The best approach to managing Diabetes is through Functional Medicine
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Diabetes Mellitus is an abnormal physiologic response to blood sugar and insulin. It is important to understand NORMAL physiology before we can understand how diabetes is abnormal.
Our blood sugar is controlled to a very narrow range. The normal range of blood glucose is 70-100 mg/dL. This range is very important!
We start to have symptoms of true hypoglycemia. Hypoglycemia can be mild, moderate, or severe.
- Mild Hypoglycemia: nausea, jittery/trembling, cold/clammy/wet skin, rapid heart beat (tachycardia)
- Moderate Hypoglycemia: irritability/anxiety,
- Severe Hypoglycemia:
The brain is a ‘Glucose Hog’! It consumes roughly 1/2 of the circulating blood sugar. It requires glucose (almost exclusively) and this is why most of the symptoms associated with true hypoglycemia are neurologic in nature. However, those who are appropriately adapted do very well with ketones as a fuel source for the brain.
Since we don’t know (at least our bodies don’t know) when we are going to be able to eat again, we have to have a mechanism that increases blood sugar to keep it above 70.
Glucagon is released from the Alpha cells in the pancreas. It is the hormone responsible for making new glucose (gluconeogenesis) in the liver and mobilizing fatty acids for energy utilization.
Cortisol is released from the adrenal glands which works to break down muscle and stimulate gluconeogenesis in the liver. Blood sugar dysregulation is a major contributor to adrenal fatigue and hypercortisolism.
Blood Sugar >100
This issue is also very important because, at levels above 100, glucose begins to be toxic. These elevated levels increase the formation of Advanced Glycation End-Products (AGE) which are very pro-inflammatory and are responsible for the multiple medical problems that patients with uncontrolled diabetes often end up getting.
Insulin is the hormone responsible for keeping blood sugar below 100. It protects us from the toxic effects of hyperglycemia.
There are 4 primary tissues that utilize and/or store most of the glucose we consume or create:
- Brain – as stated above, it utilizes a lot of glucose. It does not need insulin to get glucose into its cells
- Liver – stores about 100 grams of glucose in the form of glycogen. That isn’t very much. Its about 3 cans of Coca-Cola. The liver requires insulin to get glucose into the hepatocyte (liver cell).
- Muscle – stores a limited amount of glycogen. Muscle needs insulin to get glucose into the myocyte (muscle cell) except during exercise.
- Adipose (fat) – Adipocytes (fat cells) also require insulin to get glucose into them. This is the ultimate repository for continual elevated blood glucose, once liver and muscle sources are full. The excess glucose has to go somewhere and the adipocyte is the storage location.
The take-home point is that excess glucose in the blood is extremely toxic and we have to be able to lower it.
Hyperglycemia is very bad!
Insulin stores that extra glucose. It also has a host of other functions such as increasing eicosanoids (increased inflammation). When we think about overall health we would do well to minimize insulin. So, hyperinsulinemia is also very bad.
Hyperglycemia is worse than hyperinsulinemia!
The way to control both is to decrease ingested carbohydrates and improve insulin function.
Diabetes Mellitus is essentially an elevated blood sugar due to inadequate amounts of insulin. There are 2 types of diabetes with 2 different causes and 2 different approaches to treatment.
- Type 1 – this type of diabetes is due to an absolute deficiency of insulin. It is most often caused by an autoimmune destruction of the β-cells in the pancreas.
- Type 2 – this type is due to an inadequate amount of insulin and due to insulin resistance.
So what is the problem in diabetes? Its just sugar, right?
Elevated blood sugar levels can cause any (or all) of the following – these are the Advanced Glycation Endproducts (AGEs):
- Nerve damage (neuropathy)
- Diabetic retinopathy (eye & vision problems)
- Heart attacks
- Coronary artery disease
- Peripheral vascular disease
- Renal (kidney) failure – can lead to dialysis
- Impaired immunity (frequent infections, diabetic ulcers)
This list is only a portion of the many problems that diabetes can cause.
However, the problem is two-fold. In order to understand the full implications of diabetes, you have to understand the function and purpose of insulin. In short, insulin is the ‘storage’ hormone of the body. It is the hormone of plenty.
Here are some of the actions of insulin:
- Increases liver, muscle, and adipose tissue uptake of glucose
- Increases lipid synthesis (makes more fat)
- Increases glycogen synthesis (makes more storage form of glucose)
- Increases amino acid uptake by the cells
- Increases potassium uptake
- Decreases breakdown of protein
- Decreases lipolysis (decreases breakdown of fat)
- Decreases gluconeogenesis (less production of glucose from non-sugar substances
In normal physiology, insulin is primarily released in response to elevated blood sugar. Also with eating but that is another story for another day. So, the higher the blood sugar, the higher the insulin level. The higher the insulin level, the more energy we store. This has multiple implications.
