, minimally processed wholesome whole grain bread, including cereals and legumes as the staple food, fresh fruit, and cold-pressed extra-virgin olive oil instead of refined oils.[16] Apart from the dietary pattern, regular physical activity is also a part of the Mediterranean healthy lifestyle. This regular pattern of exercise can also be beneficial to lighten stress as well.

Though nutrition therapy and guidelines for diabetes management are available, individual has to monitor the correct body weight by inculcating physical activity or exercise regularly. A vast majority of people with diabetes are mostly confused and conflicting vehemently with nutrition advice without a doubt. It is habitually believed that diabetes especially T2D is irreversible. However, it is possible to reverse by aligning food intake and restriction portion.

 Diet and Cancer

One of the most complex diseases is Cancer with multiple interactions, mainly to do with genes, poor food intake, and lifestyle. However, metabolic and nutritional alterations can influence the survival and recovery of cancer patients.

As per the World Health Organization,[17] high number of deaths are due to cancer not sparing low-income countries like India and it is the second leading cause of death globally and responsible for 10 million deaths per year. It is reported that deaths come from cancer, which is associated with poor habits such as tobacco use, intake of alcohol, inadequate consumption fiber and lack of physical activity. Global burden disease stated that the use of tobacco is the most risk factor for cancer.[18]

On the other hand, caloric restriction (CR) is not a fad diet but a condition that has been experienced throughout human evolution. Especially during the hunter-gatherer period of ancient time, finding food was an unpredictable event. As a result, our metabolism evolved to tolerate calorie restriction and functions perfectly well under these conditions. The fact is that CR is reducing the intake of calories by 20%–40%, increasing longevity and reducing the risk of chronic diseases. Besides, it also discovered that CR activates stem cells that help to regenerate cells of the gut.[19]

Even worse, a laboratory study conducted showed that a high-fat diet (saturated fats in their diets) could dangerously influence normal intestinal stem cells by increasing their tendency to develop tumors.[20] Thus, by eliminating saturated fats, it may improve the overall ability to regenerate the circulatory system and stop the stem cells from generating new fat cells or tumor cells.[21]

Intake of high fiber

Recently, there is a rational shift in western diet from traditional food. For instance, increased intakes of ultra-processed or fast foods reduce the intake of plant-based and henceforth lack the consumption of fiber foods. The fact is that processed or refined products are low in fiber, but plant foods that are not processed have an abundance of fiber. In addition, the grained millets packed with fiber, once processed, have been removed and considered low fiber products. In a nutshell, fruits and vegetables are the prime sources of soluble fibers. Thomas et al. stated that perhaps fiber intake helps overall metabolic health and reduces the risk of CVD.[22]

It is widely known that fiber also plays a role in gut motility thus it helps in bowel movement. Based on the current evidence, many studies support these effects. A randomized controlled, double-blind trial on vegetable powder's effects a combination of “chicory, broccoli, and whole grains on constipation” alleviation in >90 participants. The individual who received the supplement powder observed tremendous improvement on their bowel movement also the stool texture (reduce stiffness and difficulties in straining out stool) at 2 and 4 weeks than who do not receive.[23] Perhaps, low dietary fiber intake is a risk factor for inflammation,[24] leading to chronic colon inflammation to colon cancer.

Dietary fiber intake correlates with NCDs death rate. The dietary fiber intake plays a significant role in gut microflora's functioning, which acts as the foremost mediator, including NCDs' metabolic processes and chronic inflammatory pathways.

 Cardiovascular Diseases and Diet

NCDs are substantially increasing in low middle-income countries and main concern is due to lifestyle transitions and leads to significant burden such as CVDs, hypertension, diabetes, and obesity.[25]

It is predicted that worldwide 2.7 billion adults may become overweight and over 177 million adults may severely be obese by 2025 WHO[26] and Fleming et al. stated that obesity can lead various chronic illnesses.[27]

Mediterranean diet for CVD

A dietary pattern on Mediterranean diet has shown to improve cardiac health. Observational studies of systematic review indicate greater adherence to the Mediterranean diet is strongly connected with a significant improvement in overall health status and a substantial reduction in mortality and morbidity from chronic diseases.[28],[29] The cardiovascular risk factors and inflammatory markers including high-sensitivity C-reactive protein have reduced consuming Mediterranean diet and low-fat diet.[30] Other systematic reviews have accumulated the evidence from both observational studies and randomized controlled trials (RCTs) in regard to Mediterranean dietary pattern and its favorable effect on metabolic syndrome.[31],[32] Other dietary patterns such as high fiber intake and Dietary Approaches to Stop Hypertension are other effective approaches in reducing CVD risk.

