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Diabetes: Integrative Management of Type 2 Diabetes

Characterized by insulin-resistance and loss of glycemic control, type 2 diabetes accounts for more than 90% of all adult diabetes cases. In the United States, more than 1 in every 10 adults is affected by diabetes, and for older adults (aged 65 and older), that figure rises to 1 in every 4. Obesity, sedentary lifestyle, and poor diet are strong predictors of type 2 diabetes, making lifestyle interventions critical tools for the management and reversal of this disease. In the following discussion, Dr. Mona Morstein, ND, DHANP, emphasizes the need for strict glycemic control achieved through structured and monitored diet, lifestyle interventions, supplements and medications, in order to attain excellent glucose control, establish weight loss, and prevent complications of type 2 diabetes.

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Q & A

Dr. Mona Morstein clarifies some key issues regarding integrative strategies to type 2 diabetes.

 

A: The American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) publish practice guidelines for diabetes. The ADA guidelines recommend that physicians choose a diet that is best for their patients, but on their website, the ADA recommends a carbohydrate intake as high as 180 grams per day. You will see in my dietary recommendations that I limit patients to no more than 30-45 grams of carbohydrate per day. Finally, neither the ADA nor the AACE recommend vitamin, mineral, or botanical supplementation. There is growing research to support the use of dietary supplements to improve insulin resistance and prevent diabetic complications, so I do recommend supplementation to complement dietary and lifestyle changes.  

Related Published Research:
American Diabetes Association. Standards of medical care in diabetes-2015. Diabetes Care. 2015;38(Supp1): S1-S99. [abstract]
Pereira CS, Molz P, Palazzo RP, et al. DNA damage and cytotoxicity in adult subjects with prediabetes.
Mutat Res. 2013 May 15;753(2):76-81. [abstract]
Handelsman Y, Bloomgarden ZT, Grunberger G, et al. American association of clinical endocrinologists and american college of endocrinology - clinical practice guidelines for developing a diabetes mellitus comprehensive care plan - 2015. Endocr Pract. 2015;21 Suppl 11-87. [abstract]
 
A: The ADA guidelines recommend testing HbA1c twice a year in patients who are meeting treatment goals and every 3 months for patients whose treatment has changed or who are not meeting treatment goals. I monitor my diabetic patients every 3-6 months with the following labs: HbA1c, fasting glucose, lipid profile, and the GlycoMark test (1,5 Anhydroglucitol [1,5 AG]). The GlycoMark test assesses glycemic control associated with average daily peak glucose levels in the last 2-3 weeks, while an A1C shows control using the prior three-month average levels.
 
The ADA guidelines set a target HbA1c of 7% or lower if it can be achieved without problematic hypoglycemia, and the AACE guidelines set a target HbA1c (AIC) of 6.5% or lower, again, if achieved without recurrent hypoglycemia. I set a target of less than 6% because cellular oxidation—and thus the development of diabetic complications--increase after an A1C of 5.5%. Both the ADA and AACE worry that by using medications to lower the A1C, which is essentially their treatment focus, an A1C might artificially be lowered through persistent and possibly serious hypoglycemic events.
 
Another problem with deciding A1C goals is that some physicians have misinterpreted results of the ACCORD study [Action to Control Cardiovascular Risk in Diabetes trial – see first abstract below] and mistakenly believe that maintaining an HbA1c less than 6.5% will increase the risk of cardiovascular disease. Instead, what we really learned from the unfortunate cardiovascular deaths in the ACCORD trial is that when patients with diabetes eat whatever they wish and are prescribed multiple medications to control their blood sugar, including thiazolidinediones, sulfonylureas, and insulin, it’s simply dangerous.  This will result in weight gain, water retention and can weaken hearts.

So, using an alternative approach to treating diabetes safely allows me to generally recommend an A1C goal of <6.0%, achieved without any hypoglycemic events. Even further, an A1C <5.5% would be ideal.
 
