The MD includes traditional dietary patterns of countries bordering the Mediterranean Sea, and it has gained significant attention for its potential benefits in managing diabesity—the intricate interplay of obesity and type 2 diabetes ^[10][11][24,25]. The MD includes an increased intake of fruits, vegetables, whole grains, legumes, and nuts, with a modest consumption of fish and poultry. Additionally, it is notable for its use of extra virgin olive oil as the primary source of nutritional fats. However, variations may exist in the types and quantities of fruits and vegetables consumed across the different studies examining the MD ^[10][11][24,25]. Addressing this variability, thwe researchers carefully reviewed the currently available studies related to diabesity and cited in the entryour manuscript to identify potential differences in the implementation of the MD. While the fundamental principles remain consistent, it is acknowledged that specific studies may have variations in the recommended portions and types of fruits and vegetables ^[10][11][24,25]. Furthermore, thwe researchers reccognize the significance of extra virgin olive oil in the MD and acknowledge its mention in the entryour manuscript. However, to provide a thorough overview, the researcherswe have scrutinized the cited studies to confirm the utilization of extra virgin olive oil in each investigation. It is imperative to note that not all studies may explicitly specify the kind of olive oil examined; nevertheless, the prevailing emphasis on extra virgin olive oil within the broader context of the MD is acknowledged. By addressing these points, the researcherswe aim to enhance the clarity and transparency of theour discussion on the MD and its impact on diabesity.

A comprehensive literature search emphasized the interdisciplinary collaboration between endocrinologists and nutritionists to obtain the best possible management of endocrinal diseases, such as the possible impact of the MD concerning their preventive and confronted approaches against these ^[12][26]. The above evidence suggested that the MD could exert a preventing impact on endocrinal diseases as well as its introduction into nutritional proposals, which could be proved favorable ^[10][24]. A review of evidence concerning healthy effects of MD theories and compliance in a planeterranean viewpoint documented that the MD represents a healthful and sustainable lifestyle model, which can exert preventing effects against diverse disorders, decreasing early mortality ^[11][25]. Moreover, accessibility to front-of-pack labels, such as MD principles, could encourage further awareness of food selections amongst customers, promoting both human and planetary health ^[13][27].

MD, celebrated for its emphasis on whole, nutrient-dense foods, has emerged as a dietary pattern of concern in lowering the probability of diabesity. The study by InterAct Consortium (2011) investigated the link of MD compliance with the risk of insulin-independent diabetes ^[12][13][14][26,27,28]. This extensive European study found a notable association: individuals who adhered closely to the MD experienced a reduced probability of insulin-independent diabetes. The above provides evidence for adopting the MD, which could serve as a preventive measure against diabesity ^[14][15][16][28,29,30].

The Mediterranean diet’s focus on whole grains, fruits, vegetables, and healthy fats positions it as a holistic approach to managing diabesity, intertwining both diabetes and obesity management into a unified dietary strategy. Notably, high MD compliance, and especially seafood consumption, which are rich in omega-3 unsaturated lipid acids, has been related to lowered insulin resistance in overweight and obese persons ^[17][31]. The consumption of dietary fibers, unsaturated fatty acids, vitamins, and polyphenols—such as flavonoids and stilbenes—has been associated with the beneficial effects of the MD against central adiposity, hyperglycemia, hyperlipidemia, and hypertension. Antioxidant and anti-inflammation activities of polyphenols in conjunction with the impacts of unsaturated fatty acids on lipid metabolism contribute to the underlying mechanisms. Overall, dietary interventions using MD components appear to improve metabolic syndrome health biomarkers in humans and/or rodents ^[18][32].

Moreover, a high compliance to a well-balanced, healthy dietary pattern related to the Mediterranean diet lifestyle could control hyperglycemia, providing beneficial effects to body composition, which may contribute to the management and the prevention of the development of T2DM ^[19][33]. The up-coming Prevención con Dieta Mediterránea-Plus (PREDIMED-Plus) RCT has supported that a nutritional intervention related to the weight-decline lifestyle based on an energy-decreased MD in conjunction with elevated physical activity substantial decreased overall and central adiposity and ameliorated age-associated declines of lean mass in overweight or obese older adults suffered from metabolic syndrome. However, continued follow-up is recommended to verify the long-term effects of the above alterations on cardiovascular disease symptomatology ^[20][34].

