Diabetes - Brandywine Chiropractic Alternative Medicine Library

Diabetes Mellitus

Diabetes is a disease that affects the body's ability to produce or respond to the hormone insulin. There are over 15 million people, or about 6 percent of the population in the U.S., who have diabetes. While more than 10 million people have actually been diagnosed with diabetes, another 5.4 million are not aware they have the disease due to an absence of symptoms. For purposes of this discussion, we'll focus our attention on diabetes mellitus, the most common form of diabetes.

Diabetes mellitus is generally divided into two categories: type I and type II. In type I, or juvenile-onset diabetes, the body produces little or no insulin. Individuals with type I diabetes are forced to rely on daily shots of insulin to survive. This is the reason type I diabetes is often referred to as "insulin-dependent diabetes." Fewer than 10 percent of the people with diabetes have type I.

In type II, or adult-onset diabetes, the body makes sufficient quantities of insulin, but has difficulty using the insulin it makes. Ninety to ninety-five percent of diabetics are classified as type II, making it the most prevalent form of the disease. Type II diabetes is seen more commonly in individuals who are over the age of 45, who are overweight, or who have a family history of the disease. In most cases, type II diabetes can be brought under control with proper diet and exercise, which has been shown to improve the blood glucose response.

Causes of Diabetes Mellitus

The cause of type I diabetes is not thoroughly understood, but is thought to be a result of the body's immune system attacking and destroying the insulin producing beta-cells of the pancreas. Diseases where antibodies (large protein molecules that bind to and help to destroy foreign molecules in the body) created for a beneficial purpose end up attacking the body's own tissues are known as "auto-immune" diseases. Antibodies for beta-cells (cells which produce insulin) are present in about 75 percent of people with type I diabetes, compared to less than 2 percent of non-diabetics. It is believed that these antibodies may have developed in response to certain chemicals, food allergies, viruses, or free-radicals. Once the insulin-producing cells in the pancreas have been destroyed, the body is no longer able to produce insulin and regulate blood sugar levels. People with type I diabetes must rely on daily shots of insulin to maintain control of the disease. Of the two types of diabetes, type I is the most serious.

Type II, or adult-onset diabetes, results not from a lack of insulin, but from an overabundance of insulin. When carbohydrates are consumed, blood sugar levels rise and signal cells in the pancreas to release insulin. Insulin removes sugar from the blood (glucose), and allows it to enter cells throughout the body, where it can be used as an immediate source of fuel, or stored for future use. People with type II diabetes have insulin resistance, meaning that their bodies do not respond well to insulin. Insulin resistance develops when the pancreas overcompensates, providing too much insulin to the bloodstream. Over time, high levels of insulin can damage sensors in the cells, making them unresponsive to the effects of insulin. To compensate, the pancreas will produce more and more insulin in an attempt to normalize blood sugar levels (healthy individuals secrete approximately 31 units of insulin daily, while obese type II diabetics secrete an average of 114 units per day). However, at some point, the sensors become so damaged that the not even the increased amount of insulin being produced by the pancreas is enough to normalize blood sugar levels. Once this point has been reached, adult-onset diabetes has developed.

Risk Factors for Diabetes Mellitus

Diabetes in its early stages has very few, or no symptoms. Many people can live for years without knowing they have the disease, making it a silent killer. Damage may occur to the eyes, kidneys and cardiovascular system even before symptoms of the disease are evident. Individuals at risk for diabetes should speak to their doctor about being tested for diabetes. It is currently recommended that all adults age 45 and older be tested for diabetes. If blood glucose is normal at the time of the first test, individuals should be tested at three-year intervals.

Type I diabetes is more likely to occur in:

Siblings of people with type I diabetes
Children of parents with type I diabetes

Type II diabetes is seen more commonly in people who:

Are over the age of 45
Are more than 20 percent above ideal body weight and who have a body mass index (BMI) greater than or equal to 27
Have a first-degree relative with the disease (i.e. mother, father, brother or sister)
Do not participate in regular exercise
Have a blood pressure reading above 140 / 90 mmHg
Have abnormal fat levels in their blood such as an HDL reading less than or equal to 35 mg/dL, or a triglyceride measurement greater than or equal to 250 mg/dL
Have the stress of an illness or injury
Have had diabetes during pregnancy
Have had a baby weighing more than 9 pounds
Are a member of a high-risk ethnic group including African-American, Hispanic-American, American-Indian, Alaska-Native, Asian-American, or Pacific Islander-American)
Have impaired glucose tolerance or impaired fasting glucose
Consume a diet low in fiber and high in refined sugar

Symptoms of Diabetes Mellitus

Individuals with type I diabetes mellitus usually know they have the disease as the symptoms are both severe and of sudden onset. In contrast, the symptoms of type II diabetes usually occur slowly over a period of time and can be difficult to recognize. In fact, many people with type II diabetes are unaware they have the disease due to the subtle nature of symptoms. Regular screening and testing for diabetes should be performed on anyone at high-risk for the disease. For the most part, the symptoms of type I and type II diabetes are similar. If you, or someone you know, is experiencing any of the following symptoms, we suggest contacting your doctor. Symptoms with an asterisk (*) next to them are found more commonly in type I diabetics, but can also occur in type II diabetes.