I also have more strict criteria for fasting glucose: the ADA recommends a fasting glucose of 80-130 mg/dL, whereas I consider less than 105 mg/dL to be acceptable and less than 90 mg/dL to be ideal.
 
In addition to these quarterly labs, I have patients keep daily glucose graphs. Fasting glucose should be less than 105 mg/dL (less than 90 mg/dL is ideal), and 1.5-hr postprandial glucose should be less than 130 mg/dL (less than 120 mg/dL is ideal). Again, these targets are much tighter than those of the ADA, which aim, for example, for a peak postprandial glucose less than 180 mg/dL.
 
Tests that should be run yearly to monitor patients with diabetes include hsCRP (recommended range < 1.0 mg/L) and fibrinogen (follow standard reference ranges) as markers of inflammation and cardiac risk. Also, a random urine microalbuminemia (follow standard reference ranges) is useful to monitor kidney function. Other tests to consider include total and free testosterone for men (total testosterone > 500 ng/dL is acceptable and > 700 ng/dL is ideal) or salivary cortisol and DHEA to evaluate adrenal function. Checking for serum ferritin helps us uncover the presence of fatty liver, common in diabetics. I also check for Vitamin D3, thyroid panels, and other labs.
 
In a discussion about laboratory testing and target values, it is important to emphasize that these are ideal goals. It can take months of commitment to lifestyle changes for patients to achieve these goals. The point is this: damage occurs in diabetes because of high blood sugar, so the focus of treatment is to work in a positive direction with the patient to achieve near normal glycemic control.
 
Test ADA Target Acceptable Value Optimal Value
HbA1c <  7% < 6% < 5%
Fasting glucose 80-130 mg/dL <105 mg/dL < 90 mg/dL
Postprandial glucose < 180 mg/dL < 130 mg/dL < 120 mg/dL
1,5 AG n/a > 10 μg/mL Higher is better

Related Published Research:
Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545-2559. [abstract]
Lee JE. Alternative biomarkers for assessing glycemic control in diabetes: fructosamine, glycated albumin, and 1,5-anhydroglucitol. Ann Pediatr Endocrinol Metab. 2015;20(2):74-78. [abstract]
Wang Y, Zhang YL, Wang YP, Lei CH, Sun ZL. A study on the association of serum 1,5-anhydroglucitol levels and the hyperglycaemic excursions as measured by continuous glucose monitoring system among people with type 2 diabetes in China. Diabetes Metab Res Rev. 2012;28(4):357-362. [abstract]
 
A: I compare diabetes to celiac disease: as a patient with celiac disease has lost the ability to consume gluten at the risk of causing terrible damage, a patient with diabetes has lost the metabolic capacity to handle carbohydrates. Carbohydrate consumption thus needs to be reduced. There are several variations of a low-carbohydrate diet, but I recommend a maximum intake of 30-45 grams of carbohydrate per day. One aspect of achieving this goal is teaching portion control.
 
Insulin resistance disrupts appetite control. Insulin resistance in the body means cells have an impaired response to insulin. In the brain, one consequence of this is a decreased ability to recognize normal satiety, so its easy to have cravings and over-eat. Insulin resistance is selectively impaired in the prefrontal cortex in overweight and obese adults, and in the hypothalamus in people with insulin resistance systemically. These brain impairments alter the homeostatic set point, reduce inhibitory control and cause to cravings and overeating.When a patient begins eating a low-carbohydrate diet, these mechanism reset, brain chemistry works better, and it becomes natural to eat normal portions of food.   
 
There are 4 variations of the low-carbohydrate diet that I recommend: the low-carb omnivore diet, the low-carb ovo-lacto vegetarian diet, the low-carb vegan diet, or the low-carb/high-fat ketogenic diet. All of these diets must be nutritionally dense and remove junk foods, refined sweets, grains, and high-carbohydrate vegetables. Fruits are usually removed, but some patients can handle some berries. The diets include 3-9 cups of vegetables per day, animal proteins (for some), healthy oils, seeds, and nuts. Coconut flour and nut flours can be used to make really innovative and tasty foods that people typically eat from grains: breads, pancakes, muffins, and even granola. Cauliflower is another excellent ingredient to substitute in recipes that would otherwise be too starchy. Stevia, erythritol, zylitol, and monk fruit are options for non-artificial sweeteners.  
 
