The present study demonstrated that dietary fiber intake was associated with better glycemic control and more favorable CVD risk factors including abdominal obesity, hypertension and metabolic syndrome, along with enhanced insulin sensitivity and reduced HS-CRP after adjusting for confounding factors. Furthermore, the proportion of participants with CKD negatively associated with dietary fiber intake, even after adjusting for obesity, hypertension or metabolic syndrome. To the best of our knowledge, there are few epidemiological studies showing associations of dietary fiber intake with glycemia and CVD risk factors in Asia, where the epidemic of type 2 diabetes is rapidly becoming a serious medical and socioeconomic issue.
A recent systematic review of the literature reported that adding fiber supplements in moderate amounts (4–19 g) to daily diet achieved little improvement in glycemic control or CVD risk factors . On the other hand, another meta-analysis  of intervention trials using high fiber diet (mean increase in fiber 18.3 g/d) in type 2 diabetic patients revealed that FPG and HbA1c were modestly lowered by 0.83 mmol/l and 0.26%, respectively, compared with a placebo. In the present study, both FPG and HbA1c negatively associated with dietary fiber intake (Table 2). In addition, the insulin sensitivity index HOMA2%-S and HS-CRP were associated with dietary fiber intake and the association remained statistically significant after the additional adjustment for BMI (regression coefficient 1.34 [0.71, 1.97], -0.048 [−0.070,-0.025], respectively). Although the effects of dietary fiber on insulin sensitivity have not been studied in type 2 diabetic patients, dietary fiber enhances insulin sensitivity in hepatic and peripheral tissues in insulin-resistant obese subjects [3–5].
It was recently reported that the consumption of high fiber diet for four weeks enhanced insulin secretion in nondiabetic overweight subjects . Dietary fiber may activate incretin secretion due to short-chain fatty acid production induced by the fermentation of dietary fiber , although, in one study, it took one year for high fiber diet to enhance glucagon-like peptide-1 secretion in healthy subjects . In the present study, the insulin secretion index HOMA2%-B was not associated with dietary fiber intake, suggesting that it is unlikely that insulin secretion induced by increased dietary fiber intake contributes to improving hyperglycemia.
In general, dietary fiber favorably affects CVD risk factors, including LDL cholesterol  and components of metabolic syndrome [34, 35]. In type 2 diabetic patients, a recent review reported that high fiber diet failed to affect the lipid levels in four out of eight randomized controlled studies . In the present study, total cholesterol and LDL cholesterol were not associated with dietary fiber intake. However, HDL cholesterol and triglyceride were significantly associated with dietary fiber intake. Dietary fiber exerts blood pressure-lowering effects [36, 37], and recently, Jenkins et al.  reported that high fiber and low glycemic index diet with legumes reduced blood pressure compared with wheat fiber diet in type 2 diabetic patients. In the present study, systolic blood pressure and hypertension were negatively associated with dietary fiber intake. Enhanced insulin sensitivity may contribute to the blood pressure-lowering effects of dietary fiber. As a result, the prevalence of metabolic syndrome was significantly associated with dietary fiber intake. Reduced fiber intake, particularly at breakfast, was found to be associated with metabolic syndrome in Brazilian type 2 diabetic patients [10, 39], although the authors did not report which component of metabolic syndrome was associated with low fiber intake. The present study demonstrated that dietary fiber intake was associated with reduced prevalence of abdominal obesity and hypertension of metabolic syndrome phenotypes independent of obesity. A reduction in abdominal obesity induced by increased dietary fiber intake has been reported in both intervention [40, 41] and epidemiological studies . However, the direct effects of dietary fiber on visceral adipose tissue remain to be elucidated.
CKD is an established CVD risk factor. The present study demonstrated the association between dietary fiber intake and lower prevalence of CKD (Table 4). Due to the cross-sectional nature of the study, preventing hyperkalemia in the advanced stage of CKD may limit the consumption of fresh fruits and green vegetables. Indeed, in this study, the proportion of participants with eGFR < 30 ml/min/1.73 m2 was negatively associated with dietary fiber intake (odds ratio 0.83 [0.76-0.91]). However, excluding participants with eGFR < 30 ml/min/1.73 m2 (n = 115) did not change the results (odds ratio 0.94 [0.91-0.97]). CVD risk factors, such as obesity, hypertension and metabolic syndrome, may contribute to the development and progression of CKD. However, adjusting for each CVD risk factor did not change the significant association between dietary fiber intake and CKD (Table 4). Although the mechanisms of action of dietary fiber in the kidneys are unknown, high dietary fiber intake is associated with a lower level of systemic micro-inflammation in both nondiabetic and diabetic patients [8, 12], as shown in the present study (Table 2). The anti-inflammatory actions of dietary fiber may be related to reduced prevalence of CKD. Recently, a large follow-up study showed that increased dietary fiber intake was associated with reduced mortality in CKD patients . In this context, dietary fiber appears to be promising non-pharmacological treatment for CKD.
The strength of the present study includes a relatively large sample size of type 2 diabetic patients consuming foods different from Western diet . A staple food in the Japanese diet is white rice, which has lower dietary fiber than whole grains. The amount of daily fiber intake in Japan declined from 20.5 g/d to 15 g/d after World War II  to a level that is lower than that observed in the US and UK . The main source of dietary fiber of Japanese people is vegetables including seaweed, a typical Japanese food, followed by cereals, legumes and fruits . The present study showed that the dietary fiber present in Japanese foods exerts beneficial effects on glycemia and CVD risk factors, thus suggesting that the usefulness of increased dietary fiber intake may extend beyond certain ethnic foods. Another strength of the study is that confounding factors included fat and saturated fatty acid intakes and physical activity, since high dietary fiber intake is often associated with healthy lifestyle, making it difficult to isolate fiber effects from general healthy lifestyle . However, some limitations should be discussed. First, the use of a self-administered food frequency dietary assessment questionnaire BDHQ is subject to measurement error in dietary intake, and actual dietary habits may not be obtained. However, the ability to rank dietary fiber using the BDHQ has been reasonably verified . Second, study participants who visit diabetologists regularly may be better educated about self-management of diabetes with respect to diet than the general population. However, the daily fiber intake of the study participants was similar to that of the general population in Japan (15 g/d). Third, since multiple outcomes were involved in the present study, multiple testing may induce false results. Finally, we cannot prove cause-and-effect relationships due to the cross-sectional design of our study, and there may be other confounding factors in addition to those evaluated in the present study.