Frequent urination *
Excessive thirst *
Weight loss *
Increased appetite *
Irritability *
Severe fatigue, tiredness, or drowsiness *
Muscle weakness
Blurred vision that changes daily
Tingling or numbness in the hands and feet
Cuts or ulcers that do not, or are slow, to heal
Frequent skin, gum and bladder infections
Dry itchy skin
Sexual dysfunction in men (impotence)

Complications of Diabetes Mellitus

With its complications, diabetes has become the sixth leading cause of death by disease in the United States. An estimated 384,000 Americans die each year as a result of diabetic complications. The likelihood of developing these complications can be significantly reduced with proper management of blood sugar levels. Monitoring and controlling fluctuations in blood sugar are the keys to avoiding many of the major complications associated with diabetes. Rather than simply provide you with a list of these complications, we find it more beneficial to first explain how and why they develop. Understanding the cause of diabetic complications is an integral part of their management and prevention. Furthermore, most people with diabetes know little or nothing about the disease they suffer from. The following sections should help to clarify things.

When food is consumed, sugars, starches and other carbohydrates are converted into glucose (blood sugar) and transported in the bloodstream to cells throughout the body. In order for glucose to actually enter the cells and be used for energy, the hormone insulin is required. People with diabetes either produce little or no insulin, or are unable to use the insulin they make, and therefore have problems removing glucose from the blood and using it for energy. This causes their blood sugar levels to become abnormally high (hyperglycemia). If the level of glucose or sugar in the blood becomes too high, it will begin to spill out into the urine, taking with it large quantities of water. At this point, symptoms of excessive urination and thirst may develop. The only way to correct this problem is to either supply insulin in the form of shots (type I diabetes) or to make the cells more receptive to the effects of insulin (type II diabetes). Taking too much insulin, skipping meals, or exercising too hard can cause blood sugar levels to fall below normal, while not taking enough insulin, eating large meals, or leading a sedentary lifestyle can cause blood sugar levels to rise to high.

Because people with diabetes are not able to use glucose as a source of fuel, they must rely on stored fat (triglycerides) to fulfill their energy requirements. When fat is metabolized for energy, ketones or ketone bodies are produced. Ketone bodies are acidic in nature. If ketone bodies in the blood build to higher than normal levels as is the case in starvation and carbohydrate-restricted diets, a condition known as ketosis will result. In normal individuals this is not a problem as they can limit production of ketone bodies, but in diabetics, the uncontrolled build up of ketone bodies can lower the PH of the blood and lead to ketoacidosis. Ketoacidosis is considered a medical emergency, and if not treated, can result in numerous metabolic problems, coma, or even death. Symptoms of ketoacidosis include extreme fatigue, nausea and vomiting. People with type I diabetes are most often affected by this condition. Dip sticks that measure the level of ketone bodies in the urine are available at most pharmacies.

Chronically elevated levels of insulin in the blood, as is the case in type I diabetes, are associated with high cholesterol and triglyceride levels, cardiovascular disease, hardening of the arteries, high blood pressure, water-retention and excess storage of fat. Blood vessels which have become hardened and narrowed can reduce the supply of blood to certain areas of the body (most often the extremities) and lead to sensory disturbances. If the blood supply to a specific area has been disrupted long enough, tissue death will occur and may require amputation. Reducing blood supply to an area of an injury can also make healing difficult.

The accumulation of sorbitol within certain tissues is also believed to play a role in the development of diabetic complications. Sorbitol, a simple sugar, is a byproduct of glucose metabolism. In normal individuals, sorbitol is converted to fructose and excreted from the cell. Diabetics have problems removing sorbitol from their cells, which can build up to abnormally high levels. Elevated levels of sorbitol are found in high concentration in the tissues commonly affected by diabetic complications such as the eyes, nerve cells and the cells of the retinol blood vessels.

Remember, the best way to prevent these complications from occurring is by monitoring and controlling any abnormal fluctuations in blood sugar levels. We have summarized both the acute and chronic complications of diabetes mellitus below.

Acute Complications

Hypoglycemia: Hypoglycemia, or low blood sugar, can result from taking too much insulin, skipping a meal, or over-exercising. Symptoms of hypoglycemia include sweating, headaches, inability to concentrate, nervousness, hunger, anxiety, personality changes, rapid heart beat, blurred vision and numbness or tingling in the mouth or lips. It is important that a good relationship exist between the patient and the physician prescribing the insulin so that dosages can be adjusted accordingly. Hypoglycemia primarily affects individuals with type I diabetes.
Diabetic Ketoacidosis (DKA): Ketoacidosis is a condition resulting from a build up of ketones or ketone bodies in the blood. This condition is considered a medical emergency, and if not treated, can result in numerous metabolic problems, coma and even death. Diabetic ketoacidosis is responsible for about 10 percent of diabetes-related deaths in people under the age of 45.