Regardless, the goal of diabetes treatment is to control blood sugar – it is very toxic at high levels.
In the case of type 1 diabetes, blood sugar control is through insulin replacement & carbohydrate control. For type 2 diabetics, the goal is to control blood sugar by decreasing carbohydrate intake and increasing the effectiveness of insulin or to increase the volume of insulin.
HOW IS DIABETES DIAGNOSED?
There are 4 ways to diagnose diabetes (regardless of the type):
- Fasting blood sugar > 126 mg/dl on 2 separate occasions
- Blood sugar > 200 mg/dl with symptoms of hyperglycemia
- 2 Hour blood sugar > 200 mg/dl during an Oral Glucose Tolerance Test (OGTT)
- Hemaglobin A1c >6.5 – the is the most common way that we diagnose diabetes in our clinic
Glucose attaches to various substances (blood vessels, nerves, hemaglobin, etc) based on the level of glucose. This ‘glycosylation’ is based on the amount of blood sugar at any given time. The higher the blood sugar level the more glucose attaches to these substances. These are the Advanced Glycation Endproducts mentioned in the video above.
Red blood cells (RBCs) have a lifespan of approximately 90-120 days. Glucose attaches to the hemaglobin in the RBCs as stated above. The hemaglobin with glucose attached is called Hemaglobin A1c. The A1c represents an ‘average’ of the blood sugar over a 90-120 day period.
A1c gives us an average blood sugar over the past 3-4 months.
Typically, the A1c goal in the treatment of diabetes is < 7.5.
However, this level of glycosylation is NOT normal.We must do better! The problem is that most people think that the way to improve this number is by increasing the dose or number of medications, adding insulin, or increasing the amount of insulin.
Diabetes will not improve by adding more medications. It won’t improve by adding insulin. The ACCORD trial clearly demonstrated this.
These methods only improve the ‘numbers’ associated with diabetes (blood sugar levels, A1c, etc) but do NOT improve the disease process.
The only way to improve your diabetes is to decrease the NEED for insulin and to make the insulin you have more efficient.
This is accomplished by controlling carbohydrate intake, increasing the efficiency of insulin, increasing the efficiency of the pancreas, and optimizing the endocrine systems that help regulate blood sugar.
WE OFTEN RECOMMEND A TOTAL DAILY CARBOHYDRATE INTAKE OF <100 GRAMS PER DAY.
WHAT IS “PRE-DIABETES”?
Pre-Diabetes is a condition of increasing blood sugar levels and/or intolerance to glucose (inability to appropriately handle glucose in the diet after meals). This is most often due to insulin resistance issues.
Basically, if you have pre-diabetes then you have severe metabolic derangement which absolutely must be addressed. Pre-diabetes should serve as a warning that there are serious problems ahead. I think it is similar to have a sign saying “Bridge Out Ahead”. If you continue down that road you will see the true severity of the problem. If you don’t pay attention to the signs then you’ll end up in a bad spot.
Pre-Diabetes is, by itself, a risk factor for cardiovascular disease and future diabetes. Again, there is already metabolic derangement which is causing problems.
THESE PATIENTS ARE AT MUCH HIGHER RISK OF BECOMING DIABETIC!
It is important to understand that diabetes begins with abnormally elevated blood sugar after a higher carbohydrate meal. This can occur with an absolutely NORMAL A1c. In fact, the first physiologic change is an increase in insulin levels in response to carbohydrate intake with normal blood sugar. This lets us know that the physiology is beginning to have a difficult time keeping up with the pace.
This is the optimal time to address this issue! However, we can’t address the issue unless we know it exists. Therefore, we need to look for this problem. Most physicians do not look for this problem at this stage.
We generally screen patients with several different tests.
Glycomark (aka Post-Prandial Glucose Index)
1-5, Anhydroglucitol (1,5-AG) is a naturally occurring dietary monosaccharide with a half-life of 1-3 days. 1,5-anhydroglucitol is particularly sensitive for detecting brief episodes of hyperglycemia that may occur in predisposed individuals following ingestion of meals containing carbohydrates.
