Summary by Marcia J. Egles M.D, March 1, 2011. Posted May 4, 2011. mk/r
Despite encouraging data that type II diabetes may be a largely
preventable disease, the twenty-first century is seeing it in epidemic
levels in the United States and worldwide. As reported by the Center
for Disease Control (CDC), from 1980 through 2007, the number of
Americans with type II diabetes has more than tripled (from 5.6 million
to 18 million) and continues to rise to now nearly 26 million.
Projections from the new 2010 census data by the CDC are even more grim
with an expected 25% of the population being diabetic by 2040 (1,2).
Worldwide Type II diabetes is reaching pandemic proportions, with no
sign of abating (3).
The escalating rates of diabetes cause great human and financial
burden, with estimated (2007) annual United States’ medical costs at
more than 174 billion dollars (1). Much of the expense and misery of
diabetes is attributable to its long-term complications which cause more
cases of blindness,
renal
failure, and amputations than any other disease (4). In addition,
diabetes is associated with a 2- to 5-fold increase in (5, 6), which
contributes to premature deaths, reducing life expectancy by up to 15
years. The diabetes-specific complications which occur in the tiny blood
vessels of the eye’s retina and the kidneys can be reduced
substantially by lowering chronic hyperglycemia (high blood sugar,7,
8). Whether similar reductions decrease cardiovascular disease in type
II diabetes is not as clear (9, 10).
The best documented strategy to avoid diabetes or to improve its
course is to maintain a healthy body weight and to exercise. This
common knowledge continues to be backed by medical research. Excellent
evidence that even modest weight loss and exercise reduces the risk of
type II diabetes is provided by many studies including the Diabetes
Prevention Program published in the February, 2002 issue of the New
England Journal of Medicine. This study reported a 58% reduction in new
diabetes cases for adults at risk for diabetes who implemented a weight
loss and exercise program compared to others who remained more
overweight and sedentary (11). Similarly, a British meta-analysis
estimates that lifestyle interventions can reduce the risk of
progression of pre-diabetes to diabetes by about 60% (12).
Exercise
High-quality studies establishing the importance of exercise and
fitness in diabetes were lacking until recently. It is now
well-established that regular physical exercise not only improves blood
glucose control, but also can prevent or delay type II diabetes, along
with positively affecting
lipids,
blood pressure,
cardiovascular events, death rate, and quality of life. (13,14) The
current recommendation of the American Diabetes Association is for
diabetics to engage in 150 minutes per week of moderate to brisk
physical activity ( 13). The exercise should be spread out over at least
three days a week, with no breaks of longer than two days.
Many at risk for diabetes cannot or do not become active. Even less
ambitious regular physical exercise also appears to be of value. A
Finnish four year study showed that high risk individuals who
significantly increased their physical activity saw the most benefit in
reducing the risk of the onset of diabetes, but also those who increased
physical activities such as walking showed at least some benefit (15).
Diet and Dietary Supplements in Diabetes Prevention and Health
The known modifiable risk factors for type II diabetes are excessive
body weight and sedentary lifestyle. Increasing age and a history of
relatives having the disease also increase the likelihood of its
development. There is no drug or dietary supplement that has been shown
to prevent diabetes. This article seeks to review current medical
research involving dietary and supplement information that may be of
value to those affected by diabetes.
Diabetes is a disease of impaired carbohydrate metabolism. Blood
levels of the carbohydrate glucose (sugar) rise too high in the blood
causing both immediate and long-term problems. The hormone insulin
which is produced in the pancreas lowers the blood glucose by moving the
glucose into the body’s cells where it is converted to energy or, if
there is excess, altered to be stored as fat. In type I diabetes, the
pancreas is unable to make sufficient insulin to lower the glucose
appropriately. A type I diabetic must receive insulin for survival. In
type II diabetes, the person makes insulin, and actually can have very
high insulin levels, however the insulin does not work as well as it
should. The body’s cells are “impaired” to the glucose lowering effects
of the insulin, and like the type I diabetic, the glucose in the blood
rises while the body’s cells starve for glucose. The extra glucose in
the blood is processed through the kidneys and spills into the urine
creating an overabundance of urine and severe thirst. Dehydration
ensues if the person is unable to keep up with the body’s loss of water
to the urine. Long-term complications of diabetes, some of which are
attributed to chronically high blood glucose, include blood vessel
disease affecting the brain, eyes, heart, kidneys, and muscles-
essentially the entire body.
