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Diabetes: Can Diabetes be Reversed? and Natural Remedies for Diabetes
Assessment and Plan: Diabetes Mellitus
Diabetes mellitus type 2 occurs more often in obese individuals regardless of age. It also occurs more often in older adults, those exposed to steroids used for other diseases, those with poor diet or with sedentary lifestyle.
Patients should follow advice and take medications as prescribed by the physician.
Diabetes mellitus type 2 may have been present for years prior to formal diagnosis, but is preventable by maintaining normal weight and healthy lifestyle habits. If new in onset, diabetes mellitus type 2 may be reversible.
Treatment of diabetes mellitus is seated in education, medications, insulin if required, dietary change, exercise, attainment of ideal weight, and supplements.
Patients should be educated about how to provide self-care for diabetes with methods for strict blood glucose control and beneficial lifestyle changes such as glucometer use, insulin sliding scale if required, dietary changes, exercise, attainment of ideal weight, and beneficial supplements.
Strict control of blood glucose will reduce rate of eye, foot, and skin complications, heart disease, hypertension, infection, hearing loss, neuropathy, nephropathy, and stroke associated with diabetes. Please see sections on hypertension, coronary artery disease, and stroke for more information.
Eliminate all concentrated sweets and sugars from the diet. Consume small meals frequently rather than large meals. Avoid large amount of carbohydrates in each meal.
Controlling blood sugar by changing the order of food in a meal: A. Shukla et al found that postmeal glucose levels were decreased by about 29%, 37%, and 17% at 30, 60, and 120 min respectively, when the protein and vegetables within a meal were consumed prior to carbohydrates compared to eating these foods in the opposite order. The authors expressed that this eating method may improve insulin sensitivity and that additional research is needed to evaluate the method for longer term glycemic control. (67)
Diets for diabetes and weight loss:
If overweight, lose weight to reach ideal bodyweight. See weight loss for further information.
Dietary changes and weight loss improves glucose control in diabetes:
Eliminate all concentrated sweets and sugars from the diet.
Consume small meals frequently rather than large meals.
Amount of weight loss required to improve diabetes: Individuals suffering from type 2 diabetes may reverse some of the effects by losing 8%-10% of initial body weight, and even a 5% weight loss may have beneficial effects on cholesterol and blood glucose (28).
According to the meta-analysis by Clifton (29):
A low-fat diet has an average weight loss is 5.4 kg at 12 months and improves diabetes and high blood pressure control.
A low-calorie diet results in slightly better weight loss than a low fat diet, but a low calorie diet of 1100-1600 calories including moderate fat intake is superior to a low-fat diet for weight loss. A protein intake of more than 1.05g/kg of body weight aided retention of lean body muscle mass during the diet.
Those on carbohydrate-restricted diets are satisfied more from the increased protein which may aide compliance and allow dieters to lose more weight than those on low-fat diets at 6 months, but after 12 months the difference is less obvious.
Anderson JW et al described that a very low calorie diet with less than 1000 kcal per day may yield somewhat better weight loss than a low-calorie diet of 1100-1600 kcal per day but the difference between these 2 diets becomes smaller in the long term (52). A very low calorie diet risks greater loss of lean body composition.
Low-glycemic-index or low-glycemic load diets contain all complex carbohydrates, eliminates concentrated sweets, deletes simple sugars, are ideal for diabetes control, and lead to weight loss, improved blood sugar, and the lowering of LDL cholesterol (24).
Weickert and Martin expressed that (24):
Insulin resistance is caused by excessive caloric intake and obesity.
Sustained low calorie diets have a strong benefit on short-term weight loss (up to 2 years), insulin resistance, and diabetes risk.
Reduction in total fat intake (<30%) has a modest benefit on weight loss, likely reduces diabetes risk but is less effective than low-carbohydrate, high-protein diets.
Fat intake >37% increases insulin resistance
Increase in monounsaturated fatty acids (>10%) has a modest benefit on insulin resistance, lowers LDL, decreases triglycerides, and lowers blood pressure.
Polyunsaturated fatty acids have been found to have a modest effect on insulin resistance.