Chronic Complications

Blindness (diabetic retinopathy): Diabetes is the leading cause of new blindness in people 20-74 years of age.
Kidney Disease (diabetic nephropathy): Diabetic nephropathy is a common complication and leading cause of death in diabetes.
Cardiovascular Disease & Stroke: People with diabetes are 2-4 times more likely to die from heart disease and stroke than non-diabetics.
Nerve Damage & Amputation: Sixty to seventy percent of people with diabetes have mild to severe forms of nerve damage, which in severe cases, can result in limb amputations. In fact, diabetes is the most frequent cause of non-traumatic lower limb amputation. Diabetics have a 15-40 times greater risk of leg amputation than non-diabetics.
Peripheral Vascular Disease: Peripheral vascular disease results from a reduced flow of blood and oxygen to the feet and legs. The principle symptom of peripheral vascular disease is pain in the buttocks, thigh, or calf while exercising or walking, a condition known as intermittent claudication. Individuals suffering from intermittent claudication are at high risk for coronary heart disease, stroke and cardiac failure.
Foot Ulcers: Diabetic foot ulcers are primarily the result of poor blood supply to the foot and peripheral nerve damage. Diabetics are 20-times more likely to develop gangrene of the foot than those without the disease.
Impotence: Impotence due to diabetic neuropathy or blood vessel blockage affects 13 percent of men with type I diabetes and 8 percent of those with type II diabetes. Men with diabetes, over the age of 50, have impotence rates as high as 50 to 60 percent.
Dental Problems: Chronically elevated levels of blood sugar can increase a person's risk for tooth and gum problems. Proper daily care at home, coupled with regular dental check-ups (every 6 months), can help to prevent these problems from occurring.
Pregnancy: Maintaining control over blood sugar levels before conception and throughout pregnancy is vital to the health of both the baby and the mother. Pregnant women with poorly controlled diabetes are more likely to:

give birth to infants with congenital malformations

deliver by cesarean section due to an increased birth weight of the infant

develop toxemia (high blood pressure, protein in the urine, and edema) during pregnancy

approximately 40 percent of the women who develop diabetes during pregnancy (gestational diabetes) and who are obese before pregnancy, will develop type II diabetes within 4 years.

Diagnosis of Diabetes Mellitus

Diabetes is a disease that affects the body's ability to produce or respond to insulin, the hormone that allows glucose to leave the blood and enter cells throughout the body. Because people with diabetes are unable to remove glucose from their blood, it builds to abnormally high levels, a condition known as hyperglycemia. The standard method of diagnosing diabetes involves measuring the amount of glucose in the blood using one or more of the tests listed below. Test results should be correlated with physical exam findings, symptoms, and medical history.

Fasting Blood Glucose Test

The fasting blood glucose test measures the concentration of glucose in the blood after an overnight fast of at least eight hours. A small sample of blood is drawn and sent to a laboratory for analysis. A normal fasting blood glucose level should be less than 110 mg/dl. A fasting blood glucose measurement of more than 126 mg/dl on two separate occasions is indicative of diabetes. The fasting blood glucose test is preferred over the oral glucose tolerance test because it is less expensive, easier to administer and more acceptable to the person being tested.

Random Blood Glucose Test

Occasionally, random samples of blood taken shortly after eating or drinking may be used to test for diabetes when symptoms are present. A blood glucose level of 200 mg/dl or higher is suggestive of diabetes, but must be confirmed on another day using a fasting blood glucose test or an oral glucose tolerance test.

Oral Glucose Tolerance Test (OGTT)

The OGTT is usually performed in the morning following a 10- to 14-hour overnight fast. Individuals should avoid consuming coffee and/or smoking prior to taking this test. It is further recommended that individuals consume a minimum of 150-200 grams of carbohydrates daily, 1-2 days prior to taking the test.

Upon arriving at the testing center, a fasting blood glucose test is administered. Following this test, subjects are required to consume a chilled solution containing 75 grams of glucose (pregnant women are given a 100 gram solution, while the test dose in children is1.75 grams per kilogram of body weight). After consuming the glucose solution, blood samples are drawn at 30-minute intervals over a two-hour period. In non-diabetics, blood glucose levels will rise and fall quickly. In diabetics, glucose levels tend to rise higher than normal and fail to come down as fast.

Patients are considered normal if their two-hour blood glucose level is below 126 mg/dL and if all values between zero and two-hours are less than 200 mg/dl. An individual is considered to have impaired glucose tolerance when their fasting blood glucose level is below 126 mg/dl and their two-hour glucose reading is between 140 and 199 mg/dl. Impaired glucose tolerance is considered a major risk factor for type II diabetes, and is found in approximately 11 percent of the population. Individuals with impaired glucose tolerance should be screened at regular intervals for diabetes. Glucose readings above 200 mg/dl at two-hours and at least once between zero time and two-hours are indicative of diabetes. In order to establish a definitive diagnosis of diabetes, a second positive test obtained on a different day is required.

For the glucose tolerance test to be considered reliable, individuals should be in good health (no colds or other illnesses), normally active (not lying down or bedridden), and not taking any medications known to impair glucose tolerance such as diuretics, glucocorticoids, nicotinic acid, or phenytoin.

An international committee of experts states that a diagnosis of diabetes is warranted for any of three positive tests, with a second positive test on a different day. These tests may include...

A fasting blood glucose test greater than or equal to 126 mg/dl.
A random blood glucose test greater than or equal to 200 mg/dl with symptoms of diabetes.
An oral glucose tolerance test value of greater than or equal to 200 mg/dl measured at the two-hour interval.