Intake of fiber

Whole plant foods are rich in fiber and intake of fiber can bring down cholesterol, help reduce weight and CVD, and various other cancers. Further, it helps in longevity, T2D, and gut health.[33],[34],[35],[36] As known fruits are rich sources of fiber and it has healthy nutrients namely Vitamin C, potassium, and significant sources of phytochemicals with a wide range of health benefits.[37] Thus, it is good to include in daily food intake. On the other hand,[38],[39],[40] western diet is significantly low in fiber, and unfortunately, it has contributed to increase weight gain, body inflammation and other chronic diseases. Pearson Stuttard et al. revealed that healthy dietary patterns, including fiber-rich (fruits and vegetables), have an essential role in preventing CVDs.[41] In addition, Bondonno et al., reported that 50 g/day of apple consumption was significantly associated lowering abdominal aortic calcification.[42] Another study in adult Chinese population revealed that consuming whole fruit of 100 g daily reduced the risk of CVD.[43] Therefore, intake of dietary fiber (fruits and vegetables) can improve cardiovascular health risk markers in the short and long term.

Fiber intake mechanism

High fiber intake is healthier for gut microbiome as it increases short-chain fatty acids (SCFAs) production and diversified microbiota, linked to lower the risk of obesity[44] and other diseases such as diabetes and inflammation. Acetate is considered moderately to cause obesity whereas butyrate and propionate are anti-obesogenic. The study stated that individual lean body mass has “higher Bacteroidetes to Firmicutes” ratio than obese category. A cross-sectional study on adults with a “BMI of 23–34 kg/m2” was observed consuming fresh fruits and dried fruits led to reducing the levels of Bacteroides group in obese subjects.[45] The components of pectin and polyphenol in fruit increase the healthy bacteria namely Bacteroidetes and Actinobacteria, and decreases the production of Firmicutes and Proteobacteria, commonly dominant in the obese category.[46],[47]

A study recommended that propionate is essential to regulate energy homeostasis by suppressing adipogenesis and inhibit adipocytes to generate in the body through the inhibition of “free fatty acid receptor 2” to stop fat accumulation by hampering lipid globules production and differentiation in the adipose tissue.[48] Fiber intake generates more propionate and is beneficial for the gut microbiome and block the fat deposit. Furthermore, SFCA can act as anti-inflammatory mediators by regulating prostaglandin E2 (PGE2) and cytokines.[49] In general, PGE2 plays a pivotal role in reducing the inflammation by suppressing T-cell receptor signaling and proliferation.

Besides, longitudinal studies found that longer telomere length was remarkably predictive by having good body weight (not excess), correct body composition such as BMI, anthropometric such as waist circumference, and dietary inflammatory markers, and these were associated with high intake of fruit (fiber) associated with high adherence to the Mediterranean diet.[50],[51] A cohort study observed that the intake of fruit fiber regulates the function of epigenetic gene for immune surveillance, and chromosome and telomere maintenance pathways of the gut microbiota.[52] Fiber increased the SCFAs production henceforth, improving inflammation, increase in colonic peptides in glucose and prevent insulin imbalance and help lipid metabolism.[53] Pectin has a significant impact on colonic microbiota by changing the anti-inflammatory profile by increasing the Bacteroidetes and Firmicutes ratio. It increases Bifidobacterium and Clostridium species and helps in colonic mucosal barrier and aligned mucosal immunity. Further increased the production of butyrate and reduces the enteric pathogens like Bacteroides.[54],[55],[56]

Putting all together, it is necessary to investigate various other links and plant-based fiber with the specific microbiota to enhance or leverage the SCFA production as it prevents obesity, diabetes and acts as anti-inflammatory mediators. Thus, high fiber intake is pivotal in NCDs prevention.