Low-carbohydrate diets (a minimum of 130 g/day is recommended) have a modest benefit on weight loss in the short term and have beneficial effects on HDL (“good”) cholesterol and triglycerides.
High protein intake increases satiety, has a weight lost benefit in the short term and has beneficial effects on HDL, LDL cholesterol, and blood pressure.
Low glycemic index diets have a modest benefit on weight loss, improve LDL cholesterol, inflammatory markers, and probably reduce cardiovascular risk.
Dietary fiber >14 g/1000 kcal and day has a modest benefit on weight loss and is beneficial on insulin resistance.
Soluble fiber (mainly fruit and vegetables) has a modest benefit on weight loss, plus lowers glycemic index, LDL cholesterol, and triglycerides.
Insoluble cereal fiber (cereals, wheat bran and whole grain products) has a modest benefit on weight loss and a strong benefit on insulin resistance.
Mediterranean style diets have a modest benefit on weight loss, insulin resistance, diabetes risk, reduced risk for cardiovascular disease, lower inflammatory cytokines, improved lipid profiles and increased survival. (24)
Westman, EC et al found that a ketogenic, low-carbohydrate diet with under 20 grams of carbohydrates per day compared to a low glycemic reduced calorie diet of 500 kcal below maintenance kcal resulted in the following results after 24 weeks (25):
The low carb diet resulted in a better improvement of hemoglobin A1C of -1.5%, the reduced calorie diet improved hemoglobin A1C by -0.5%,
Bodyweight improved by -11.1 kg and -6.9 kg respectively
HDL improved by 5.6 points in the low carb diet and did not improve in the other diet.
Diabetes medications were reduced or eliminated in 95.2% and 62% in each of the diets respectively.
A low-carbohydrate, high protein diet may increase the risk of mortality (please see weight loss section for more information)
Vegetarian diet and diabetes mellitus:
Barnard, ND et al found that a low fat vegan vs. American Diabetes Association diet for 74 weeks (26):
Reduced weight by 4.4 kg and 3.9 kg in the vegan and conventional groups, respectively.
On the vegan diet, total cholesterol and LDL cholesterol decreased by 20.4 mg/dL and 13.5 mg/dL, respectively.
On the conventional diet, total cholesterol and LDL cholesterol decreased by 6.8 mg/dL and 3.4 mg/dL respectively.
In a two-year study with 15,200 men and 26,187 women non-diabetics, the development of diabetes cases were significantly reduced in vegans, lacto-ovo, and semi vegetarians compared to non-vegetarians and the vegetarian diets appeared to negate the higher risk of diabetes present in African Americans (27).
Diet for diabetic gastroparesis:
According to Sadiya (3):
Gastroparesis leads to early satiety, abdominal distension, reflux, stomach spasm, postprandial nausea, vomiting, change in drug absorption, and weakening of glycemic control.
To improve symptoms eat small frequent meals
Increase liquid calories
Reduce high fat intake.
Lower high fiber intake from fruits and vegetables
Food that is poorly digested such as fiber can collect in the stomach and form a mass called a bezoar.
Juicing fruits and vegetables to obtain nutrients without the fiber may improve gastroparesis.
For further information about gastroparesis, please see University of Virginia Nutrition Services, Gastroparesis Diet Tips which may be accessed here (59): gastroparesis handout
Dietary habits to avoid in patients with diabetes:
Caffeine may worsen glucose control:
Blood glucose levels increase after caffeine intake at the 2nd, 3rd, and 4th hours compared to placebo. (35)
Caffeinated coffee before a meal resulted in significant insulin sensitivity reduction of 40% and 29% after a high glycemic index meal and a low glycemic meal respectively compared to decaffeinated coffee (36).
Areca-nuts: Areca nut chewing is associated with hyperglycemia, type 2 diabetes, metabolic syndrome, obesity, increased body mass, higher triglyceride levels, oral cancer, oral submucous fibrosis, and periodontal disease (37).
Physical activity and diabetes mellitus: For starting exercise in patients with chronic illness, consult a physician and see aerobic exercise and weight training sections. The most benefit from physical activity is achieved with at least 2.5 hours of aerobic exercise of moderate intensity per week and by performing resistance exercises for muscle strengthening not only by all healthy individuals, but also by those suffering from obesity, diabetes, hypertension, atherosclerotic cardiovascular disease, and cancer (53).