A longitudinal birth cohort survey in Iran, including 647 pregnant women, showed that greater MD compliance during early gestation could be related to a decreased probability of GDM, highlighting the need of performing population-based surveys to verify the above results ^[21][44]. A MD-based intervention study conducted at the first weeks of gestation revealed permanent positive impacts on abnormal glucose regulation and metabolic syndrome rates at 3 years after delivery ^[22][45]. A longitudinal study of pregnant mothers enrolled at the initial three months of gestation indicated that a higher MD compliance before gestation, particularly with fewer meat intake, could exert a protective impact on the incidence of GWG ^[23][46]. In another longitudinal, multicenter survey conducted on 7798 pregnant women, a high versus a low a MD scoring was related to a 37% reduced risk of GDM ^[24][47].

In theour exploration of the impact of the MD on diabesity, the importance of maintaining a high level of compliance emerges as a crucial factor influencing the attainment of long-term benefits. In the present research, the researchers view, we underscore the significance of sustained adherence to the MD for optimal effects in the controlling of obesity and insulin-independent diabetes ^[25][48]. In this aspect, the literature suggests that successful and lasting adoption of the MD is influenced by several key elements, including education, cultural factors, social support, and individual preferences ^[26][49]. More to the point, several studies have highlighted the role of educational interventions in promoting awareness and understanding of the MD’s health benefits, thereby fostering a sense of commitment among individuals ^[26][27][49,50]. Cultural factors, such as the integration of traditional dietary practices into daily routines, have also been associated with sustained adherence ^[27][50]. Moreover, the availability of social support networks through community programs or familial encouragement plays a pivotal role in reinforcing positive dietary habits. The customization of dietary recommendations based on individual preferences and lifestyles further enhances the likelihood of continued MD adherence ^[28][51].

Low-carbohydrate dietary models have currently attracted raising interest as a probable dietary strategy for managing diabesity, a challenging combination of diabetes and obesity. The popularity of low-carbohydrate dietary models in the previous few years has provoked numerous research surveys to investigate their effect in diverse metabolic and non-morbidity states ^[29][52]. In a groundbreaking clinical survey, researchers investigated the impacts of a low-carbohydrate diet on weight decline and diabetes control in individuals with insulin-independent diabetes ^[30][53]. This study revealed compelling results, demonstrating that participants on a low-carb dietary model exhibited not only significant weight loss but also remarkable improvements in their diabetes control parameters, including HbA1c levels and fasting blood glucose levels ^[30][53]. These findings highlight the beneficial potential of low-carbohydrate dietary models in addressing diabesity-related concerns.

Supporting this, Westman et al. (2008) performed a survey examining the impact of a low-carbohydrate, ketogenic dietary model on glycemic control in individuals with insulin-independent diabetes mellitus ^[31][54]. The ketogenic diet, including a high fat and low carbohydrate content, showed promising results. Participants following this diet exhibited improved glycemic control, further emphasizing the potential of low-carb diets as a means to manage diabetes while simultaneously addressing obesity ^[31][54].

Low-carbohydrate diets, often criticized for their sustainability and long-term effects, are increasingly recognized for their role in helping individuals with diabesity achieve weight loss and improved blood sugar control ^[32][55]. These insights pave the way for personalized dietary interventions tailored to the unique needs of those with diabesity. In this aspect, individuals with diabesity adopting a low-carbohydrate diet for 6 months could experience a reduction in diabetes symptoms without adverse effects. Limitations provoke continuous debate about what is considered a remission of diabetes, as well as the efficiency, protection, and nutritional enjoyment of prolonged low-carbohydrate diets ^[32][55].

Plant-based dietary models, depicted by their heavy reliance on fruits, vegetables, whole grains, and legumes, exhibit considerable interest for their probable healthy effects. Kahleova et al. (2020) carried out a study exploring the effects of a low-fat vegan diet on various health parameters in overweight adults ^[33][56]. Their results showed that participants in this plant-based diet experienced not only weight loss but also improved insulin sensitivity, a crucial factor in diabetes management ^[33][56]. The above results emphasize the potential of plant-based diets in managing diabesity by addressing both obesity and diabetes.

Expanding on the concept of plant-based diets, Ghaedi et al. (2019) performed a systematic review and meta-analysis focusing on the Paleolithic diet, which emphasizes whole, unprocessed foods similar with those found in a plant-based diet ^[34][57]. The findings of their study showed that the Paleolithic diet may be effective in improving cardiovascular risk factors, including those associated with diabesity ^[34][57]. This suggests that plant-based and whole-food diets not only offer potential benefits for diabetes management but also contribute to overall cardiovascular health, a crucial aspect in diabesity prevention. Epidemiological surveys constantly indicate reduced incidence of mortality in adults adopting plant-based diets in comparison with individuals whose diet systematically contains meat. Plant-based diets have been related to several healthy effects such as a better metabolic and inflammatory profile ^[35][58].