Conventional Management of Diabetes Mellitus

Because poorly managed diabetes can lead to a host of long-term complications, the primary focus of any diabetes management program should be to limit or prevent these complications from occurring. It has clearly been established that the complications of diabetes are a direct result of abnormalities in blood glucose. The Diabetic Control Complications Trial (DCCT) confirmed that near normalization of blood glucose levels may decrease the risk of diabetic eye problems by 76 percent, kidney disease by up to 56 percent, and nerve damage by up to 60 percent in patients with type I diabetes. Many authorities also contend that good blood glucose control can also help to reduce the complications of type II diabetes.

The American Association of Clinical Endocrinologists has adopted a series of guidelines for the management of diabetes mellitus. Adhering to these specific guidelines can not only help to reduce a persons risk of diabetic complications, but can also improve a patients' quality of life and lower the total cost of care associated with diabetes mellitus. For this system of management to be successful, the following are required.

Active participation in the program by the patient
A health care team which is committed to patient care
Adherence to the schedule of interactions recommended between the patient and the health care team

It is important that people with diabetes seek out a health care team which is managed and led by a clinical endocrinologist or other physician with experience in diabetes management, and includes a nurse or dietitian skilled in diabetes education, and, as needed, an exercise physiologist, psychologist and pharmacist.

The American Association of Clinical Endocrinologists (AACE) has recommended a three-phase diabetic management program. Phase I involves assessing the patients' current disease status and risk factors for long-term diabetic complications. The phase I evaluation should include a thorough patient history, comprehensive physical examination and laboratory evaluation. Doctors should also assess a patients' knowledge base regarding diabetes and willingness to participate in a program of intensive treatment for diabetes during the initial phase of management.

Phase II of the AACE's diabetes management program is focused on evaluating the patients physical condition, level of blood glucose control and degree of compliance. This stage of care may involve an interim history, physical exam, laboratory evaluation and a review of the patients' self-monitored blood glucose results. The patients' understanding of diabetes mellitus and self-management skills should also be evaluated during the second phase of management. It is recommended that phase II evaluations be scheduled at intervals of no longer than 3 months.

The goal of third and final phase of any diabetic management program should be to assess for the presence of and/or evaluate the severity of diabetic complications using a series of four complication modules. These include: retinal evaluation, cardiac/peripheral vessel evaluation, renal evaluation and neuropathy evaluation. Complication modules should be performed in conjunction with phase II follow-up assessments.

Ultimately, it is the patient who is responsible for adhering to a diabetic management program. Rather than follow an intensive plan of action such as the one recommended by the AACE, many people with diabetes opt for standard medical care. However, this type of care may lead to a higher rate of serious complications, whereas intensive diabetes management programs can help to maintain normal or near normal blood glucose levels and avoid many of the complications associated with diabetes mellitus. Standard or conventional programs to manage diabetes typically consist of the following measures.

Insulin Shots: Type I diabetics must begin using insulin as soon as they are diagnosed with diabetes, while type II diabetes may initially be controlled through dietary changes, regular exercise and diabetes pills. Because insulin is unable to be absorbed orally, it must be administered by way of injections. Insulin preparations may be derived from a variety of sources (beef, pork, or human synthetic insulin), and can differ in their duration of action (rapid, intermediate, or long-acting) and solubility (crystalline vs. soluble). Because human synthetic insulin is almost identical to the insulin produced by the body, few diabetics experience problems when using it. Conventional insulin therapy involves administering a mixture of rapid- and intermediate-acting insulin once or twice daily. Research suggests that this relatively crude approach to managing diabetes can increase a person's risk of long-term complications. A newer, more sophisticated method of insulin therapy has recently been developed. This method, known as "intensive insulin therapy," requires patients to either increase the number of daily insulin shots they take to three or four, or to use an "insulin pump" to administer a continuous supply of insulin. Intensive insulin therapy is designed to mimic the way a healthy pancreas continuously varies insulin levels in the blood, and has been shown more effective than conventional insulin therapy at limiting long-term diabetic complications.
Diabetes Pills: Diabetes pills, or oral hypoglycemic agents, are typically prescribed for people with type II diabetes. These drugs work by enhancing the sensitivity of cells in the body to insulin, and by increasing the amount of insulin secreted by the pancreas. Examples of oral hypoglycemic agents include: Diabinese, Glucotrol, Diabeta, Tolinase and Orinase. There is a considerable amount of evidence to suggest that these type of drugs (sulfa-drugs) have the potential to produce serious side effects, as well as increase a person's risk of death. A study conducted by the University Group Diabetes Program (UGDP) examined the long-term effects of Orinase (tolbutamide) and found that the ratio of deaths due to heart attacks or stroke was 250% greater for type II diabetics using Orinase compared to a group controlling their type II diabetes through diet alone. Side effects reported in the study included hypoglycemia, allergic skin reactions, fatigue, headache, nausea and vomiting, and liver damage. Dr. Michael Berger, professor of medicine at Dusseldorf University, Germany and author of the book Oral Agents in the Treatment of Diabetes Mellitus, writes "Unfortunately the use of sulfa-drugs has become entrenched as the treatment of laziness, both on the part of the physician and the patient. How much easier is it to prescribe or swallow a pill then to explain or observe a weight-reduction diet in combination with an increase in caloric expenditure (exercise)." Dr. Berger believes that sulfa-drugs should only be reserved for use in patients who remain diabetic despite significant weight loss, or who are of normal weight and active. We offer the following recommendations for type II diabetics who are currently using sulfa-drugs...