According to the American College of Sports Medicine and the American Heart Association (AHA) (13):
Adults with type 2 diabetes may benefit from aerobic activity slowly increased to moderate-intensity (50-70% of peak heart rate) or vigorous-intensity (above 70% peak heart rate) aerobic activity at least 3 days per week with no more than 2 consecutive days without exercise.
Exercise should add up to a minimum of 150 minutes per week of moderate-intensity and/or a minimum of 90 minutes/week of vigorous-intensity exercise.
Muscle-strength training exercises should also be performed 3 days each week using a variety of exercises involving the major muscle groups. This regimen should progress to include 3 sets of 8-10 reps with use of a weight that cannot be lifted more than 9 or 10 times.
Aerobic exercise such as a brisk half-an-hour walk every day can significantly reduce (improve) HbA1c (glycated hemoglobin test indicating how well diabetes is being controlled over 3-4 months), blood pressure, blood lipids and coronary heart disease risk in patients with and without diabetes mellitus (16).
Insulin sensitivity was sustained 15 days longer in type 2 diabetes mellitus patients who exercised for 56 minutes at a low intensity compared to those who exercised for 34 minutes at a high intensity (17).
Exercise guidance for type 1 (insulin-dependent) and 2 (non-insulin-dependent) diabetes (14):
May increase risks of hypoglycemia among Type I diabetics.
To prevent hypoglycemia or hyperglycemia, eat a meal 1-3 hours before exercise, but if blood sugar is less than 100 mg/dL, a pre-exercise snack is needed. If blood sugar is greater than 250 mg/dL or serum ketones are positive, postpone exercise. If currently taking subcutaneous insulin, it should be given 1 hour prior to exercise in the abdomen. Injections in the fingers, and other extremities, should be avoided. If insulin peaks or hypoglycemia develops while exercising, decrease insulin prior to next workout.
During long vigorous exercise, carbohydrate feedings (30-40 grams for adults, 15-25 grams for children) are recommended every 30 minutes.
Plenty of water or other fluids should be taken while exercising.
Monitor blood glucose before, during, and after a long exercise session.
12-24 hours after exercising, calorie intake should be increased based on how hard and long the exercise period was.
Patients with diabetes and heart disease: Intensive cardiac rehabilitation showed significant improvements in body mass index (BMI), triglycerides, low density lipoprotein cholesterol, total cholesterol, hemoglobin A1c, systolic blood pressure, diastolic blood pressure, depression, hostility, exercise, and functional capacity at 12 weeks and 1 year (18).
Integrative medicine treatments for patients with diabetes mellitus:
Fiber and diabetes mellitus: Guar gum, glucomannan, or psyllium husk fibers are recommended as a fiber supplement to reduce HbA1C, fasting blood glucose, improve the lipid profile, lowered blood pressure and assisted in weight loss by providing fullness to reduce hunger.
Guar gum has been taken at a dose of 10 grams per day for 8 weeks (2), 20 grams per day for 4 weeks (3), 15 grams per day for 42 weeks (5), or 30 grams per day for 6 weeks (6). Benefits of guar gum include:
Reduction in fasting blood glucose of 16.9 mg/dL (1)
Improvement of HbA1C by 0.5-1% (1,2,5)
Total cholesterol reduction in one study of 21% (3), another study showed cholesterol reduction of 13% (5), and a third study showed total cholesterol was lowered by 0.6 mmol/L (6).
Lowered post-prandial blood glucose (3,7)
Reduced insulin requirement (3,7)
Weight loss (4)
LDL reduction of 8% (5)
Decreased systolic and diastolic blood pressure by 6 mmHg and 3 mmHg, respectively (6)
Increase in insulin sensitivity (6).
One study showed no improvement of total cholesterol, triglycerides, HDL, or LDL (1).
One study showed no improvement of insulin sensitivity or HbA1C (3).