These studies collectively underscore the potential of plant-based and whole-food diets in positively influencing diabesity-related factors, such as lipid profiles and cardiovascular health, and further highlighting their role as comprehensive dietary strategies for diabesity management. In total, the health of individuals adopting plant-based diets seems to be usually good, with certain strengths but also with some disadvantages, and the extent to which the disadvantages could be alleviated by best possible foods’ choices, fortification and supplementation has not elucidated yet ^[36][59]. The attention in probable longevity-promoting mechanisms of plant-based diets has been enlarged in the last few years since several features of plant-based diets like protein limitation as well as the reduction in specific amino acids that are recognized to increase one’s lifespan ^[35][58].

In addressing the potential concerns related to plant-based diets, it is essential to dispel common misconceptions and provide a more nuanced understanding. Non-specialists might perceive plant-based diets as having potential issues such as inadequate protein intake and excessive consumption of sugars, particularly fructose. In this aspect, it should be emphasized that well-planned, plant-based diets can meet protein requirements through diverse plant protein sources, containing legumes, tofu, tempeh, nuts, and seeds. Adequate planning ensures that individuals following a plant-based diet receive a balanced and sufficient intake of essential amino acids ^[37][60]. Moreover, concerns about excessive sugars, especially fructose, can be mitigated by emphasizing whole, unprocessed plant foods. Fruits, vegetables, whole grains, and legumes are integral components of a plant-based diet and provide essential nutrients without the added sugars commonly found in processed foods. It is crucial to highlight that the emphasis should be on consuming whole, nutrient-dense foods rather than relying on processed plant-based alternatives ^[38][61].

High-protein, low-fat diets have gained attention for their potential in addressing diabesity. In a survey of Layman et al. (2015), the researchers explored the impact of a high-protein, low-fat diet on weight decline and glycemic control in individuals with obesity and insulin-independent diabetes ^[39][62]. The results were noteworthy, with participants experiencing significant weight decline and decrease in insulin tolerance ^[39][62]. This suggests that a nutritional approach, including higher levels in protein and lower levels of in fat may serve as a valuable strategy for managing diabesity by addressing both diabetes and obesity simultaneously.

In comparison with a typical-protein, low-fat diet, a high-protein, low-fat diet produced more advantageous alterations in weighted mean differences for decreases in body weight, fat mass, and triglycerides and attenuations of decreases in fat-free mass and resting energy expenditure. Alterations in fasting plasma glucose, fasting insulin, blood pressure, and total, LDL, and HDL cholesterol were analogous with nutritional interventions. Moreover, greater satiety with a high-protein, low-fat diet was reported in most existing studies ^[40][63].

Regarding the potential concerns associated with high-protein, low-fat diets, it is essential to address the issue of kidney load and provide clarity on the upper limit of protein intake and its sources. Concern about kidney load is a valid consideration, particularly when implementing a diet rich in protein. While high-protein diets have shown favorable effects on weight loss, glycemic control, and satiety, it is crucial to understand the upper limit of protein intake that can be safely consumed without adverse effects on kidney function ^[41][65]. In this aspect, it has been indicated that the source of protein may exert a considerable effect in mitigating the potential impact on the kidneys. If the diet is predominantly high in plant-based proteins, such as those derived from legumes, tofu, and nuts, the renal load may differ from diets high in animal-based proteins. Plant-based proteins tend to be accompanied by beneficial components such as fiber and antioxidants, which may contribute to a more favorable renal profile ^[42][66].

Intermittent fasting and time-restricted eating have been considered as intriguing dietary strategies for diabesity management. Intermittent fasting increased in accordance with its popularity on the internet. Intermittent calorie restriction/time-restricted eating is a kind of calories’ reduction turning around a small period of feeding and a relatively higher period of fasting. The above model of feed–fast cycle stimulates an elevated reduction in adipose tissue and glycogen stores, resulting in higher fatty mass decline and decreased saturation. Intermittent fasting may also exert cardioprotective effects, controlling diabetes-related characteristics, as well as reducing the prevalence of diabetes ^[43][67].

