Diabetes (both type I and II) are on the rise in United States and represent a large problem due to the series of health complications associated with the disease. Nutritional intervention signifies one successful alternative form of treatment for preventing, managing, and slowing down the progression of diabetes. Unfortunately there is not a “cookie cutter” diet for patients with diabetes; each diet must be specifically tailored for each patient’s individual needs. The American Diabetes Association (ADA) developed their own series of goals and recommendations for medical nutrition therapy (MNT) in pre-diabetic patients, individuals at risk for diabetes, and actual diabetic patients. According to the ADA, 22% of people with diabetes use some type of herbal therapy and 31% used some type of dietary supplements. With so many people trying alternative methods of treatments for their metabolic disorder, it would be practical for primary care practitioners to be well versed on the research behind effectiveness of the most common treatments and with their interactions with every day drugs.
The ADA’s goal of MNT for individuals at risk for diabetes or who are pre-diabetic is “to decrease the risk of diabetes and cardiovascular disease by promoting healthy food choices and physical activity leading to moderate weight loss that is maintained” (Albright, S61). The ADA has four main goals for individuals with diabetes. The first focuses on maintaining blood glucose, lipid/lipoprotein profiles, and blood pressure to as close to normal ranges and as safely as possible. The second emphasizes slowing or averting the chronic complications that arise from diabetes. The third addresses individual nutritional needs of the patient by accepting cultural and personal preferences for diet. The fourth goal attempts to maintain the pleasure of eating by limiting food choices based on scientific evidence (Albright, S61).
The ADA recommends diabetic and pre-diabetics obtain MNT from a registered dietician who specializes or has experience working with diabetic patients. The nutritionist will be able to customize the individual’s diet to their daily nutritional needs based on their level of exercise, activities of daily living, complicating health factors, and personal preference for foods. Controlling body weight and reducing excessive adipose tissue is vital for pre-diabetic or diabetic patients due to the risk of comorbidities associated with individuals possessing BMI’s greater than 25. Excessive obesity increases resistance to insulin, which is why weight loss is important in treatment of diabetics and pre-diabetics; Studies demonstrate decreased insulin resistance, increased glycemia, and decreased blood pressure in diabetics (type II) who lost moderate weight (5% of body weight) (Bantle, 152). Scientifically a macronutrient composition has not been established which is ideal for weight loss diets. Short term, 6 months duration, individuals on low carbohydrate diets have experienced more weight loss than those on low fat diets; however, long term, one year or longer, there is no significant difference between weight loss with either diet (Igbal, 779). The ADA explains through its research that “subjects with type 2 diabetes demonstrated a greater decrease in A1C with low carbohydrate diets compared to low fat diets” (Albright, S63). Carbohydrates are important sources of energy, fiber, vitamins, and minerals. The ADA warns that there are no studies regarding the long term metabolic effects of low-carbohydrate diets and advises participants to use these types of diets with caution. Very low calorie diets consist of less than 800 calories a day are known for generating rapid weight loss; however, this weight is quickly gained back after individuals return to a normal diet (Albright, S63).
Although genetics play an important role in the occurrence of type II diabetes, lifestyle factors of increased energy intake and decreased physical activity greatly increase the risk for diabetes. Clinical studies with the Diabetes Prevention Program (DPP) demonstrated promising results of lowering several risk factors of diabetes by increasing physical activity in patients, promoting moderate weight loss of at least 7% body fat, reducing fat and caloric intake in patients, and alter patients’ diet to foods that decrease the risks of diabetes. Patients were encouraged to perform at least 150 minutes of physical activity per week. Vigorous exercise has been shown to “improve insulin sensitivity, independent of weight loss, and reduce risk for type 2 diabetes” (Hirst, 763). Patients in this trial achieved their goal of moderate weight loss (7% body fat) through weekly exercise and following the recommendations and alterations to their diet.
Patients in this study were encouraged to make several alterations to their diets. Monitoring carbohydrate consumption and altering which types of carbohydrates are consumed represents a powerful method for controlling blood glucose to as near normal levels as possible as well as maintaining proper glycemic control. Patients were encouraged to consume most carbohydrates in the form of fruits, vegetables, whole grains, legumes, and low fat milk. Sucrose containing foods were substituted for other carbohydrates in order to lower blood glucose levels. Patients were encouraged to use low glycemic foods instead such as oats, blueberries, beans, lentils, apples, pasta, and barley (Hirst, 766). The ADA recommends diabetic patients follow the minimal RDA of 130g/day for carbohydrates and 14g of fiber/1,000 kcal (Albright, S65). Fiber rich foods, such as legumes, fruits, vegetables, and whole grain products, provide vital nutrients for good health as well improve insulin sensitivity in diabetic patients. The ADA has several studies that demonstrate increased dietary fiber intake increases insulin sensitivity “as well as improved ability to secrete insulin adequately to overcome insulin resistance” (Liese, 970). It has been speculated that diets containing resistant starches (potatoes, legumes) and high amylose prevent hypoglycemia and reduce hyperglycemia; however, the ADA acknowledges there are no long term studies proving this theory (Albright, S64).