All patients need to count carbohydrates to keep them below 30-45 grams per day, and those following a ketogenic diet keep them below 20-30 grams per day. Allowable protein intake can be calculated by the weight of the patient (weight (lbs) ÷ 2.2 = weight (kg) ÷ 6 = ounces per day; 1 ounce of protein = 6 grams of protein. Measuring carbohydrate and protein intake is especially important for patients taking insulin. I never have patients count or limit fat grams because fats do not metabolize to glucose.
 
There are a huge number of resources and recipes available to support patients following a low-carbohydrate diet. One of the cookbooks I recommend is called Saving Dinner the Low-Carb Way, but patients should be warned not to add the carbohydrates at the end of the recipes. There are endless web sites to access low-carb recipes. This is not about deprivation; there are innumerable ways to make this diet very delicious and very enjoyable.
 
I do not believe people should snack, but instead eat three meals a day and then fast for 12 hours from supper to breakfast.  Most people are middle-aged, have desk jobs and do not need extra snacking calories. If their meals are put together well, they can easily go from breakfast to lunch and from lunch to supper with no in-between eating. 
 
Example Menu Plan: Low-Carbohydrate Omnivore Diet
Meals Carbohydrate Allowance Protein
Allowance*
Breakfast Eggs with vegetables
 
 ≤ 6-10 grams 3 ounces (18 grams)
Lunch Green salad topped with a variety of vegetables, walnuts, berries, and feta cheese. Almond muffin.
 
≤ 12-15 grams 4 ounces (24 grams)
Dinner Broiled fish with stir-fried vegetables and cauliflower “rice.”
 
≤ 12-15 grams 5 ounces (30 grams)
Snacks: NOT RECOMMENDED Nuts and raw vegetables
 
≤ 0-5 grams 2 ounces (12 grams)
Daily carbohydrate and protein allowance ≤ 30-45 grams ≤ 12 ounces (72 grams)
*Protein allowance is based on 160-lb patient

Related Published Research:
Arora SK, McFarlane SI. The case for low carbohydrate diets in diabetes management. Nutr Metab (Lond). 2005;216. [abstract]
Bazzano LA, Hu T, Reynolds K, et al. Effects of low-carbohydrate and low-fat diets: a randomized trial. Ann Intern Med. 2014;161(5):309-318. [abstract]
Dashti HM, Mathew TC, Hussein T, et al. Long-term effects of a ketogenic diet in obese patients. Exp Clin Cardiol. 2004;9(3):200-205. [abstract]
Gannon MC, Nuttall FQ. Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes. 2004;53(9):2375-2382. [abstract]
Tay J, Luscombe-Marsh ND, Thompson CH, et al. A very low-carbohydrate, low-saturated fat diet for type 2 diabetes management: a randomized trial. Diabetes Care. 2014;37(11):2909-2918. [abstract]
Yancy WS, Foy M, Chalecki AM, Vernon MC, Westman EC. A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab (Lond). 2005;234. [abstract]

 
A: Exercise is a top priority for patients with diabetes. Exercise decreases insulin resistance, decreases lipids, lowers blood pressure, promotes weight loss, increases lean muscle, controls appetite, and improves sleep and mood. The ADA recommends 45 minutes of exercise 3-4 times per week with resistance training twice a week. I like to see patients exercise for 1 hour 5 days a week, including 20-30 minutes of resistance training per day. The resistance training is vital because it burns glucose 19 times more effectively than aerobic exercise. Furthermore, building lean muscle increases the ability to metabolize glucose even at rest. Steady-state aerobic exercise is a good place to start for patients who are not in the habit of exercising, but high-intensity interval training is more time-efficient, burns fat more effectively, and increases mitochondrial density. I recommend interval training workouts by Fitness Blender (or other similar exercise program) that is available on YouTube for patients who need free workouts they can do at home or traveling. Morning exercise before breakfast burns more fat, and walking after meals for 15 minutes helps manage postprandial glucose.
 
