Purely Dietary Control of Type II Diabetes Mellitus: A Review and a Five-Year Case Study
How some TLC and a change in diet helped a patient control his Type II diabetes
By Steven G. Bander, DO
Diabetes Mellitus (DM) is the sixth leading cause of death in the United States. Six million people were diagnosed in 1980, in 18.2 million received the same diagnosis in 2004.(1) Seventy-five percent of these people will die from some form of cardiovascular disease. Diabetes Mellitus is considered a “coronary risk equivalent,” and the American Heart Association says that diabetes is a cardiovascular disease.(2)
Studies comparing therapeutic lifestyle change (TLC) and Metformin showed reduction of DM incidence in 2.8 year follow-up of 58 percent and 31 percent, respectively, compared to placebo. Two times the TLC group regained normal glucose tolerance, signifying a reversal of impaired glucose tolerance as defined by the American Diabetes Association (ADA).(3)
Metabolic Syndrome is a cluster of risk factors discussed in the National Cholesterol Education Program – Adult Treatment Panel III (NCEP-ATP III) (4), which is responsible for much of the cardiovascular morbidity among overweight and obsess people and those with Type II DM.(5)
Risk Factors
Risk factors include:
• Abdominal obesity
• Elevated triglycerides
• Low HDL
• Hypertension
• Fasting blood sugar (FBS) levels of 100 or greater
The presence of three or more of these risk factors constitutes meeting the criteria for the syndrome (Table 1).(5)
Insulin resistance with excess upper body adiposity seems to be the central pathogenic factor in Metabolic Syndrome.(6) The link between insulin resistance and cardiovascular disease is thought to be medicated by oxidative stress-causing endothelial cell dysfunction, promoting vascular damage and atheroma formation.(7)
Treatment Strategies
Clinical trials suggest that aggressive TLC makes it possible to prevent or postpone the onset of diabetes, hypertension and other cardiovascular disease.(3) Weight loss improves all aspects of metabolic syndrome, as well as reducing cardiovascular mortality. Even if patients cannot lose weight, diet and exercise have been shown to lower blood pressure and improve lipid levels, as well as improve insulin resistance.(8) Walking or jogging one hour per day will produce significant loss in abdominal fat in men, even without calorie restriction.(9)
Diet
In treating elevated triglycerides and low HDL, carbohydrate intake can be replaced by food rich in mono-unsaturated fats, or low glycemic index foods – similar to those found in the Mediterranean diet.(10, 11)
Recommendations for sedentary patients with insulin resistance (especially if obese or with elevated waist circumference) include a low carbohydrate diet that eliminates sodas, juice drinks and refined grains. Long-term effects of the low carbohydrate diet have not been studied adequately, but short-term effects include lowering triglycerides, increasing HDL and decreasing weight.(12)
Another strategy for diet therapy is to replace high-glycemic index (HGI) food with low-glycemic index foods (LGI) that contain more fiber. LGI foods produce lower levels of post-prandial glucose and insulin.(13) In diabetes, clinical experience seems to indicate that reduced total carbohydrate intake with increased fiber demonstrates far better improvement in blood glucose whether or not weight loss is present. HGI meals produce an initial period of high blood glucose and insulin levels, followed in many individuals by reactive hypoglycemia, counter-regulatory hormone secretions and elevated free fatty acid secretions. These events may promote excessive food intake, beta cell dysfunction, dyslipidemia and endothelial dysfunction.(14)
A list of low-glycemic index foods versus high-glycemic index foods is found in Table 2. A comprehensive list of more than 750 glycemic-indexed foods and their glycemic load has been developed.(15) A Web site for this information is http://www.mendosa.com/diabetes.htm.
Case Presentation
Patient History
The patient was a 53 year-old white male in no acute distress. His initial weight was 238 lbs., and his height was 5’11” in November, 1999. The patient had noticed a weight loss down to 226 after changing from diet sodas to “juice drinks” (10 percent fruit juice with high fructose corn syrup). He also noted increased thirst, polyuria and polydipsia. In November, 1999, the patient’s fasting blood sugar (FBS) was 104. In February 2000 the patient’s FBS was 324. Triglycerides were 331 LDL 126; HDL 31 – other CMP values were within normal limits. HgbA1C level was 9.34.