Changes in circulating 1,5-anhydroglucitol levels reflect recent changes in glycemic control more accurately than hemoglobin A1c or fructosamine. Structurally similar to glucose, 1-5-anhydroglucitol is acquired from many different foods (soy, rice, and pasta are particularly rich in 1,5-anydroglucitol with smaller amounts found in meats, fish, fruits, vegetables, tea, milk, and cheese.
Specific biological activities of 1,5-AG in the body, if any, are unknown. 1,5-AG levels remain very stable in the body, undergoing little or no appreciable catabolism and achieving a steady state between ingestion and urinary excretion with the total body pool maintained in the 500-1000mg range. In the kidney, nearly the entire filtered load of 1,5-AG undergoes tubular reabsorption via a specific fructose-mannose active transporter.
When glucose levels are elevated above the renal threshold for glucosuria (~180 mg/dL), tubular glucose concentrations rise and compete with 1,5-AG for absorption by the tubular fructose-mannose transporter. this results in decreased tubular reabsorption, increased urinary excretion, and reduced plasma concentrations of 1,5-AG.
Levels of 1,5-AG vary inversely with changes in glucosuria according to a constant formula: 1,5-AG x urinary glucose = 16. 1,5-AG responds sensitively and rapidly to changes in serum glucose, reflecting even transient elevations of glucose within a few days, and with degree of change depending on both magnitude and duration of hyperglycemia and glucosuria. Circulating 1,5-AG is NOT affected by hypoglycemia.
1,5-AG levels less than 10 mcg/mL are considered abnormal.
Circulating 1,5-AG reflects every acute hyperglycemic “spike,” even those occurring in the fasting state. Several studies have demonstrated the ability of 1,5-AG to differentiate diabetic patients with postprandial hyperglycemia from those with normal prandial glucose, despite similar low-normal HbA1c levels.
Blood sugar can be checked 1 & 2 hours after eating by simply checking blood sugar at these times. This is a valuable tools and extremely cost effective.
Finally, there are Continuous Plasma Glucose (CPG) monitoring devices that will measure blood sugar every 5 minutes for a week and, arguably, give us the best information of how each patient is handling their blood sugar, insulin, diet, etc.
The good news is that these 5 things are proven to prevent diabetes in these patients:
- Healthy weight (BMI of < 25)
- Healthy Diet – I have seen this single intervention CURE diabetes in multiple patients!
- 1 glass of alcohol per day
- No smoking
BY THE WAY, THERE IS NO SUCH THING AS ‘BORDERLINE DIABETES’!
Blood sugar levels are contingent upon multiple factors such as exercise, carbohydrate intake (type and quantity), insulin levels and sensitivity, hormone levels, etc. The goals of therapy are to decrease blood sugar levels, both after meals and fasting.
Blood sugar control is accomplished by a variety of interventions. It seems that the medical community has adopted the mentality of controlling increasing blood sugar with increasing amounts of insulin. While this will decrease the damage caused by hyper-elevated blood sugar levels, it is only increasing the amount of systemic insulin which causes more storage of adipose and further exacerbates insulin resistance.
More insulin resistance causes worsening blood sugar levels which will ultimately be treated with increasing levels of insulin. And the problem perpetuates itself.
Remember, insulin is toxic but it is less toxic than elevated blood sugar.
We MUST break this cycle!
TYPE 1 DIABETES MANAGEMENT:
There are TWO required treatments for optimal health.
- Insulin – Remember, Type 1 diabetes has an absence of insulin. We cannot survive without it but we sure don’t want too much of it!
- Control of carbohydrate intake.
I believe that we should manage Type 1 diabetes with appropriate intake of complex, low-glycemic index carbohydrates. This means vegetables NOT grains! Do not listen to the lies that tell you ‘whole grains are healthy’. They are carbohydrates. All grains must go! Get your carbs from veggies!
Blood sugar elevations are controlled by adjustments in insulin.
Insulin pumps are the most appropriate therapy in my experience.
The next best is Basal/Bolus insulin therapy. This is much more ‘physiologic’ than the older regular or NPH insulin therapies.
Basal insulin is long acting insulin that is generally given once a day (larger doses may be given twice a day). There is no peak and the insulin is steadily effective over a 24 hour period.
Bolus insulin is giving a prescribed amount of short-acting insulin in conjunction with carbohydrate intake. Generally, patients are given a prescribed carb/insulin ration so that they will take a set amount of insulin for a set intake of carbohydrates every time you eat.
TYPE 2 DIABETES MANAGEMENT:
As stated previously, insulin resistance plays a major role in Type 2 diabetes. The key to treatment is in improving insulin sensitivity and decreasing carbohydrate load in the diet.