Adopt a healthy eating and exercise program to lose weight

If your current doctor refuses to assist you in losing weight, find a doctor who will

If you are at or below your ideal body weight and still suffer from type II diabetes, switch to insulin.

Dietary Changes: Consuming healthy foods is essential in the management of diabetes mellitus. Eating right can help to control swings in blood sugar which subsequently can help to protect against the long-term complications associated with diabetes. Healthy eating plans are discussed in detail below.
Regular Exercise: Regular exercise can help to lower blood sugar levels and improve the body's ability to utilize glucose. Diabetics who participate in regular exercise tend to have reduced insulin requirements. Aside from its benefits on blood sugar control, regular exercise can also help to improve overall fitness, control weight and reduce the risk of many diabetic complications.
Patient Education: People with diabetes can reduce their risk for complications if they are educated about the disease. Teaching diabetics the importance of, and skills necessary to maintain control over their blood sugar should be a major goal of any diabetes management program.

Natural Approach to Diabetes Mellitus

General Recommendations

See your doctor regularly: People with diabetes should attempt to see a diabetes specialist at least once every six months, and more if needed. It may also be beneficial to schedule regular appointments with a nurse educator, dietitian, and/or exercise physiologist.
Have regular eye exams: Regular eye exams by an ophthalmologist can help to detect eye problems associated with diabetes before they become severe. Diabetes is the leading cause of new blindness in people 20-74 years of age. Eye damage has no symptoms in its early most treatable stages, making regular exams even more important.
Monitor blood sugar levels daily using a home testing unit: The Diabetes Control and Complications Trial proved that keeping blood sugar levels as close as possible to normal may help to lower the risk for diabetes eye problems by 76%, kidney damage by up to 56%, and nerve damage by up to 60% in patients with type I diabetes. Many authorities contend that good blood sugar control can also help to reduce the likelihood of complications in type II diabetics.
Get regular exercise: An appropriate exercise program is vital to any diabetes treatment program. Regular exercise can improve insulin sensitivity, reduce the need for medication, improve glucose tolerance, reduce serum cholesterol and triglyceride levels, increase HDL levels, improve mood and self-esteem, reduce stress, increase energy, and help to maintain an ideal body weight. When combined with the proper diet, exercise has the ability to control type II diabetes without the need for medication. Prior to beginning an exercise program, it is important to obtain medical clearance, especially if you are over the age of 35 and/or have had diabetes for 10 years or more.
Keep blood pressure under control: Having high blood pressure can increase a diabetics risk of suffering from long term complications such as diabetic retinopathy, kidney disease, cardiovascular disease and nerve damage. People with diabetes should have their blood pressure checked regularly (every 3 months) by their doctor. If blood pressure is found to be elevated, strategies to reduce it should be implemented immediately.
Control and monitor fat levels in the blood: Diabetics are 200-300 times more likely to die from coronary artery disease than non-diabetics. An aggressive approach by both physician and patient should be taken to reduce the risk factors linked to heart attack and stroke. Of particular importance is the reduction of LDL cholesterol and triglycerides in the blood, while increasing HDL cholesterol levels. Recommendations include:

Consuming a diet low in fat, especially saturated fat

Increasing the consumption of fiber-rich plant foods such as fruits and vegetables, legumes and grains

Losing weight if necessary

Getting regular aerobic exercise

Avoiding the use of tobacco

Maintain an ideal body weight: Nearly 90 percent of the people with type II diabetes are obese. There is a tremendous body of evidence implicating obesity in the development of type II diabetes. Many type II diabetics suffer from elevated levels of insulin, indicating a loss of tissue sensitivity to insulin. Achieving an ideal body weight has been shown to improve insulin sensitivity and restore normal blood sugar levels in diabetics who are obese. In many instances, type II diabetes can be controlled through diet and exercise alone. Individuals needing assistance with weight loss should consult a dietitian and certified personal trainer.
Do not smoke: Smoking is a contributing factor in many of the long-term complications associated with diabetes including cardiovascular disease, high blood pressure and poor circulation. Tobacco not only reduces the compliance (elasticity) of arteries, but also constricts peripheral blood vessels and can lead to Buerger's Disease, a severe disease where blood flow is blocked to a specific area of the body resulting in amputation of the affected limb. Smoking has also been shown to increase the rate at which LDL cholesterol is oxidized, thus accelerating the formation of plaque and blockages inside the arteries.

Dietary Guidelines

Following a healthy eating plan is an essential component of any diabetes management program, whether it is type I or type II. Eating right not only helps to control weight, but can also help to stabilize blood sugar and fat levels in people with diabetes, thus reducing a patients risk of long-term diabetic complications. The goals of any nutritionally-oriented diabetes management program should be as follows:

The maintenance of near normal blood sugar levels
Achieving optimal blood lipid levels (cholesterol, triglycerides, etc...)
Prevention or treatment of diabetic complications such as hypoglycemia, high blood pressure, kidney disease, and cardiovascular disease.
Attaining and/or maintaining an ideal body weight
Improving overall health

Although there are several diets commonly recommended in the management of diabetes, the best one appears to be a diet plentiful in cereal grains, legumes, and root vegetables, and low in simple sugars and fats. This type of eating plan is known as a high complex carbohydrate, high fiber diet, or HCHF diet for short. Clinical trials using this type of diet have consistently demonstrated superior results over other types of diets including carbohydrate restriction, high-protein, and the diet currently recommended by the American Diabetes Association (ADA). Benefits of the HCHF diet include increased tissue sensitivity to insulin, improved cholesterol ratios (HDL/LDL), weight control, reduced blood sugar concentration following meals, and improvement in overall health.