There are a few safety considerations when it comes to exercise. If a person has never exercised before, and particularly if they have hypertension, it is a good idea to send them for a cardiac workup. Another safety precaution is to have patients work with a personal trainer for 1-2 sessions to learn proper form and avoid injuries, especially when starting to use free weights or weight machines. Patients should also get new sneakers every year and consider orthotics to support proper alignment. If a patient is taking insulin, and the diabetic patient is starting to do long, strenuous exercising, like running marathons, or hiking with elevation, their physician will likely need to decrease the basal and bolus before, during, and/or after exercise. Other medications that may need to be adjusted include sulphonylureas, GLP-1 injections, SGLT2-inhibitors, and metiglinides.
 
Sleep is another critical piece. People who get 7-9 hours of sleep per night are most likely to have a normal body mass index (BMI). Those who get only 2-4 hours per night are 235% more likely to be obese than those who sleep 7 or more. Lack of sleep causes a decrease in leptin, increase in ghrelin, and increase in cortisol—hormonal changes that will disrupt appetite control, cause carbohydrate cravings, and increase blood glucose. In addition, 40% of patients with obstructive sleep apnea have diabetes, so a sleep study is indicated for diabetic patients who are tired during the day. We need to encourage good sleep hygiene and offer interventions to aid sleep. I like to start with regular exercise, Epsom salt baths, and good sleep hygiene, such as turning off lights in the house after 8 pm and turning off the computer, tablets, and cell phones (their blue light eminations interfere with sleep onset).  People should not watch violent TV and news and then go to bed, but instead should read, relax, do puzzles, and things which help initiate sleep and soothe the mind.  If supplements are needed, I will first chose from one of these:  Passiflora incarnata (passionflower), Valeriana officinalis (valerian), Scutellaria officinalis (skullcap), Humulus lupulus (hops), Withania somnifera (ashwaganda), Magnolia spp. (magnolia), tryptophan, GABA, or magnesium.
 
Finally, consider that “stress” increases the secretion of the adrenal hormones cortisol and epinephrine. Those hormones drive hepatic gluconeogenesis (turning protein into sugar) and increase blood glucose. I do not want my patients to use the word “stress” in our office visits, because this word allows people to avoid facing the actual emotion they are experiencing. I need to know if they are feeling anxiety, depression, worry, or anger, etc, and I need to know how that is impacting their life and if it is affecting their ability to pay attention to their diabetes. I recommend counseling, support groups, massage, yoga, meditation, creative hobbies, gratitude journals, spiritual connections, and/or other relaxing and enjoyable activities to help patients feel at peace and in control of their disease and their life. 

Related Published Research:
Castaneda C, Layne JE, Munoz-Orians L, et al. A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 diabetes. Diabetes Care. 2002;25(12):2335-2341. [abstract]
Gangwisch JE, Malaspina D, Boden-Albala B, Heymsfield SB. Inadequate sleep as a risk factor for obesity: analyses of the NHANES I. Sleep. 2005;28(10):1289-1296. [abstract]
Meslier N, Gagnadoux F, Giraud P, et al. Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome. Eur Respir J. 2003;22(1):156-160. [abstract]
Surwit RS, van Tilburg MA, Zucker N, et al. Stress management improves long-term glycemic control in type 2 diabetes. Diabetes Care. 2002;25(1):30-34. [abstract]
Talbott SM, Talbott JA, Pugh M. Effect of Magnolia officinalis and Phellodendron amurense (Relora®) on cortisol and psychological mood state in moderately stressed subjects. J Int Soc Sports Nutr. 2013;10(1):37. [abstract]

 
A: Dietary supplements are just that—things to supplement a comprehensive protocol. Supplementation can help lower glucose levels or insulin needs, but it will be a much more subtle effect than dietary changes.
 