The patient started on Metformin hydrochloride (Glucophage) and Pioglitazone hydrochloride (Actos), with improvement in HgbA1C to 7.3 in three months. Prandid 2mg ac was added. Best HgbA1C with this combination was 6.9. Maximum weight was 268. The patient was refused disability insurance with this HgbA1C, and became very depressed. He began a progressive low-carbohydrate diet (see Table 2) of a hybrid of Adkins™, etc. Within two weeks he had to discontinue the Prandin due to low blood sugar episodes. At four weeks, the Glucophage was discontinued. At six weeks, all medications were discontinued. His laboratory results three months after discontinuation of medication and the initiation of a low-carbohydrate diet were:
• HgbA1C 5.9
• HDL 41
• LDL 56
• Triglycerides 159
• Weight down to 238
Patient did well until 2005, with progressive “cheating” on diet. His weight rose to 258 lbs., and his HgbA1C levels had risen to 7.3. On November 15, 2005, the patient resumed more aggressive dietary regimen, and experienced a 10-pound weight loss and an HgbA1C reduction to 6.7 on January 19, 2006. His target weight is currently 238 lbs., and his target HgbA1C is ± 5.9 (see Table 4).
It is interesting to note that during the period between 2000 and 2005, no exercise regimen was used to obtain improvement in HgbA1C levels. On his last visit, this patient was urged to pursue regular exercise (four to five times per week, for 30 to 60 minutes per session) in an attempt to improve HgbA1C levels and help exercise tolerance, as well as to speed weight loss. Also, it is interesting to note that while the patient’s two-hour post prandial blood sugar is usually in the 104 to 134 range, occasionally it rose to 200 with mild alcohol consumption (two to three ounces) or with increased intake of high carbohydrate foods such as popcorn, tortillas or chips. Caloric intake also appeared to be a major factor in his lack of weight loss – where previously it was not as important as carbohydrate intake.(16)
Discussion
As cited earlier, diabetes mellitus and metabolic syndrome have reached epidemic proportions in the U.S., even to the extent that as of January 15, 2006, the New York City Board of Health required mandatory electronic reporting of glycosylated hemoglobin values by laboratories to the city’s Department of Health and Mental Hygiene.(1) Evidence from the Diabetes Prevention Program demonstrated that DM Type II can be reduced or prevented in the short-term by TLC.(4)
However, the old way of simply telling the patient to “lose weight and exercise” is usually an ineffective approach which may actually create resistance. This is because the patient may feel loss of autonomy and a sense of helplessness. Resistance is the patient’s way of trying to resolve the discomfort of ambivalence caused by trying to frighten him or her into compliance.(17) New approaches stressing the patient’s ability to have some element of choice and control of the situation may instill confidence that a change can take place.(18)
Conclusion
Clearly, this case presentation demonstrates and confirms what other previously mentioned studies have suggested: that diet alone may be as effective as – or sometimes even more effective than – medication in reducing HgbA1C levels and lipids in Type II Diabetes and patients having metabolic syndrome. These results have been sustained in this patient for more than six years.
It is important to remember, however, that high motivation is a critical component in the success of any therapeutic lifestyle change program. While the aggressive low-carbohydrate diet may not be appropriate for everyone, certainly suggestions of several variations of moderate caloric restriction and exercise programs have been made. These are all designed to decrease weight and body-mass index (BMI), while offering lifestyle changes that the patient can realistically live with over the long haul. In one study, 91 percent of the cases of diabetes could be attributed to habits and behaviors that did not conform to a low-risk pattern. Lifestyle patterns and behaviors are under the control of an individual.(19)
It is our responsibility as physicians to provide our patients with the most appropriate form of therapy to employ safely before pharmaceutical use. This treats the cause of the problem, not just the symptoms – a far more osteopathic approach.