Patients in the DPP program were encouraged to minimize intake of trans fats, limit saturated fat to <7% of total calories, diabetics were encouraged to consume <200mg/day of cholesterol, and were encouraged to consume two or more servings of fish per week (Hirst, 767). The ADA recommends the dietary goals for diabetics be the same as individuals with preexisting cardiovascular disease (CVD). Metabolic studies have shown following this recommended dietary fat regiment has lowered LDL cholesterol without negatively affecting HDL cholesterol levels, improved fasting plasma glucose levels (A1C), and reduce adverse CVD outcomes (Albright, S66).
DPP patients were encouraged to consume the RDA recommended protein amount of 10-35% of energy intake (0.8g of protein/kg of body weight) and not recommended high protein diets of > 20% of calories. ADA studies have shown that protein consumption will raise insulin response while not affecting glucose plasma concentrations (Albright, S66). ADA short term studies high protein diets (>20%) “reduce glucose and insulin concentrations, reduce appetite, and increase satiety” (Gannon, 2376). The ADA claims micronutrient management of diabetes to be ineffective. The ADA believes “there is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies” (Albright, S67). The ADA also advised against antioxidant supplementation (vitamin C and E) and chromium supplementation since there is a lack of their efficacy (Albright, S67).
Overall the ADA found positive results for their MNT recommendations with pre-diabetic and diabetic patients. Studies of the MNT trails found a 1% decrease in HbA1C (A1C) for type I diabetes and a 1-2% decrease in type II diabetes patients. Pre-diabetic patients in the MNT trials had LDL cholesterol lowered by 15-25 mg/dl. These improvements were noted after 3-6 months of the MNT trial commencement (Albright, S61). The ADA’s DPP program successfully lowered the following CVD risk factors: dyslipidemia, hypertension, and inflammatory markers (Albright, S64).
The MNT recommendations from the ADA for treatment of diabetic and pre-diabetic patients represent a viable, affordable option for patients. Although there are several good recommendations for dietary changes with the ADA’s MNT therapy we are wary of some the ADA’s recommendations against supplementation with anti-oxidants, vitamins, and other minerals. The ADA receives research money from several private donors including several MD’s, endocrinologists, Hopkins Family Foundation, as well from Takeda Pharmaceuticals (Our Research Resources, American Diabetes Association). Alternative medicine with supplementation through various vitamins and minerals is often labeled as ineffective due to lack of research through the conventional medical community; however, one cannot help but question the validity of this research since research funding comes from companies that have a major financial incentive for these outcomes. Naturally occurring vitamins and minerals are not allowed to be patented for private or public profit. Several naturally occurring herbs, vitamins, and minerals were cited earlier in this paper from countries other than the US in which research supported the use of these naturally occurring substances.
The typical cost of nutrition consultation is $50-100, depending upon the level of nutrition degree and experience of the practitioner, as well as the cost of food (Council Cost Estimates, Pennsylvania Health Care Cost Containment Council). There are several degrees with varying credentials for nutritionists. Certified Nutritional Specialists (CNS) are the highest qualified nutritional professional; these specialists have obtained either a masters or doctorate nutritional degree from a university, performed 1000 hours of supervised internship, and passed a national exam from the Certification Board of Nutrition Specialists (CBNS). Certified Clinical Nutritionists (CCN) represents the next tier of nutrition specialists; these individuals have obtained a bachelor’s degree in nutrition from a university, performed a 900 hour internship, obtained either a 56 hour minimum post-graduate study or master’s degree in human nutrition, and passed a national exam issued by the CBNS. A Registered Dietitian (RD) denotes a nutrition expert with a four year bachelor’s degree, 900-1200 hours in a dietetic internship through an accredited program, and passed a national dietetics registration exam. There are also Certified Nutritionists that must have obtained a two year college degree and passed a proctored exam (Description of Degrees/Credentials, American Nutrition Association). We would personally advise patients to seek the nutritional advice from a CNS, CCN, or RD since they are required to have more extensive training and clinician experience than just certified nutritionists.
Finding an expert in nutrition is fairly easy with the assistance of the internet. CNS, CCN, and RDs are numerous across the country. Appointments can be made to meet with these nutrition experts either through the telephone or e-mail. Patients will then meet with these professionals in person to discuss their medical history, activities of daily living, goals for their dietary changes, as well as answer any questions and concerns patients may possess. These nutrition consultants customize diets to each patient’s unique circumstances and needs. Simple blood tests performed by the patient’s primary care physician can monitor the patient’s progress with these dietary changes to ensure patient safety and general progress.