Don’t eat as many carbohydrates. This is like having your house on fire and deciding to throw gasoline on it. Give me a break! Nothing could be worse. Quit eating all of the stuff that is causing the problem.
There are several potential causes of insulin resistance. While we don’t know the exact cause, the following factors increase a person’s risk of insulin resistance:
- Genetic factors
- Metabolic Syndrome
- Some medications can lead to insulin resistance
So, treatment should be aimed at minimizing the risk factors. If you are obese, then you have to fix that! In fact, if you are obese (and even if you aren’t), you have a chance to CURE your diabetes.
We have a stepwise approach to the treatment of Pre-Diabetes and Diabetes Type 2. Start with Step 1 & 2 as a foundation and go up as needed.
Eat less than 100 grams of carbohydrates per day. This is very important. All carbohydrates count toward this total. To make it easier, make sure your diet consists of meats, vegetables, some fruit (you should limit these), nuts & seeds. You should NOT be eating any refined sugars, grains, or dairy.
Exercise! The ideal form of exercise is high-intensity exercise. You should be lifting weights. Heavy weights. You should be doing sprints. Hard sprints. You should be working out hard! You may not be ready for this right now but we need to start working toward this goal.
To put this in perspective, Dr Robert Huizinga, the Medical Director on NBC’s ‘The Biggest Loser’, has demonstrated repeatedly that he has cured diabetes in multiple patients… in less than 12 weeks! There was one patient in particular who presented to the Ranch on 11 diabetes medications include 3 different injections every day. In 2 weeks he was off of all medications. In 10 weeks his blood sugar was completely normal. This included after an oral glucose tolerance test.
You can turn this around! The question is, how bad do you want it?
Supplements: there are a number of supplements that I generally recommend
- Gymnema sylvestre – this is an Ayurvedic herb that has been used for centuries for blood sugar control.
- Alpha Lipoic Acid – the important thing here is the controlled release form. There are multiple reasons for this but it truly does matter. We have this in our clinic in the controlled (sustained) release form. You should take it twice a day and away from meals. It is included in the Mitochondrial Revolution as well. There is also some evidence that it can improve diabetic neuropathy.
- Revolution IS – contains several supplements that work synergistically to improve the action and function of insulin.
You can take all of these, some of them, or none of them.
Medications: the use of medications depends on the severity of the blood glucose control problem, patient physiology, other medications, and a number of other factors. However, it is not uncommon that we will start medications early in order to facilitate optimal control. Once we begin to get the blood sugar under control we typically start decreasing the dose and quantity of medications.
- Metformin – this is one of the foundational medications in blood sugar control. We often start this medication at 500mg twice daily and adjust from there.
- GLP-1 – these are generally given by injection and help decrease post-prandial (after meals) blood sugar. They can also decrease weight.
- DDP-IV Inhibitors – GLP-1 helps improve post-prandial blood sugar levels and is broken down by DPP-IV. These medications decrease the inactivation of GLP-1 and are oral medications. They do not decrease weight but don’t make you gain weight (they are weight neutral). These medications are available in combination with metformin for convenience since they are often given together.
We often use these medications for ‘Pre-Diabetic’ patients because our goal is optimal health which includes blood sugar control. Unfortunately, the insurance companies don’t always agree with our use of these medications without an actual diagnosis of Diabetes. Metformin is generally very inexpensive but the other medications can be a bit pricey.
Once we get control of blood sugar we start decreasing Step 4 first and decreasing intervention until we can control everything with the Healthy Trinity alone.
WHAT NEEDS TO BE CHECKED WITH DIABETES?
Proper management of diabetes requires consistent medical surveillance of certain things that are often affected by diabetes. Here is what should be checked to make sure that you stay as healthy as possible.
- Nephropathy – since diabetes can affect the kidneys, you should have a urine test (microalbumin/creatinine ratio) to make sure your kidneys are working correctly. This test is looking for small amounts of protein leaking into the urine. Another good option for following kidney function is Cystatin-C.
- Retinopathy – you should see an eye doctor every year to have a diabetic eye examination
- Neuropathy – you should check your feet daily looking for any lesions, redness, or injuries. You should also have your feet checked with a monofilament exam (in the clinic) at least once per year.
- Diabetes is a coronary artery disease equivalent (meaning diabetics are at the same risk of heart attacks as someone who has already had one). Therefore, you should have your cholesterol checked. The goals for your labs (and blood pressure – 130/85) are slightly different than for non-diabetics.