Guar gum adverse reactions and interactions: 62.5% of patients receiving guar gum experienced side effects including abdominal cramps, diarrhea (most common), and skin itching (1). Another study noted flatulence, loose stools, and a feeling of stomach discomfort (5).
Psyllium fiber has been taken at a dose of 5.1grams twice per day a half hour before breakfast and dinner for 6 weeks (8). Benefits of psyllium fiber include:
Significant reduction in fasting blood glucose and HbA1c (8), increase in HDL (8), and was tolerated well with less flatulence occurring in the psyllium group than the placebo group, similar diarrhea and constipation in both groups, and less flushing in the psyllium group in those taking metformin.
Glucomannan
Glucomannan (from konjac root) taken at a dose range of 1.2 to 15.1 grams per day for 3-16 weeks yielded the following average benefit across 14 studies (9):
Decreases in total cholesterol by -19.28 mg/dL
Lowered LDL cholesterol by -15.99 mg/dL
Triglycerides reduced by -11.08 mg/dL
Reduction in body weight by – 0.79 kg (-1.74 lbs)
Lowered fasting blood glucose by -7.44 mg/dL.
No effect on HDL or blood pressure was seen.
Glucomannan at a dose of 10 grams per day plus plant sterols at a dose of 1.8 grams per day was more effective than glucomannan alone (10):
LDL was 2.95 mmol/L after glucomannan plus plant sterols vs. 3.60 mmol/L after placebo.
Total cholesterol was also lower after glucomannan plus sterols at 4.72 mmol/L vs. placebo of 5.47 mmol/L.
Glucomannan at a dose of 3.6 grams per day for 28 days reduced LDL by 20.7% and fasting glucose levels by 23.3% (11).
Glucomannan-enriched biscuits (0.7 g/412 kJ [100 kcal-100 calories] of glucomannan) or placebo of wheat bran fiber biscuits taken by subjects on medication and a low cholesterol diet every day for three weeks significantly improved blood sugar control by 5.7% measured by fructosamine (a measurement of long term glucose control and lowered systolic blood pressure by 6.9% but body weight, HDL, LDL, and total cholesterol, triglycerides, glucose, insulin, and diastolic blood pressure were not affected (12).
Fiber adverse reactions and interactions.
Dry powdered fibers are generally safe when mixed with adequate water or another liquid, but are not without health risks.
At least 8 ounces of fluid is recommended when taking dry fibers such as glucomannan, Konjac root, guar gum, Citrucel, and psyllium (Metamucil).
Health Canada issued a warning that glucomannan fiber has resulted in choking, obstruction of the throat, esophagus or bowels according to reports when not consumed with an adequate amount of fluid (54).
The warning also stated that the fiber should not be taken before bed (54).
Fibers may also bind medications and interfere with absorption resulting in a reduction in the desired effect of the medication. Therefore, medications should be taken at least 2 hours before or after the fiber.
Vitamin D and diabetes: Recent guidelines reflect a gradually increasing acceptance of enhanced vitamin D supplementation, which has a wide margin of safety, and the potential for individual health improvement may be substantial. Please see the section on vitamin D for further details.
After comparing type 2 diabetics with non-diabetics, a retrospective analysis showed that patients with type 2 diabetes have a very low 25-hydroxy vitamin D level, high triglycerides, a high LDL, and increased HbA1C which were all were found to be consistently associated with vitamin D deficiency in diabetes mellitus type 2 patients (38).
Vitamin D and diabetes mellitus type 1:
The incidence of type 1 diabetes in young children was reduced by vitamin D supplementation (39,57).
A low hydroxyl vitamin D level appeared to increase the risk of developing the disease (57).
Endocrine Society’s Clinical Guidelines for vitamin D (40):
Vitamin D deficiency: 25(OH)D < 20 ng/ml.
Vitamin D insufficiency: 25(OH)D of 21–29 ng/ml.
Vitamin D sufficiency: 25(OH)D of 30–100 ng/ml.
Recommended vitamin D intake:
Children < 1 year old: 400-1,000 IU per day
Children 1-18 years old: 600-1,000 IU per day
Adults: 1,500-2,000 IU per day to maintain 25(OH)D concentrations of 40–60 ng/ml.