Food choices and activities are highly individual, but lifestyles
that promote a normal body weight are extremely advantageous against
diabetes. In general foods that generate less glucose as they are
digested, that is, ones with a lower “ glycemic load” are easier on a
diabetic’s strained glycemic system. Low glycemic foods would include
foods low in carbohydrates. Some carbohydrate type foods are more
glycemic than others – sugary foods would be the highest glucose
burden. However some carbohydrate rich foods are more complex and are
relatively difficult for the body to process into glucose. Unrefined
or whole grain foods and legumes would be examples. The presence of
fiber in the food further slows the absorption of the glucose and can
lower the glycemic load.
Several studies support the idea that diabetics do better in general
with lower glycemic and higher fiber foods. Brown rice, which is a less
processed, higher fiber and lower glycemic alternative to the more
popular white rice, is an example of one such beneficial food. ( See
NHRI articles on brown rice ) One study estimated that replacing 50
grams per day (uncooked, equal to one-third serving per day) of white
rice with the same amount of brown rice was associated with a 16%
reduced risk of diabetes ( 16).
Other relatively low-glycemic , high fiber food choices include nuts
and seeds. These are also sources of omega-3 fatty acids which have
been demonstrated to be of value to both cardiovascular disease and to
diabetes ( NHRI reviewed ,17 ). Walnuts in particular have been a
focus of research and may improve blood vessel health in diabetics (
NHRI reviewed ,18 ).
An overall way of eating that has gained increasing recognition as
beneficial especially to those with diabetes and heart disease is the
Mediterranean diet (19). The Mediterranean diet is rich in fruit,
vegetables, nuts, legumes, whole grains, fish and low-fat dairy products
with olive oil as its main source of fat. Red wine is consumed in
small to moderate quantities. Meat and eggs are eaten in minimal
amounts. An ever-increasing number of studies, including clinical
trials (20,21), underscores the particular benefits of this nutrient
rich, high fiber style of eating in the management and prevention of
diabetes.
In a recent four year study from Naples, Italy (20), a
Mediterranean-style low-carbohydrate diet was compared with a low-fat
diet of similar calories in 215 newly diagnosed, type II, overweight
diabetics. Participants in one group were assigned to follow a
Mediterranean diet with no more than half their daily calories from
carbohydrates. Participants in the other group were assigned to follow a
low-fat diet similar to that recommended by the American Heart
Association – with no more than 30 percent of its daily calories from
fat and 10 percent from saturated fat.
Both diet groups saw benefits. Of those on the Mediterranean diet,
56% were in control of their diabetes without the use of diabetic
medications, compared to 30 per cent of the low-fat diet group.
Participants assigned to the Mediterranean-style diet also lost more
weight and experienced greater improvements in glycemic control and
coronary risk measures than did those assigned to the low-fat diet.
This study emphasizes that for many type II diabetics, diabetes can be
well controlled by diet.
Dietary Supplements in the Prevention and Treatment of Diabetes
Chromium
Chromium is a naturally occurring element found in tiny, “trace”
amounts in a widespread variety of foods. Chromium has been a logical
focus of diabetes research, because of observations made in the
development of intravenous food in the 1970’s. Patients who were unable
to eat were fed nutrients through their veins. After many months of
only intravenous food, they developed diabetes. When trace amounts of
chromium were added to the experimental intravenous food, the diabetes
resolved (22).
Intravenous food (”TPN”) has since been formulated with trace
chromium. Although chromium has been shown to be involved in
carbohydrate and lipid metabolism, and thought to affect insulin action,
the molecular mechanisms concerning chromium remain unknown. Similar
cases of definite chromium deficiency in persons who are able to eat
regular food have not been medically demonstrated.
The tantalizing possibility of chromium insufficiency as a cause of
type II diabetes has been studied. Despite the attention chromium has
received, chromium’s role in diabetes remains uncertain. To date,
although studies have shown lower chromium levels in diabetics as
compared with peers, chromium supplements have not demonstrated benefit
in the prevention of diabetes (24).These studies have not been large
clinical trials and doses and duration of chromium used have been
variable. No toxic concerns were reported with dosages of chromium
picolate up to 1000 micrograms per day for 64 months (25).