The American Diabetes Association Diet

The ADA recommends that complex carbohydrates such as breads, pasta, rice, and potatoes make up 55-60 percent of total calories; protein makes up 20 percent of total calories; and that fat make up 15-30 percent of total calories in the "diabetic diet."

The ADA has developed an "exchange list" system of food choices in which foods are placed into one of six lists according to their nutrient content. The six groups are: starch/bread, meat/substitute, vegetables, fruit, milk, and fats. Portion sizes are indicated for each food to help keep caloric values equal for all foods in a specific list. Meal plans usually specify how many choices may be taken from a list for a meal or snack. This system of meal planning offer some beneficial support to diabetics, especially if it is supplemented with dietary fiber.

Dietary Fiber & Fiber Supplements

Fiber is classified as a complex carbohydrate that cannot be broken down or absorbed by the body. For this reason, fiber has no caloric or nutritional value. Population studies have identified diabetes as being one of the diseases most clearly linked to inadequate dietary fiber. In fact, diabetes is found most commonly in populations consuming a fiber-depleted, high refined-carbohydrate diet (the typical diet of most Americans).

The type of fiber offering the greatest benefit in terms of blood glucose control are the water-soluble fibers such as gums, pectins and hemicelluloses. Soluble fibers work by slowing down both the absorption and digestion of carbohydrates, thereby preventing rapid rises in blood sugar. Other benefits of soluble fiber include: increased tissue sensitivity to insulin, improved glucose uptake by the liver and cells, reduced risk of cardiovascular disease, weight loss, and protection against certain cancers. The best sources of soluble-fiber are legumes (beans), oats, oat bran, nuts, seeds, pears, apples, grapefruit, and most vegetables. People with diabetes should try and consume between 25 and 50 grams of soluble-fiber daily, divided among several meals.

For patients unwilling to increase their intake of dietary fiber, fiber supplements are an option. Supplementing the diet with plant fiber (guar gum and pectin) has demonstrated a positive impact on diabetes control. Many doctors commonly recommend fiber supplements to patients with diabetes. Diabetics on a fiber-supplemented diet are typically able to reduce their insulin requirements to one-third of those following the standard ADA diet (the ADA diet does not recommend the use of fiber supplements). Despite these benefits, fiber-supplemented diets are still not nearly as effective as a HCHF diet.

When selecting a fiber supplements, be sure it contains a mixture of both soluble and insoluble fibers. Psyllium (Metamucil, Fiberall) is probably the best option since it contains a blend of 75 percent soluble fiber and 25 percent insoluble fiber. When using a fiber supplement, be sure and increase your daily dose gradually to reduce the likelihood of experiencing bloating and/or diarrhea.

The Food Pyramid

People with diabetes should strive to improve their choice of foods. The food pyramid can be used as a beginning guide for people with diabetes. The pyramid is divided into sections, with each section providing some, but not all, of the nutrients required on a daily basis. Foods shown at the bottom of the pyramid should be consumed in greater amounts than those found towards the top of the pyramid. Again, the pyramid is only a guide and should not be used as a nutrition planning tool in people with diabetes.

The Bottom Line

With respect to dietary management of diabetes, we offer the following recommendations. Keep in mind, however, that these are only general recommendations and that individual requirements may vary. Always obtain the consent of your diabetes specialist prior to making any changes in your diabetes management program. These recommendations apply to both type I and type II diabetics.