Upper limits of vitamin D intake were also set as follows: 2000 IU per day for children up to age 1 year, 4000 IU/day for children aged 1 – 18 years, and up to 10,000 IU/day for adults aged 19 years and older.
Caution in patients with chronic granuloma forming disorder or lymphoma as vitamin D may cause high calcium levels (40).
Cinnamon and diabetes mellitus:
A meta-analysis and systematic review by Allen, Robert W et al revealed the following statistically significant results of cinnamon taken at a dose of 120 mg to 6000 mg per day for 5-18 weeks over placebo. A dose of 1-6 grams per day showed a decrease of fasting blood glucose in 6 trials, and most showed improvements of lipid parameters. 2 of the trials showed 1-1.2 grams of cinnamon per day decreased fasting blood glucose and HcA1C. Overall results of the meta-analysis showed (55):
Reduction of fasting blood glucose 8.67-40.52 mg/dL (average 24.59 mg/dL).
Lower total cholesterol by 1.44-29.76 mg/dL.
Lower LDL 1.63-17.21 mg/dL.
Lower triglycerides by 10.91-48.27 mg/dL.
Increase in HDL 1.09-2.24 mg/dL.
No significant change in HbA1C.
In a comparison between cinnamon, cardamom, saffron, and ginger supplementation for diabetes control, cinnamon was the only one in this group which improved fasting blood glucose (66).
Cinnamon adverse reactions and interactions:
Cassia cinnamon contains coumarin which may result in hepatotoxicity (50.55), and should be avoided in amounts greater than a light flavoring in foods.
No human studies of Ceylon cinnamon were located, but Ceylon cinnamon is recommended over Cassia cinnamon because it has been tested to have undetectable levels of coumarin (51), and likely has similar hypoglycemic action (56).
According to the authors of the meta-analysis by Allen, Robert W et al, none of the 10 trials reviewed reported any significant adverse effects, but animal studies with Cassia cinnamon showed liver toxicity, lowering of platelet counts, increase risk of bleeding, and allergic reactions. Potential interactions with cinnamon include medications which affect platelets and anticoagulants. Caution in patients taking Cassia cinnamon with compromised liver function. (55)
Flavonoids and diabetes mellitus type 2: Wedick and colleagues found the following (34):
A 23% lower risk of type 2 diabetes was noted when ≥2 servings per week of blueberries was consumed compared to eating <1 servings per month.
A 23% lower risk of type 2 diabetes was noted when apples and pears were consumed at ≥5 servings per week compared to <1 servings per month.
Alpha-lipoic acid and diabetes: A small trial of oral alpha lipoic acid (ALA) at a dose of 600 mg twice daily for 4 weeks significantly improved insulin sensitivity over placebo but the difference was not statistically significant. (19)
Broccoli sprouts and diabetes mellitus type 2: Broccoli sprouts and hyperlipidemia: Broccoli sprouts may be produced by anyone at home in a Mason jar. They appear to have numerous potential health benefits and are an inexpensive way to add nutrition to the diet. Research is currently being conducted in a variety of potential treatments but is in early stages.
Type 2 diabetes patients who received placebo, broccoli sprouts powder, 5 grams daily or 10 grams daily, for 4 weeks showed the following results (32):
Total cholesterol decreased 6.9%, 13.6%, and 10.1% respectively
LDL lowered by 3%, 14.9% and 10.5% respectively
HDL decreased by 13.9%, 13%, and 4.6% respectively
Triglycerides lowered by 6.9%, 7.2% and 18.7% respectively
Fasting blood sugar reduced by 1%, 13.1% and 19.3% respectively
Please see the broccoli sprouts section for further information.
Diabetic peripheral neuropathy:
Alpha-lipoic acid (a fatty acid supplement) and diabetic peripheral neuropathy:
Alpha-lipoic acid at an oral dose of 600 mg per day reduced stabbing pain, burning pain, paresthesia, and asleep numbness from diabetic peripheral neuropathy by 62% vs. 26% with placebo (21). Higher doses were used but symptoms of nausea, vomiting, and vertigo worsened as the dose of ALA increased (21).