The first 2 supplements I typically recommend are a high quality multi-vitamin/mineral formula (3-6 capsules/day) and fish oil (at least 1000 mg EPA + 750 mg DHA/day). The multi-vitamin/mineral is needed to replenish nutrient status, optimize antioxidant status, and support all enzyme systems. Studies show that HbA1c levels rise as magnesium levels decline. Zinc is involved in insulin production, secretion, and utilization, and chromium is part of the glucose tolerance factor at the insulin receptor, making the cell more sensitive to insulin Vitamin C decreases sorbitol and fructose production in cells, reducing oxidative damage, and vitamin E prevents formation of advanced glycation end products (AGEs). A good multi-vitamin/mineral can ensure that all of these nutrients are replete. Fish oil can lower lipids, improve insulin sensitivity, protect against neuropathy, and support the mood and brain health, by enhancing positive neurotransmitter production. I find omega-3 fatty acid deficiency in the diet is very common.
 
More specific supplementation for diabetes can be added individually or in combination, but some of the most important to consider are the following: R-alpha lipoic acid (R-ALA), Gymnema sylvestre (gymnema), berberine, taurine, and herbal antioxidants. R-ALA is a well researched antioxidant that can help prevent and heal diabetic complications. R-ALA improves insulin sensitivity, prevents glycosylation of proteins, protects the nerves and the kidneys from oxidative damage, and reduces the risk of nonalcoholic fatty liver disease. The R isomer is twice as potent as the S isomer; when the product is simply called Alpha Lipoic Acid, it contains 50% R and 50% S, so I specifically recommend R-ALA (600-900 mg/day), which is 100% the R isomer.
 
Gymnema sylvestre regenerates beta cell function in the pancreas, enhances insulin sensitivity, reduces blood sugar levels, impairs a person’s ability to taste sweets, and decreases carbohydrate cravings. Studies have been conducted at doses of 400 mg/day, but I have safely used up to 2400 mg/day. Berberine (500 mg 3x/day) can be equally as effective as metformin at lowering fasting blood glucose and HbA1c, and also protects the liver and regenerates healthy bacteria in the intestine, called the microbiome. Interestingly, a disrupted microbiome can make a person more systemically insulin resistant. Taurine (1000-1500 mg/day) has been shown to prevent oxidative damage in red blood cells caused by elevated glucose levels. Taurine prevents lipid peroxidation, prevents glycosylation of proteins, and protects kidney cells from apoptosis due to hyperglycemia.
 
Herbal antioxidants are key to preventing complications of diabetes. Curcumin from Curcuma longa inhibits TNF-α, which can create insulin resistance at the cellular level. Curcumin has also been shown to reduce the risk of developing Alzheimer’s disease in patients with diabetes. Cinnamomum spp. (Cinnamon), Vaccinium myrtillus (bilberry) extract, Camellia sinensis (green tea) extract, Gingko biloba, and resveratrol are other important antioxidants that offer multiple benefits for patients with diabetes.
 
Nutrients for Type 2 Diabetes*
Nutrient Dose range
R-alpha lipoic acid (R-ALA) 600 - 900 mg/day
Gymnema sylvestre 400 – 2400 mg/day
Berberine 500 mg 3x/day
Taurine 1000 – 1500 mg/day
Curcumin 250 mg/day or more
Cinnamon 1000 – 2000 mg/day
Bilberry extract 160 mg/day or more
Green tea extract 200 mg/day
Gingko biloba 200 mg/day
Resveratrol 100 mg/day
*These are to be added to a quality multivitamin/mineral formula and fish oils. Many can be combined in a single product.