Steven G. Bander, DO, is a 1982 graduate of the Texas College of Osteopathic Medicine, Ft. Worth, Texas. He first received his certification in family medicine in 1990, and is currently in private practice at the Bander Family Medical Center in Wylie, Texas.
| Table 1: NCEP-ATP III Metabolic Syndrome Clinical Identification of the Metabolic Syndrome |
|
| Risk Factor | Defining Level |
| Abdominal Obesity | Waist Circumference |
| Men | > 102cm (>40 in.) |
| Women | > 88cm (>35 in.) |
| Triglycerides | ≥ 150 mg/dL |
| HDL cholesterol | |
| Men | < 40 mg/dL |
| Women | > 50 mg/dL |
| Blood Pressure | ≥ 130/≥85 mmHg |
| Fasting glucose | ≥ 100 |
| Table 2 | |
| Top 10 Low GI Foods | Top 10 High GI Foods |
| These foods support normal blood sugar levels and an optimal insulin response | These foods can produce harmfully high blood sugar levels and a high insulin response |
| Apples | Candy |
| Berries and cherries | Cookies |
| Barley | Juices with added sugar |
| Grapefruit | White potato |
| Legumes (lentils, beans) | Chips (corn and potato) |
| Nuts (almonds, walnuts, soy nuts, peanuts) | Sweetened cereal |
| Oatmeal (unsweetened) | Sweetened soda |
| Green Peas | Sweet snacks |
| Tomatoes | White Bread and bagels (processed flour) |
| Unsweetened plain yogurt | White rice |
| Table 3: Low-Carb Diet |
| Avoid |
| Bread, rolls, totillas, pastry, doughnuts, bagels |
| Pasta |
| White Rice |
| Starchy vegetables: potatoes, corn, red beans, navy beans, peas, carrots |
| Cereal |
| Fruit juice and dried fruit |
| Salad dressing and Miracle Whip-type dressings |
| Anything labeled “low fat” |
| Chewing gum (even sugar free stimulates appetite and insulin production) |
| Diet or regular sodas (the sparkling kind with no sugar or artificial sweeteners are okay) |
| Sugar and aspartame |
| Eat Freely |
| Green vegetables: salads, cabbage, green beans, broccoli, greens, spinach, etc. |
| Other vegetables: cauliflower, squash, tomatoes, hears of palm, olives, cucumber |
| Meat: beef, chicken, pork (use moderately), fowl, game |
| Butter (avoid margarine), sour cream |
| Half and Half |
| Salad Dressings: Oil and vinegar, Caesar, Ranch, real mayonnaise, mustard |
| Eggs (even if your cholesterol is high, you may eat these two to three times per week) |
| Real Cheese (not “cheese food” or “cheese product”) and yogurt (not the sweetened kind with fruit) |
| Unsweetened coconut |
| Unsweetened cocoa |
| Coffee and Tea (in moderation) |
| Oil: olive and palm are best. Avoid oil heated to high temperatures |
| Drink six to eight glasses of filtered water daily |
| Nuts (raw is best) |
| Lemon and Lime |
| Eat Only in Moderation (if necessary) |
| Oatmeal or similar cooked, whole grain cereal |
| Brown Rice |
| Fruit: eat small portion as a snack, not as part of a meal. Diabetics need to avoid very sweet fruit such as grapes, bananas and pineapple |
| Tofu |
| Wine |
| Table 4 | ||||||
| Date | 11/99 |
2/2000 |
5/2000 |
8/2000 |
11/2005 |
1/2006 |
| Weight (lbs) | 238 |
226 |
268 |
238 |
258 |
248 |
| FBS | 104 |
324 |
134 |
119 |
143 |
127 |
| HgbA1C | n/a |
9.34 |
6.9 |
5.9 |
7.3 |
6.7 |
| LDL | n/a |
126 |
125 |
56 |
122 |
92 |
| Triglyceride | n/a |
331 |
339 |
159 |
335 |
148 |
| HDL | n/a |
31 |
30 |
41 |
33 |
45 |
References: