LifeStyle management

First Let's Review: We use the HbgA1c as our 3 month guide to how our glucose control has generally been.

normal under 5.6% with fasting glucose under 100.

insulin resistance or prediabtes or glucose intolerance  5.6%-6.5% fasting glucose 100-128mg/dl.

Diabetes Mellitus over 6.5% or fasting glucose over 128mg/dl on 2 occasions.

Aggressive lifestyle changes is the bedrock upon which we add medication.As many of my patients know, these changes improve glucose metabolism allowing for lowering of medications, stopping medication as we drift down from diabetes to prediabetes, and finally normalization of insulin function.The purpose of treating prediabetes with aggressive lifestyle intervention is to prevent the development of Diabetes Mellitus and all of its cardiovascular neurological eye and renal complications.

As a foundation, your diet should start with whole grains, legumes (beans, lentils, peas), fruits, and vegetables. We want foods with a Low Glycemic Index: the glycemic index (GI) identifies foods that raise blood sugar rapidly; fortunately, beans, oats, sweet potatoes, and wheat pasta, are foods with lower glycemic indices; breads such as pumpernickel, rye, multigrain and sourdough, and tortillas and lower GI cereals are bran cereals, muesli, and rolled or steel-cut oats and grains such as barley, parboiled rice, couscous, corn, and quinoa. High GI foods are sugary products like cookies, white bread, corn flakes, and puffed rice cereals etc.

Gravitate away from animal products – that means less use of red meat, poultry, pork, fish, dairy products, and eggs. Animal products contain saturated fat, which is linked to heart disease, insulin resistance, and various cancers. The animal protein can also aggravate kidney disease and calcium loss.About 10% of our diets should be protein and plant sources found in whole grains, legumes, and vegetables appear to be of a better quality, nutritionally speaking, than animal sources of protein.

Although vegetable oils are healthier than animal fats, they are still high in calories; 1 gram of any fat or oil has nine calories, while 1 gram of carbohydrate has only four calories.Avoid oily sauces, salad dressings and fried foods. Limit olives, avocados, nuts, and peanut butter and seeds to modest amounts because the calories in “good” fats and “bad” fats is the same. Choose mostly foods with no more than 2–3 grams of fat per serving.We only need a small amount of fat daily.

Slowly increase dietary fiber consumption to 40gms daily. Beans, vegetables, fruits, and whole grains like whole-wheat pasta, barley, oats, quinoa are all good sources. The goal is at least 3gms of fiber/serving on labels and 10 to 15gms/meal.   Expect a change in bowel habits. Gassiness from beans is usually temporary and can be minimized with small servings and thorough cooking and if preparing them from dry uncooked form, presoaking them before cooking.

Modest but consistent physical activity such as a 30 minute walk at least 5 days a week raises good HDL cholesterol, lowers blood pressure, improves glucose metabolism, boosts the immune system and lowers overall mortality rates 30%.If we have discussed moderately vigorous physical activity in the office, such as bicycling, then 3 times weekly has been shown to achieve these benefits; again, consistency is the key.

SUPPLEMENTS For Diabetes Mellitus

  1. Bile Acid Sequestrants: This was the first class of cholesterol lowering medications when I started practicing medicine in the early 1990's ! They bind the "bad" LDL cholesterol causing  an average decrease of LDL cholesterol of between 10% and 25%; several even raise “good” HDL cholesterol around 5% . Because a portion of the bad cholesterol fat is bound in the intestine and removed in the stool, that portion of cholesterol fat is never absorbed into the bloodstream. Since limiting fat intake is a critical piece of treating diabetes, this cholesterol lowering medication lowers HbGA1C on average, an additional  0.5% . The most bothersome side effect is modest constipation which patients with the diarrhea form of IBS often find beneficial ; those on the other hand who are already dealing with troubling constipation are probably not going to tolerate this class. They can also raise Triglycerides modestly, around 10%. Bile Acid Sequestrants are prescription medications but if tolerated, lowers cholesterol AND  HbGA1C levels with a modest side effect profile; I have therefore included this class before discussing over the counter supplements.

2. Cinnamon: A 2012 (chochrane) review study looked at 577 patients given an average of 2000mg daily of cinnamomum cassia for between 4 to 16 weeks (modest length of time); no significant difference was found in HbGA1C, serum insulin nor post prandial glucose. However another 2016 metanalysis(large review study) by the Academy of Nutrition and Dietetics did  find a “modest effect on HbGA1C and fasting glucose.” It appears the discrepancy may be due to a toxic additive Coumarin found mostly in the Chinese cinnamon , which is correctly named Cassia cinnamon. True cinnamon is from Ceylon and does NOT have a glucose lowering effect (nor the toxic coumarin) , suggesting the anti diabetic effect may have been due to the hepatotoxic coumarin. Bottom line? True Ceylon cinnamon is nontoxic, and although has no glucose lowering effect , still has potent antioxidant benefits .

3. Chromium: There are mixed study results demonstrating improved glucose and lipid parameters (lowering of triglycerides and increased HDL “good” cholesterol). Its effect seems to be more pronounced in those individuals with actual chromium deficiency. Supplementation with 150-200ug daily appears adequate to resolve this; chromium picolinate appears to be the more effective form. 

4. GLA or gamma Linolenic (omega 6) fatty acid  is not always converted from the omega 3 fatty acid,  alpha linoleic acid, which is found in canola oil, flaxseed, chia seed, soybean and walnuts. GLA promotes anti inflammatory, vasodilation and platelet inhibitory (blood thinning) effects. This may explain its effect lessening peripheral neuropathy pain and improving neuronal function. 

5. Vanadium is an essential trace mineral that appears to have a role in carbohydrate metabolism, lowering glucose levels. The average diet should provide adequate needs, about 10-30 ug/day and is found in mushrooms, seafood, soybeans and some cereals. Supplements are in the vanadyl or vanadate forms and usually contain around 10mg; the upper dosage limit of the vanadium form has been established 1.8mg/day.  This is important as toxic effects on kidney, nervous system, and chromosomal damage (promoting carcinogenic cancer effects) have been described at high “mega” doses giving this supplement a “narrow therapeutic window” meaning the ratio of risk to benefit is not very large. Follow the directions; “more is not better”.

6. Fenugreek or Trigonella Foenumgraecumis rich in steroid saponins (compounds with cholesterol like structure ) and improves glycemic control and lipids, it is felt by limiting cholesterol and glucose intestinal absorption. Additionally it potentiates (increases) insulin secretion. Fenugreek acts as an estrogen receptor modulator which raises a caution flag with estrogen mediated cancers. However , studies have actually shown anti-cancer potential against breast and ovarian cancer.

7. Alpha Lipoic acid is an antioxidant that appears to increase insulin activity and lessen symptoms of peripheral neuropathy. The average dosage is 600 to 800 mg daily.

8. Mamordica Charantia also known as “Bitter Melon” exhibits anti-lipemic (lipid lowering) and anti-diabetic effects by increasing insulin sensitivity in Type II diabetics and limiting lipogenesis in fatty tissue, and limiting lipid accumulation in fatty liver, and appears safe.