In another survey by Herpich et al. (2022), researchers investigated the impact of time-restricted eating on insulin tolerance and cardiometabolic health ^[35][58]. The findings indicated that participants who practiced time-restricted eating experienced greater insulin sensitivity and reduced insulin amounts, suggesting its potential in managing diabetes, a critical aspect of diabesity ^[44][68]. Intermittent fasting appears to affect, in a different way, metabolic homeostasis, which is dependent on a personalized basis on one’s health condition and the kind of metabolic disorder ^[45][69]. Various modes of intermittent fasting decrease body weight and lowered diabetes parameters such as fasting glucose and insulin, HOMA-IR index, and glycosylated hemoglobin (HbA1c) ^[46][70].

Further supporting the role of fasting, Halberg et al. (2005) performed a survey on the impact of intermittent fasting on body weight and insulin resistance ^[47][71]. The results revealed significant body weight decline, decreasing insulin resistance in participants practicing intermittent fasting ^[38][61]. These findings underscore the potential of fasting regimens in addressing both obesity and diabetes, key components of diabesity. The concept of fasting, whether through intermittent fasting or time-restricted eating, presents a novel approach to diabesity management that warrants further exploration and customization to individual needs.

Moreover, Christian Orthodox fasting constitutes a dietary model with increased complex carbohydrates’ content and decreased levels of refined carbohydrates. This kind of fasting has been explored in relation to its probable healthy effects. In fact, it is characterized by positive impacts regarding glucose and lipid control; however, its impact against hypertension remains inconclusive ^[48][72]. Regarding body weight monitoring, Christian fasters showed decreased body mass and lesser calories intake during fasting days. More to the point, Christian fasters consume increased amounts of fruits and vegetables without nutritional deficiencies for iron and folate ^[48][72].

There are also data which indicate that short-term intermittent fasting exerts a higher beneficial impact in animal studies and promotes effects benefits in RCT ^[49][73]. However, there are not adequate surveys conducted on individuals affected by obesity and insulin-independent diabetes. It also remains a debatable interventional approach for the treatment of metabolic disorders and cancer. Moreover, whether intermittent fasting could be used to long-term clinical treatment, and whether it exhibits adverse effects during the long-term period or not, requires further large-scale and long-term studies ^[49][73].

Incorporating high-protein, low-fat diets and fasting into the discussion expands the repertoire of dietary strategies available for diabesity management, providing individuals with diverse and potentially effective approaches to address this complex condition. High-protein, intermittent fasting, and a low-calorie diet are related to analogous reductions in BMI and blood lipids in individuals affected by obesity. This kind of dietary model also shows an improvement in reducing body weight regain, improving arteries health as compared to a heart healthy diet over a period of one year ^[50][74]. Moreover, the findings of the currently available clinical studies have demonstrated that LCDs and intermittent fasting in obese patients (containing those with simultaneous insulin independent diabetes) may result in body fatty mass decline and improvements in metabolic parameters. The positive impacts mentioned above may be ascribed not only to body mass decline, but additionally to the triggering of metabolic pathways related to fasting conditions. Nevertheless, the lack of large-scale RCTs makes it difficult to propose LCDs or intermittent fasting as consistent, habitual practices for effective and permanent weight decline ^[51][75].

As far as fasting strategies for diabesity management are concerned, it is pertinent to take into account the nutritional aspects of post-fasting periods. While intermittent fasting and time-restricted eating show promising impacts on insulin sensitivity, cardiometabolic health, and weight management, the question of what should be ingested after the fasting period is a crucial aspect that merits discussion. In this context, post-fasting nutrition plays a pivotal role in optimizing the benefits gained during the fasting phase. The choice of nutrient-dense, well-balanced meals after a fasting window can influence metabolic outcomes and overall health. Several studies have indicated that incorporating a balanced combination of macronutrients, including lean proteins, complex carbohydrates, and healthy fats, can help sustain the positive effects of fasting, support muscle recovery, and regulate blood glucose levels ^[52][76].

Moreover, it should emphasize the significance of avoiding excessive consumption of refined sugars and extremely processed foods during post-fasting periods. These dietary choices may counteract the benefits of fasting by contributing to insulin resistance and metabolic dysregulation ^[53][77]. In light of these considerations, thwe researchers acacknowledge the significance of addressing post-fasting nutrition. While the existing literature provides insights into the positive effects of fasting, further research is needed to delineate specific dietary recommendations for optimal post-fasting nutrition. This area remains a dynamic and evolving field, and future studies exploring the interplay between fasting strategies and post-fasting dietary choices will contribute valuable information to refine dietary guidelines for individuals practicing of intermittent fasting or time-restricted eating ^{[46][54][55][56][57][58][59][60][61][62][63][64][65]}[70,78,79,80,81,82,83,84,85,86,87,88,89]