For persons having type II diabetes, chromium supplements may hold
some benefit. The same review study(24) which concluded no benefits had
been shown of chromium to the prevention of diabetes also asserted that
their meta-analysis of 14 clinical trials showed,” Chromium
supplementation significantly improved glycemia among patients with
diabetes.” Another review (26) observed that many of the chromium
studies which showed no benefit used doses of less than 200 micrograms
per day. A more consistent clinical response is observed with daily
supplementation of chromium greater than 200 micrograms per day for a
duration of more than two months. In addition, chromium picolate
appears to be clinically more effective than chromium chloride in both
human and animal studies. Although the use of supplemental chromium has
gained in acceptance among diabetes physicians (27), currently the
American Diabetes Association does not endorse it because of the
conflicting studies (28).
More clinical trials are in progress. Supplements containing
chromium picolinate in combination with biotin are undergoing extensive
study with a dose of 600 micrograms per day plus 2 milligrams daily of
biotin (29).
Chromium has been reported to reverse corticosteroid-induced
diabetes. In case studies of patients with steroid-induced diabetes
treated with 600 micrograms per day chromium picolate, fasting blood
glucose values fell from 250 to 150 mg/dl. The requirement for
antidiabetic drugs was also reduced by 50% in these patients. Chromium
picolate at doses of 600 micrograms per day has been recognized by some
diabetologists as valuable in the treatment of steroid–induced diabetes
(30).
Vitamin C
The anti-oxidant vitamin C, or L- ascorbic acid, is an essential
dietary nutrient in humans. The nutritional disease of scurvy results
from severe vitamin C deficiency. As little as 10 mg daily of vitamin C
will prevent scurvy. The daily amounts of vitamin C for optimal health
might be higher than that needed to avoid scurvy, with some experts
advocating large daily amounts, in excess of 2 grams per day in some
circumstances. Other studies have warned against exceeding 300 mg per
day and that adequate vitamin C is obtained by regularly eating ordinary
amounts of fruits and vegetables ( 31).
Oxidative stress has been implicated in both the onset of type II
diabetes and the worsening of its complications (32,33). The intriguing
utility of the antioxidant vitamin C to the prevention and treatment of
diabetes has received attention in medical research. Type II diabetics
have been found in observational studies to have lower than normal
levels of vitamin C and other antioxidants(34,35,36).
The first major clinical trial (37) looking at the potential of
preventing type II diabetes by the long-term supplementation of
antioxidant vitamins was reported in 2009. This 9 year study, the
Women’s Antioxidant Cardiovascular Study,(WACS), involved 8171 female
health professionals over the age of 40 who were at risk for
cardiovascular disease. They were randomly assigned to receive 500 mg of
vitamin C daily, vitamin E ( RRR-alpha- tocopherol acetate, 600 IU
every other day), beta-carotene ( 50 mg every other day), or placebos.
Although there was a slight but statistically insignificant reduction in
the number of women who developed diabetes in the vitamin C group, the
study concluded that it showed no significant overall effects of vitamin
C, vitamin E or vitamin A on the risk of developing diabetes in women
with high risk of heart disease. This study also noted that a subgroup
of women with high cholesterol, showed a less than expected number of
new diabetes cases in the vitamin C group. Further study with a larger
number of this subgroup would be needed to determine if those with high
cholesterol might lessen their risk of diabetes through treatment with
vitamin C. Because of the strength of preliminary studies which link
low levels of vitamin C to type II diabetes, further clinical trials
looking at vitamin C supplements will likely be reported. At this time
however, there is insufficient evidence for diabetologists to recommend
that vitamin C supplements be given for the primary prevention of type
II diabetes (37).
As to whether diabetics would benefit from vitamin C supplementation
is a current ongoing question of research. Similar in some respects to
the vitamin C deficiency disease scurvy, patients with diabetes have
fragility and poor healing of blood vessels and connective tissue.
Besides its importance as an antioxidant, vitamin C is essential to the
body’s production and maintenance of collagen which is a key structural
component of blood vessels and other body structures.
A 16-year study of 85,000 women, 2% of whom were diabetic, found that
vitamin C supplement use (400 mg per day or more) was associated with
significant reductions in the risk of fatal and nonfatal coronary heart
disease in the entire vitamin C group as well as in those with diabetes
(38). Reaching an opposite conclusion, a 15-year study of
postmenopausal women found that diabetic women who reported taking at
least 300 mg per day of vitamin C from supplements when the study began
were at significantly higher risk of death from coronary heart disease
and stroke than those who did not take vitamin C supplements (39).