A review of studies found that oral alpha lipoic acid decreases neuropathic pain when given for a period of 3 weeks at a dose of 600 mg per day and was given an A recommendation grade, but higher doses may not offer additional benefit (22).
Compared to a placebo group, 600 mg of alpha-lipoic acid IV for 5 days/week for a total of 14 treatments resulted in significant improvement of pain, numbness while asleep, prickling, and signs of neuropathy (20).
A meta-analysis of 15 randomized controlled trials found that IV administration of 300-600 mg per day of alpha lipoic acid for 2-4 weeks for treatment of diabetic peripheral neuropathy was associated with a significant improvement in nerve conduction velocity and neuropathic symptoms (23).
Capsaicin and peripheral neuropathy:
In a study by Anand et al, a topical skin patch with 8% capsaicin placed for 1 hour was successful at producing pain relief at the site of peripheral neuropathy for up to 12 weeks by possible mechanism of defunctionalized peripheral nerve function (46). The high dose, 8% capsaicin patch was also studied for use on postherpetic neuralgia and was also found to be effective at pain relief for 12 weeks (48).
A review of studies on the use of low dose of 0.075% capsaicin cream versus placebo showed that low dose topical capsaicin was ineffective for pain without significant effect beyond placebo (47).
Topical capsaicin adverse reactions:
Treatment of peripheral neuropathy by capsaicin has a low risk of both adverse systemic reaction and drug interactions (46).
Skin reactions were more common with capsaicin than placebo though this became better with time and adverse effects were rare systemically (47).
Diabetic peripheral arterial disease (PAD) in patients with diabetes:
Propionyl-L-carnitine has been studied for use in (PAD) at a dose of 500-1000 mg oral 3 times daily with most studies showing a benefit in severe disease with improvement in walking distance of over 40%, but has been less effective for mild peripheral arterial disease. Minimal adverse effects have been reported (60).
Propionyl-L-carnitine compared to placebo was believed to reduce lactic acid formation in ischemic tissue to improve walking distance and symptoms of pain in diabetes mellitus type 2 patients with (PAD) (42).
Propionyl-L-carnitine given IV at 1200 mg for 5 sessions per week for 4 weeks improved walking distance and pain over placebo. When a vascular compression device, (Vascupump) was added for 5 days/week for 4 weeks, this resulted in an even greater improvement in walking distance (43).
Various pneumatic arterial compression devices have shown evidence that patients with PAD which are not candidates for re-vascularization (arterial bypass) or arterial stent procedures may benefit from treatment with these devices (especially those intolerant to exercise). Research with these devices have reported benefits such as walking distance, leg pain, improved arterial circulation on imaging, and reductions in requirements for amputation. (43,61,62,63)
Diabetes with chronic venous insufficiency: Please see the section on chronic venous insufficiency.
Andrographis paniculata and diabetes: More research is needed prior to considering the use of this agent in diabetes (44).
Metformin and diabetes mellitus type 2: Metformin (850 mg) at a dose of three times daily for 4.3 years was associated with a significant 19% decrease in baseline vitamin B12 level and an elevated homocysteine level was also seen (45).
Coenzyme Q10 and endothelial function: A meta-analysis examining the results of five randomized controlled trials with 194 subjects found that coenzyme Q10 increased endothelial-mediated dilation of blood vessels which may improve endothelial dysfunction (49).
Diabetic retinopathy: A number of studies have shown that Pycnogenol, French maritime pine bark extract, improved blood vessel resistance, reduced leakages into the retina, was at least as effective as calcium dobesilate, and was well tolerated with gastric discomfort being the most common side-effect (41).
Emblica officinalis (gooseberry), fenugreek (herb), and Andrographis paniculata have promising future possibilities for use in diabetes mellitus, but more research is needed to determine efficacy and safety (33).
Nonalcoholic fatty liver disease (NAFLD) and diabetes: Patients with nonalcoholic fatty liver disease (NAFLD) who complied with regular aerobic exercise for 30 min per day at least 5 days per week to achieve around 70% of maximal heart rate for 6 months duration achieved weight loss, improved insulin resistance, reduced aminotransferase level, and improved liver histology over noncompliant subjects (15).