 Diet and Gut Microbiome

Diet is not only essential to maintain normal growth, development, and reproduction, but the interesting fact is that it can modulate and support the digestive tract of gut microbiota. The bacteria inside the body in the intestinal tract have a symbiotic relationship with their host. There are good and bad bacteria; good bacteria are known as beneficial bacteria. They can produce natural antibiotics that can resist harmful bacteria and make good bacteria, further produces beneficial B vitamins in the small intestine. Good bacteria have the potential to bring in many health benefits. For instance, they can help in food digestion by providing extra enzymes, such as lactase, in the small intestine and strengthen the immune system. How gut microbiota can alter microbial gut health and prevent NCDs is discussed below.

David et al. stated that either animal or plant diet could alter gut microbiota and overwhelms inter-individual differences in microbial gene expression.[57] The microbiome contributes to homeostatic regulation in different tissues in the body.[58] The interrelationship of human brain and gut health is considered as mutualistic symbiosis, a unique connection[59] and eubiotics are a balance of the microbes in the gut. However, gut can be easily disrupted, leading to the development of various chronic diseases including inflammatory conditions if fiber intake is inadequate.[60] Most microbiome-linked pathologies suggest a lifestyle modification focusing on food intake if the gut is disrupted and loss of beneficial and protective microbes.[61] Western diet, basically low in fiber, may reduce the diversity of microbiota leading gut dysbiosis.[62] In addition, poor intake of fiber and the excessive intake of fat and sugar products may contribute to depleting some specific bacterial species.[63] These alterations may lead to gut abnormality contributing to an increase of chronic inflammatory diseases such as autoimmune disorder, allergies, intestinal bowel disease (IBD), colorectal cancer, obesity, and other related NCDs however be prevented on fiber intake.[40] A diet rich in fiber contributes to healthy gut microbiota with increased diversity of the microbiota and short-chain fatty acid production (SCFAs).

On the other hand, low fiber and high sugar intake can eventually reduce the diversity of the gut bacteria and reduce the ability to produce SCFAs, leading to gut-related diseases. Henceforth, a diet high in fiber can make SCFAs enhance mucus and anti-microbial peptide production and increase tight junction protein expression. Thus, inadequate fiber and excess sugar consumption can alter and disrupt the gut microbiota. It also leads to increased susceptibility to infections, IBD, and impaired physiology.[64]

Besides dietary intake,[65] interestingly, chronic stress massively alters intestinal microbiota composition, primarily depleting Lactobacilli.[66] The bottom line is the maintenance of a healthy gut through nutrition, the use of dietary supplements, and lesser stress to reduce NCDs associated with threatening lifestyles. Putting it altogether, the gut microbiota plays a crucial role in NCDs since it actively interferes to maintain gut homeostasis, nutrient metabolism, and the immune system.[5]


The findings show that NCDs could slow down by the following certain diet approaches and diet patterns. Dietary restriction and reducing high-calorie food are best practices to delay the onset of NCD. Other strategies such as eliminating refined products, sugary products, and diet switching from Westernize to traditional intake like the Mediterranean diet are healthier practices and improving overall health. Moreover, probiotic foods are beneficial to the gut host, and choosing nutrient-dense foods high in fiber have positive influences on the host metabolism. Fiber does not only help to strengthen and versatile the gut but there is evidence that it acts as a healer to almost all NCDs. Thus, intake of fiber and dietary modification, which induces health benefits, must dive deeper into the connection between the gut microbiome and NCDs.

Ethical approval statement

This review paper is not currently being considered for publication elsewhere and the review paper has no interaction with animal nor did human but purely collected from various journals sources. Henceforth no ethical consent form necessary.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1WHO. Healthy Diet; 2018. Available from: [Last accessed on 2021 Apr 24].
2Stewart TM, Bhapkar M, Das S, Galan K, Martin CK, McAdams L, et al. Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy Phase 2 (CALERIE Phase 2) screening and recruitment: Methods and results. Contemp Clin Trials 2013;34:10-20.
3Dinu M, Pagliai G, Casini A, Sofi F. Mediterranean diet and multiple health outcomes: An umbrella review of meta-analyses of observational studies and randomised trials. Eur J Clin Nutr 2018;72:30-43.
4Malinowski B, Zalewska K, Węsierska A, Sokołowska MM, Socha M, Liczner G, et al. Intermittent fasting in cardiovascular disorders – An overview. Nutrients 2019;11:673.
5Rinninella E, Cintoni M, Raoul P, Ianiro G, Laterza L, Lopetuso LR, et al. Gut microbiota during dietary restrictions: New insights in non-communicable diseases. Microorganisms 2020;8:1140.
6WHO; 2021. Available from: [Last accessed on 2021 May 16].
7Hill JO, Wyatt HR, Peters JC. Energy balance and obesity. Circulation 2012;126:126-32.
8WHO. Why Does Childhood Overweight and Obesity Matter?; 2019. Available from: [Last accessed on 2021 Mar 22].
9NFHS, 2015-2016. Available from: [Last accessed on 2021 Aug 13].
10NFHS, 2019-2020. Available from: [Last accessed on 2021 Oct 06].
11WHO. Obesity and Overweight: Fact Sheet 311. WHO Media Centre; 2016. Available from: [Last accessed on 2021 Aug 03].
12Costa-Font J, Mas N. Globesity'? The effects of globalization on obesity and caloric intake. Food Policy 2016;64:121-32.
13International Diabetes Federation. Global and Regional Diabetes Prevalence Estimates for 2019 and Projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. 9th ed. Amsterdam Elsevier publication: International Diabetes Federation; 2019. Available from: [Last accessed on 2021 Dec 11].
14Schwingshackl L, Missbach B, König J, Hoffmann G. Adherence to a Mediterranean diet and risk of diabetes: A systematic review and meta-analysis. Public Health Nutr 2015;18:1292-9.
15Bloomfield HE, Koeller E, Greer N, MacDonald R, Kane R, Wilt TJ. Effects on health outcomes of a Mediterranean diet with no restriction on fat intake: A systematic review and meta-analysis. Ann Intern Med 2016;165:491-500.
16Tosti V, Bertozzi B, Fontana L. Health benefits of the Mediterranean diet: Metabolic and molecular mechanisms. J Gerontol A Biol Sci Med Sci 2018;73:318-26.
17WHO; 2019. Available from: [Last accessed on 2021 Dec 11].
18GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1659-724.
19Igarashi M, Guarente L. mTORC1 and SIRT1 cooperate to foster expansion of gut adult stem cells during calorie restriction. Cell 2016;166:436-50.
20Beyaz S, Mana MD, Roper J, Kedrin D, Saadatpour A, Hong SJ, et al. High-fat diet enhances stemness and tumorigenicity of intestinal progenitors. Nature 2016;531:53-8.
21Li W. Eat to Beat Disease – The Body's Five Defence Systems and the Foods that Could Save Your Life. 1st ed. London, United Kingdom: ISBN13 9781785042157; 2019. p. 101-34.
22Barber TM, Kabisch S, Pfeiffer AF, Weickert MO. The health benefits of dietary fibre. Nutrients 2020;12:3209.
23Woo HI, Kwak SH, Lee Y, Choi JH, Cho YM, Om AS. A controlled, randomized, double-blind trial to evaluate the effect of vegetables and whole grain powder that is rich in dietary fibers on bowel functions and defecation in constipated young adults. J Cancer Prev 2015;20:64-9.
24Bach Knudsen KE, Lærke HN, Hedemann MS, Nielsen TS, Ingerslev AK, Gundelund Nielsen DS, et al. Impact of diet-modulated butyrate production on intestinal barrier function and inflammation. Nutrients 2018;10:1499.
25Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224-60.
26World Obesity Org; 2020. Available from: [Last accessed on 2021 Jul 05].
27Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384:766-81.
28Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: An updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr 2014;17:2769-82.
29Rosato V, Temple NJ, La Vecchia C, Castellan G, Tavani A, Guercio V. Mediterranean diet and cardiovascular disease: A systematic review and meta-analysis of observational studies. Eur J Nutr 2019;58:173-91.
30Nordmann AJ, Suter-Zimmermann K, Bucher HC, Shai I, Tuttle KR, Estruch R, et al. Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. Am J Med 2011;124:841-51.e2.
31Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The effect of Mediterranean diet on metabolic syndrome and its components: A meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol 2011;57:1299-313.
32Luque V, Escribano J, Closa-Monasterolo R, Zaragoza-Jordana M, Ferré N, Grote V, et al. Unhealthy dietary patterns established in infancy track to mid-childhood: The EU Childhood Obesity Project. J Nutr 2018;148:752-9.
33Health Dietary Guidelines; 2015. Available from: [Last accessed on 2021 Aug 13].
34Veronese N, Solmi M, Caruso MG, Giannelli G, Osella AR, Evangelou E, et al. Dietary fiber and health outcomes: An umbrella review of systematic reviews and meta-analyses. Am J Clin Nutr 2018;107:436-44.
35Miller V, Mente A, Dehghan M, Rangarajan S, Zhang X, Swaminathan S, et al. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): A prospective cohort study. Lancet 2017;390:2037-49.
36Dreher ML. Connection between fiber, colonic microbiota, and health across the human life cycle. In: Dietary Fiber in Health and Disease. Basel, The Switzerland: Springer International Publishing AG; 2018. p. 67-93.
37USDA. National Nutrient Database for Standard Reference. Washington, DC, USA: USDA; 2018.
38Deehan EC, Walter J. The fiber gap and the disappearing gut microbiome: Implications for human nutrition. Trends Endocrinol Metab 2016;27:239-42.
39Lie L, Brown L, Forrester TE, Plange-Rhule J, Bovet P, Lambert EV, et al. The association of dietary fiber intake with cardiometabolic risk in four countries across the epidemiologic transition. Nutrients 2018;10:628.
40Rivière A, Selak M, Lantin D, Leroy F, De Vuyst L. Bifidobacteria and butyrate-producing colon bacteria: Importance and strategies for their stimulation in the human gut. Front Microbiol 2016;7:979.
41Pearson-Stuttard J, Bandosz P, Rehm CD, Penalvo J, Whitsel L, Gaziano T, et al. Reducing US cardiovascular disease burden and disparities through national and targeted dietary policies: A modelling study. PLoS Med 2017;14:e1002311.
42Bondonno NP, Lewis JR, Prince RL, Lim WH, Wong G, Schousboe JT, et al. Fruit intake and abdominal aortic calcification in elderly women: A prospective cohort study. Nutrients 2016;8:159.
43Tian X, Du H, Li L, Bennett D, Gao R, Li S, et al. Fruit consumption and physical activity in relation to all-cause and cardiovascular mortality among 70,000 Chinese adults with pre-existing vascular disease. PLoS One 2017;12:e0173054.
44Davis HC. Can the gastrointestinal microbiota be modulated by dietary fibre to treat obesity? Ir J Med Sci 2018;187:393-402.
45Fernández-Navarro T, Salazar N, Gutiérrez-Díaz I, de Los Reyes-Gavilán CG, Gueimonde M, González S. Different intestinal microbial profile in over-weight and obese subjects consuming a diet with low content of fiber and antioxidants. Nutrients 2017;9:551.
46Rautiainen S, Wang L, Lee IM, Manson JE, Buring JE, Sesso HD. Higher intake of fruit, but not vegetables or fiber, at baseline is associated with lower risk of becoming overweight or obese in middle-aged and older women of normal BMI at baseline. J Nutr 2015;145:960-8.