Macronutrient intake should be as follows: 55-60 percent of total calories from complex carbohydrates, 20 percent of total calories from lean proteins, and 20-25 percent of total calories from fat (preferably mono- and polyunsaturated vegetable oils and lean proteins such as chicken and fish). From a clinical perspective, first priority should be given to the total amount of carbohydrates consumed throughout the day and at each meal, rather than the type of carbohydrates consumed (simple vs. complex). The total amount of carbohydrates a diabetic can consume throughout the day and at each meal is determined by such things as their weight, activity level, what type of medications they are using, and when, and other factors such as age and any medical conditions they may be suffering from (i.e. high blood lipids). All diabetics should work with a registered dietitian to help establish their meal planning parameters.
Consume several small meals daily: Consuming several smaller meals (4-6) throughout the day, rather than a few large meals can help with blood glucose control. For example, a 5'4" woman with diabetes who weighs 120 pounds and wants to maintain her current weight may be prescribed a total of 250 grams of carbohydrates daily. In order to prevent her blood sugar from rising to high at any one meal, she should try and divide her total carbohydrate allowance into several meals (i.e. 3 meals each containing 60 grams of carbohydrates and 2 snacks each containing 35 grams of carbohydrates), rather than eat them all in one or two sittings. It is her choice how she "spends" those 35 or 60 grams of carbohydrates. One day she may feel like having a half cup of rice and a glass of milk, while on another day she may choose to have a glass of milk and a piece of cake. Yes, we did say cake! Many people are under the false pretense that people with diabetes cannot consume sugar. Essentially, a gram of carbohydrate is a gram of carbohydrate, whether it's from an apple or a piece of cake. Of course, one must take into account the nutritional value of the foods they choose to eat. Thirty-five grams of carbohydrate from fiber-rich plant foods are much more nutritious than thirty-five grams of carbohydrates from a piece of cake.
Attempt to eat meals and snacks at regular times: Eating meals and snacks at the same time each day can help to improve blood glucose control.
Increase consumption of foods rich in soluble fiber: Foods high in soluble fiber help to both slow the digestion and absorption of carbohydrates, which leads to improved blood glucose control. Good sources of soluble fiber include oats, oat bran, legumes, apples, grapefruit, and most fresh vegetables.
Choose a diet low in fat, especially saturated fat: People with diabetes are at an increased risk for developing cardiovascular disease. Reducing the amount of fat in the diet can help to control blood lipid levels and reduce the likelihood of experiencing certain diabetes-related complications. Dietary fats should come from sources such as lean meats, fish, and vegetable oils rich in mono- and polyunsaturated fats such as corn, olive, peanut, safflower, and sunflower oil.
Use sugar in moderation: Many people with diabetes believe they must avoid sugary foods such as cakes and cookies. The truth is, people with diabetes can eat sugar and sugar-rich foods, but should do so in moderation as excesses in the diet can lead to weight gain, nutritional deficiencies, and poor blood glucose control. Nonnutritive sweeteners such as saccharin, aspartame, and acesulfame K are safe for diabetics to consume, as they have no effect on blood glucose levels. We do suggest avoiding them if possible as they are synthetic sweeteners and may pose other health risks.
Use salt in moderation: Consuming excess amounts of salt can increase the risk of high blood pressure in susceptible individuals. High blood pressure is commonly found among diabetics and can increase their risk for complications such as kidney disease, heart disease and stroke. To cut back on salt, avoid adding salt when cooking and to foods at the table. In addition, many canned and processed foods are very high in salt and thus should be avoided.
Consume alcohol in moderation: When diabetes is under control, blood glucose levels will not be affected by moderate consumption of alcohol. For diabetics using insulin, one or two alcoholic beverages (12 oz. beer, 5 oz. wine, or 1.5 oz. distilled spirits) is acceptable. As a word of caution, alcohol can increase the risk for hypoglycemia in patients treated with insulin or sulfa-drugs. If alcohol is consumed by such people, it should only be done so in combination with a meal. People with nerve damage, pancreatitis, and elevated blood lipid levels should abstain from using alcohol.