Neither of these two large, long studies were randomized controlled
clinical trials. Clinical trials to date, which have been shorter in
duration than these two long -term studies, have not found antioxidant
supplementation that included vitamin C to reduce the risk of
cardiovascular disease in diabetic or other high-risk individuals
(40,41).
With the extensive WACS clinical trial (37) using 500 mg daily of
supplemental vitamin C for 9 years and finding no cardiovascular risk,
perhaps a prudent approach for a diabetic would be to eat daily foods
that contain vitamin C, and if choosing to use a supplement, to stay
below 500mg vitamin C per day. Diabetics should be aware that
“megadose” vitamin C, that is, doses above 2 grams per day, has been
reported to cause hyperglycemia (42).
Vitamin D
Similar to the state of vitamin C research, many strong medical
studies have found an association of the onset of type II diabetes with
low levels of vitamin D (43). Any prevention of diabetes by
supplementing vitamin D, however, has yet to be clearly demonstrated by
clinical trial (44).
Aloe Vera
There is emerging evidence that products from the aloe plant may be
efficacious for diabetics. The range of aloe products is quite diverse,
from many species of aloe and from three different parts of the plant.
Aloe studies are few in number, and not uniform with regards to dosage
or product. A pharmaceutical review of recent studies (45) concluded
that a ”preponderance of evidence“ showed that oral aloe vera might
beneficially reduce blood glucose levels in diabetics. Because of
currently insufficient data, however, this review board could not
recommend the use of aloe vera for the management of diabetes or
dyslipidemia.
Patients using an aloe preparation should be aware that since aloe
can have the desirable effect of lowering blood sugar, it can also lower
blood sugar dangerously too low, therefore, blood sugars must be
carefully monitored. Adverse effects such as diarrhea, with potentially
serious electrolyte imbalances, can occur as aloe can act as a
laxative. Aloe should be discontinued one to two weeks prior to
surgery as cases of prolonged surgical bleeding have been reported with
its use (46).
Cassia Cinnamon
One fairly well studied supplement used to help hyperglycemia in
diabetics is cassia cinnamon. Animal and laboratory studies have
indicated that cinnamon may mimic the effects of insulin and make cells
more sensitive to insulin (47).
In diabetic patients, some studies have shown a favorable response;
some no effect. The most comprehensive review of cinnamon use in
diabetics, published in 2008 by the journal Diabetes Care(46), found no
metabolic benefits to the use of cinnamon by type I or type II
diabetics. Specifically, no benefits to fasting blood glucose, lipids,
or cholesterol were observed in a meta-analysis of five small clinical
trials. An earlier small study, published by the same journal in
December 2003 (47), had reported a modest reduction in blood sugar by
diabetics using a quarter teaspoon to a teaspoon of cinnamon daily.
More studies on the effects of cinnamon in diabetes are still ongoing,
but in the hierarchy of research studies, a meta-analysis of clinical
trials is considered to be more reliable than a single clinical trial.
More recently, a 2009 study reported antioxidant effects of cinnamon
studied in type II diabetics (50). A twelve week , small clinical
trial in Britain in 2010 again reported small improvements in blood
sugar and blood pressure in diabetics taking 2 grams of cinnamon daily
(51). In a 2009 a randomized controlled trial (52) with 109 type 2
diabetics whose A1c levels were 7 or higher at baseline, cassia cinnamon
capsules at a dose of 1 g daily for 90 days, added to usual care,
lowered their A1c by 0.83%. In contrast, those who received usual care
but no cinnamon lowered their A1c by 0.37%. These investigators
recommended cinnamon as an adjunct to diabetes care for patients with an
A1c level greater than 7.0%.
Most people find cinnamon to be likable and it may help at least to a
small degree in diabetes. Cinnamon’s safety record is excellent.
(Coumadin patients need to know that cinnamon can prolong the protime.)
Cinnamon can make whole grains and other fiber-rich foods more
appealing without adding calories, fat or salt. Two grams of cinnamon is
a bit less than half a teaspoon.
Conclusion
Current medical research shows that Type II diabetes mellitus is a
largely nutritional disease, the course of which can be significantly
improved through lifestyle interventions such as advantageous food
choices and exercise. Diabetes is also a longterm, discouraging
battle. Those contending with its threats often suffer blame from
themselves and criticism from those around them. As with many chronic
diseases, diabetics are at increased risk of clinical depression (53).
This review is offered in the hope that those seeking help with diabetes
will find encouraging information to bolster themselves against this
disease.
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