47Aguirre M, Jonkers DM, Troost FJ, Roeselers G, Venema K. In vitro characterization of the impact of different substrates on metabolite production, energy extraction and composition of gut microbiota from lean and obese subjects. PLoS One 2014;9:e113864.
48Iván J, Major E, Sipos A, Kovács K, Horváth D, Tamás I, et al. The short-chain fatty acid propionate inhibits adipogenic differentiation of human chorion-derived mesenchymal stem cells through the free fatty acid receptor 2. Stem Cells Dev 2017;26:1724-33.
49Kim S, Rimando J, Sandler DP. Fruit and vegetable intake and urinary levels of prostaglandin E2 metabolite in postmenopausal women. Nutr Cancer 2015;67:580-6.
50García-Calzón S, Gea A, Razquin C, Corella D, Lamuela-Raventós RM, Martínez JA, et al. Longitudinal association of telomere length and obesity indices in an intervention study with a Mediterranean diet: The PREDIMED-NAVARRA trial. Int J Obes (Lond) 2014;38:177-82.
51García-Calzón S, Zalba G, Ruiz-Canela M, Shivappa N, Hébert JR, Martínez JA, et al. Dietary inflammatory index and telomere length in subjects with a high cardiovascular disease risk from the PREDIMED-NAVARRA study: Cross-sectional and longitudinal analyses over 5 y. Am J Clin Nutr 2015;102:897-904.
52Nicodemus-Johnson J, Sinnott RA. Fruit and juice epigenetic signatures are associated with independent immunoregulatory pathways. Nutrients 2017;9:1038.
53Keenan MJ, Marco ML, Ingram DK, Martin RJ. Improving healthspan via changes in gut microbiota and fermentation. Age (Dordr) 2015;37:98.
54Luis AS, Briggs J, Zhang X, Farnell B, Ndeh D, Labourel A, et al. Dietary pectic glycans are degraded by coordinated enzyme pathways in human colonic Baicteroides. Nat Microbiol 2018;3:210-9.
55Simpson HL, Campbell BJ. Review article: Dietary fibre-microbiota interactions. Aliment Pharmacol Ther 2015;42:158-79.
56Garcia-Mantrana I, Selma-Royo M, Alcantara C, Collado MC. Shifts on gut microbiota associated to mediterranean diet adherence and specific dietary intakes on general adult population. Front Microbiol 2018;9:890.
57David LA, Maurice CF, Carmody RN, Gootenberg DB, Button JE, Wolfe BE, et al. Diet rapidly and reproducibly alters the human gut microbiome. Nature 2014;505:559-63.
58Schroeder BO, Bäckhed F. Signals from the gut microbiota to distant organs in physiology and disease. Nat Med 2016;22:1079-89.
59Walter J, Britton RA, Roos S. Host-microbial symbiosis in the vertebrate gastrointestinal tract and the Lactobacillus reuteri paradigm. Proc Natl Acad Sci U S A 2011;108 Suppl 1:4645-52.
60Hand TW, Vujkovic-Cvijin I, Ridaura VK, Belkaid Y. Linking the microbiota, chronic disease, and the immune system. Trends Endocrinol Metab 2016;27:831-43.
61Logan AC, Jacka FN, Prescott SL. Immune-microbiota interactions: Dysbiosis as a global health issue. Curr Allergy Asthma Rep 2016;16:13.
62Sonnenburg ED, Smits SA, Tikhonov M, Higginbottom SK, Wingreen NS, Sonnenburg JL. Diet-induced extinctions in the gut microbiota compound over generations. Nature 2016;529:212-5.
63Sonnenburg ED, Sonnenburg JL. Starving our microbial self: The deleterious consequences of a diet deficient in microbiota-accessible carbohydrates. Cell Metab 2014;20:779-86.
64Makki K, Deehan EC, Walter J, Bäckhed F. The impact of dietary fiber on gut microbiota in host health and disease. Cell Host Microbe 2018;23:705-15.
65Diaz Heijtz R, Wang S, Anuar F, Qian Y, Björkholm B, Samuelsson A, et al. Normal gut microbiota modulates brain development and behavior. Proc Natl Acad Sci U S A 2011;108:3047-52.
66Marin IA, Goertz JE, Ren T, Rich SS, Onengut-Gumuscu S, Farber E, et al. Microbiota alteration is associated with the development of stress-induced despair behavior. Sci Rep 2017;7:43859.