Related Published Research:
H P, O C, DA U, O G, Ng D. The impact of Vitamin D Replacement on Glucose Metabolism. Pak J Med Sci. 2013;29(6):1311-1314. [abstract]
Geohas J, Daly A, Juturu V, Finch M, Komorowski JR. Chromium picolinate and biotin combination reduces atherogenic index of plasma in patients with type 2 diabetes mellitus: a placebo-controlled, double-blinded, randomized clinical trial. Am J Med Sci. 2007;333(3):145-153. [abstract]
Jeenger MK, Shrivastava S, Yerra VG, Naidu VG, Ramakrishna S, Kumar A. Curcumin: a pleiotropic phytonutrient in diabetic complications. Nutrition. 2015;31(2):276-282. [abstract]
Kamenova P. Improvement of insulin sensitivity in patients with type 2 diabetes mellitus after oral administration of alpha-lipoic acid. Hormones (Athens). 2006;5(4):251-258. [abstract]
Li D, Zhang Y, Liu Y, Sun R, Xia M. Purified anthocyanin supplementation reduces dyslipidemia, enhances antioxidant capacity, and prevents insulin resistance in diabetic patients. J Nutr. 2015;145(4):742-748. [abstract]
Ramadass S, Basu S, Srinivasan AR. SERUM magnesium levels as an indicator of status of Diabetes Mellitus type 2. Diabetes Metab Syndr. 2015;9(1):42-45. [abstract]
Shanmugasundaram ER, Rajeswari G, Baskaran K, Rajesh Kumar BR, Radha Shanmugasundaram K, Kizar Ahmath B. Use of Gymnema sylvestre leaf extract in the control of blood glucose in insulin-dependent diabetes mellitus. J Ethnopharmacol. 1990;30(3):281-294. [abstract]
Egshatyan LV, Kashtanova DA, Popenko AS, et al. Gut microbiota and diet in patients with different glucose tolerance. Endocr Connect. 2015 Nov 10. [abstract]
Siddiqui K, Bawazeer N, Joy SS. Variation in macro and trace elements in progression of type 2 diabetes. ScientificWorldJournal. 2014;2014461591. [abstract]
Sirdah MM. Protective and therapeutic effectiveness of taurine in diabetes mellitus: a rationale for antioxidant supplementation. Diabetes Metab Syndr. 2015;9(1):55-64. [abstract]
Wu JH, Cahill LE, Mozaffarian D. Effect of fish oil on circulating adiponectin: a systematic review and meta-analysis of randomized controlled trials. J Clin Endocrinol Metab. 2013;98(6):2451-2459. [abstract]
Yin J, Xing H, Ye J. Efficacy of berberine in patients with type 2 diabetes mellitus. Metabolism. 2008;57(5):712-717. [abstract]
 
A: Medications are needed when a patient cannot maintain a fasting glucose less than 110 mg/dL or an HbA1C less than 6%, while they are following the alternative diabetic protocol. Medications are also indicated for patients who refuse to follow the diet, will not exercise, or are not engaged in the protocol. The first medicine to add is metformin. If the patient does not have moderate or advanced kidney failure, metformin is safe and effective. About 33% of patients, however, can have some gastrointestinal side-effects from metformin. To minimize that side effect, start low (500 mg twice daily) and titrate up (to 1000 mg twice daily if needed), and have patients take it directly after meals with a full stomach. If the patient still gets an upset stomach, try the extended release form. Almost all patients can handle the extended release form of metformin, but insurance coverage for this form can be problematic. If additional medications are needed, the ADA and AACE guidelines leave it to the physician’s discretion to choose which drug to add.  

Related Published Research:
American Diabetes Association. Standards of medical care in diabetes-2015. Diabetes Care. 2015;38(Supp1): S1-S99. [abstract]
Handelsman Y, Bloomgarden ZT, Grunberger G, et al. American association of clinical endocrinologists and american college of endocrinology - clinical practice guidelines for developing a diabetes mellitus comprehensive care plan - 2015. Endocr Pract. 2015;21 Suppl 11-87. [abstract]

 

 

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Expert Bio

Mona Morstein
ND

Dr. Mona Morstein has a B.S. in Foods and Nutrition and earned her naturopathic degree and did her residency at National College of Naturopathic Medicine in Portland, OR. Following graduation Dr. Morstein established a successful private practice in Great Falls, MT that she ran for 13 years.
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