As an alternative care specialists, it will not be uncommon to be addressing a population of diabetics who try their own herbal remedies which they either read about in magazines or have been present to them culturally. One such example is the Eastern European remedy of dandelion root for stabilizing blood sugar. Typically, the roots and leaves are picked and dried and then made into hot tea by being steeped in hot water. The roots can also be eaten as salads. It is effective because it has an effect that is much like a diuretic. There have been a few empirical studies that help support that claim. In a 2001 study at the University of Zagreb, the scientists were able to lower the blood sugar in diabetic mice using an extract containing dandelion. This has been a traditional Eastern European remedy and the scientists were trying to help verify whether it was an old wives tale or whether there was some credibility to this treatment that was widespread within the diabetic community in their country. Something to be aware of, before advising your patients to take dandelion root, is that it has many possible interactions with other medications. Dandelion root can decrease the effectiveness of several antibiotics by decreasing their absorption, it interacts with lithium, changes the way the liver processes certain medications such as glucuronidated drugs, and there is a chance that it increases your potassium significantly.
Another natural remedy that is expected to help lower blood sugar is called beanpod tea. There is little research done on this remedy, but it is strongly present in the diabetes community across personal blogs and message boards. There are a few brands of tea out there, but they are mostly marketed as weightloss/de-tox teas. Beanpod tea is made of the pods of kidney, white, baby and lima beans. What research is available shows that it is fairly ineffective unless taken in large doses and that it might be more effective to just eat the beans as a food. Bean pod tea is said to directly stimulate the pancreas into producing its own insulin, but this claim seems to be unsubstantiated when looking at scientific research. One thing that is rather striking though is that when looking into the medical interactions for bean pod tea, WebMD says that there is a moderate interaction present with all diabetes medication. It goes on to say that the beanpod tea may lower your blood sugar and that you need to monitor yourself closely while taking it because it puts you at risk of a lower dosage of your medication. There is no one opinion on beanpod tea, so the patients should see what works for them and alter their medications appropriately.
One more herbal remedy is called corn silk. Corn silk is made of the long shiny fibers that are at the top of a cob of corn. Typically it is boiled and ingested as tea, but it can also be chopped up and added to a salad. There is some really interesting research supporting its effectiveness. According to a study performed in 2009 by the China Academy of Chinese Medical Sciences, corn silk extract considerably reduced hyperglycemia in diabetic mice. The corn silk did not reduce hyperglycemia by increasing glycogen and inhibiting gluconeogenesis. It actually stimulated the pancreas to increase insulin levels and it helped recover injured B-cells. If you’re using corn silk, you have to be careful if you’re on diabetes or hypertension medication, as it is known to lower blood pressure and blood sugar. There have also been interactions noted with Coumadin, corticosterioids and diuretic drugs.
Chromium supplementation is recommended for diabetics because of its role in making glucose tolerance factor, which, in turn, improves insulin in action. In a double-blind, placebo-controlled study, patients who supplemented chromium had better long term and short term control of their blood sugar levels than patients who were taking the placebo. Another study by the University of Maryland found a correlation between chromium supplements and better sugar control in gestational diabetes. When taking NSAIDS regularly, patients should avoid taking chromium, because the NSAIDS are known to increase chromium levels in their body on their own.
The ginseng plant has also been known to lower the blood sugar level. It has not only shown that fasting glucose and after-meal glucose levels were lowered with ginseng intake, but A1c levels were also lowered. A study on mice performed by the University of Maryland determined that ginseng berry was more effective than ginseng root on lowering the blood sugar levels in mice. In another study, they found that mixing ginseng in a high-sugar drink left type-2 diabetics with less of an increase in blood sugar levels. Ginseng increases the rate at which your body processes a lot of substances, from alcohol and coffee to most medications. If your patient is taking anything that would be processed by the liver or pancreas, caution should be used with ginseng.
Personally we would recommend nutritional consultation to any diabetic or pre-diabetic patient to help with the complications of the disease. The nutritional experts will be able to cater diets for patients that do not cause complications with any current medications the patient is taking, but as always a patient should be advised to speak with their primary care physician regarding any contraindications to starting MNT. Additionally, every dietary recommendation should be made on a patient by patient basis, but as a general ranking of the aforementioned supplements, the best one would be corn silk. The studies on it are not numerous, but what is there indicates that corn silk is extremely effective and can even go so far as healing some of the damage done to the insulin receptors. All of the other herbs and supplements aid in insulin uptake. The downside to corn silk is that it does have a few interactions, so one would have to be wary of what the patient is taking before blindly recommending it.