Nutritional Support

Chromium (200-1,000 mcg daily): Chromium, an essential component of the glucose tolerance factor (GTF), plays an important role in blood sugar regulation primarily by improving the sensitivity of tissues to insulin. When chromium status is normal, much lower amounts of insulin are required. Several double-blind studies, involving type I and type II diabetics, have found that supplementing the diet with chromium can reduce fasting blood glucose levels, improve glucose tolerance, decrease insulin levels, and reduce total cholesterol and triglyceride levels. These effects are most pronounced in diabetics who have a chromium deficiency. Diabetes 1997, 46;11:1786-91 Diabetes Care 1994, 17:464-79
Vitamin C (1,000-2,000 mg daily in divided doses): Diabetics are at a greater risk for vitamin C deficiency than non-diabetics. This is because the cellular uptake of vitamin C is facilitated by insulin and inhibited by high blood sugar. A number of studies have found people with diabetes to have 30 percent lower tissue concentrations of vitamin C than those without the disease. This deficiency appears to be the result of the disease rather than inadequate dietary intake. A vitamin C deficiency can lead to a number of problems including an increased tendency to bleed, poor healing of wounds, increased cholesterol levels, vascular disease, and a depressed immunity. At high doses, vitamin C has been shown to limit the accumulation of sorbitol in the red blood cells of diabetics and to prevent the glycosylation of proteins, two factors which have been implicated in the development of diabetic complications (eye, nerve and kidney disease). Drugs prescribed to reduce sorbitol accumulation (aldose reductase inhibitors) have produced equivocal results, but are associated with a host of side effects. Vitamin C supplementation may provide a safe alternative to drug therapy for many diabetics. Diabetes 1992, 41:167-73 Diabetes 1989, 38:1036-41
Vitamin E (800-1,200 IU daily): People with diabetes appear to have an increased need for vitamin E. Large doses of vitamin E have been shown to improve the action of insulin, limit damage to cell membranes, inhibit the glycosylation of proteins, and reduce the susceptibility of LDL cholesterol to oxidation, all of which may help to prevent or delay long-term diabetic complications. In one study, ten healthy subjects and fifteen type II diabetics underwent an oral glucose tolerance test before and after taking 1,350 IU of vitamin E daily for four months. Vitamin E was found to significantly improve glucose tolerance and insulin sensitivity in both groups, with the greatest benefit occurring in the diabetic group. People deficient in vitamin E have a 3.9 times greater risk of developing diabetes than those with optimal vitamin E status. Am J Clin Nutr 1995, 61:848-52 Br Med J 1995, 311:1124-27
Niacin/Nicotinamide (100-200 mg daily): Like chromium, niacin is an essential component of the glucose tolerance factor (GTF), making it a key nutrient in the management and treatment of diabetes. Nicotinamide supplementation has been shown to exert many favorable effects in diabetics such as protecting the insulin-producing cells of the pancreas from damage by the immune system. In a 1996 study, researchers from New Zealand published the findings of a diabetes prevention trial involving over 170 children at risk for type I diabetes. The study found that nicotinamide supplementation resulted in a 50 percent reduction in the development of diabetes over a five-year period, suggesting a protective effect. Other studies involving nicotinamide supplementation have demonstrated positive effects in terms of reduced insulin requirement, enhanced metabolic control, and increased beta-cell function. Pediatr Endocrinol Metab 1996, 9;5:501-9 J Nutr Med 1990, 1:217-25
Biotin (9-16 mg daily): Biotin supplementation may help to improve blood glucose control in people with diabetes by enhancing insulin sensitivity and increasing the activity of glucokinase, an enzyme involved in the metabolism of glucose. Glucokinase concentrations have been found to be very low in diabetics. High-dose biotin therapy can reduce fasting blood glucose levels and improve blood sugar control in both type I and type II diabetes. Insulin requirements may need to be adjusted in patients receiving large doses of biotin. Renal Fail 1996, 18;1:131-7 Biomed Pharmacother 1990, 44:511-14
Vitamin B12 (1,000-2,000 mcg daily): Vitamin B12 is required for the normal functioning of nerve cells. A vitamin B12 deficiency can lead to symptoms of numbness and tingling or a burning sensation in the extremities. Supplementation with vitamin B12 has been shown to reduce nerve damage caused by diabetes. Researchers are unsure whether this improvement is due to the correcting of a deficiency state, or to the normalization of impaired vitamin B12 metabolism seen in many diabetics. Curr Ther Res 1995, 56:656-70
Magnesium (300-600 mg daily): Studies have found that up to 30 percent of people with diabetes are deficient in magnesium. Magnesium is required for the uptake of glucose into cells, and a deficiency can worsen control of diabetes. Symptoms of a magnesium deficiency include impaired insulin secretion, reduced tissue sensitivity to insulin, and an increased risk of damage to blood vessels. Low levels of magnesium may also be a contributing factor in heart disease, eye disorders, and bone problems. The American Diabetes Association (ADA) has recommended that diabetics deficient in magnesium take supplements in order to improve glucose tolerance and the action of insulin. Magnesium supplements may also help to prevent diabetic complications such as heart and eye disease, and have been shown to reduce blood pressure in type II diabetics. Ann Pharmacother 1993, 27:775-80 Hypertens 1996, 10;8:517-21
Zinc gluconate (30-50 mg daily): People with diabetes are commonly found to be deficient in zinc, due to excessive losses in the urine. Zinc supplementation has been shown to improve insulin levels in both type I and type II diabetics. In addition, zinc helps to improve the rate at which wounds heal in people with diabetes. J Clin Biochem Nutr 1992, 12:204-15 J Am Pod Assoc 1981, 71:536-44
Flavonoids (1-2 grams daily): The flavonoids are a group of plant pigments that have the ability to modify the body's response to allergens, viruses and carcinogens. These compounds act as potent antioxidants in the body and offer protection against a wide variety of free-radicals. Recent research suggests that people with diabetes can benefit from a diet rich in flavonoids, as they have been shown to enhance insulin secretion and are powerful inhibitors of sorbitol accumulation (the accumulation of sorbitol within cells is believed responsible for many of the complications associated with diabetes). Other benefits of flavonoids include increased intracellular concentration of vitamin C, increased strength of small blood vessels and immune system support, all of which are of benefit to diabetics. The best dietary sources of flavonoids are citrus fruits, berries, onions, parsley, green tea, and red wine (diabetics should limit their intake of alcohol as it can impair blood glucose control). In addition to consuming a flavonoid-rich diet, people with diabetes may also benefit from taking an additional 1-2 grams of flavonoids in the form of a mixed flavonoid supplement or a flavonoid-rich extract such as grape seed, green tea, or bilberry extract. Wld Rev Nutr Diet 1976, 24:117-91
Gama-linolenic acid (500-600 mg daily): A disturbance in the metabolism of essential fatty acids has been identified in people with diabetes. One of the primary disturbances is in the conversion of linoleic acid to gamma-linolenic acid (GLA). This disturbance may lead to defects in nerve function. The Gamma-Linolenic Acid Multicenter Trial examined the effects of GLA supplements in diabetics. In the study, 111 patients with mild diabetic neuropathy were given 480 mg of GLA daily in the form of evening primrose oil capsules for one year. Patients supplemented with GLA demonstrated statistically significant improvements in a multitude of parameters including conduction velocity, hot and cold thresholds, sensation, reflexes, and muscle strength. The most pronounced effects were seen in patients with relatively well controlled diabetes. Good sources of GLA include evening primrose, borage, and black current oil. Diabetes Care 1993, 16:8-13
Omega-3 fatty acids: Increased consumption of omega-3 fatty acids can benefit people with diabetes by helping to reduce their risk of cardiovascular disease. In the past, concerns have been raised as to the safety of omega-3 fatty acids in diabetics, but more recent studies suggest they are safe in low doses. Increased consumption of cold-water fish (salmon, mackerel, halibut, etc...) has been shown to reduce triglyceride levels and raise HDL cholesterol (good cholesterol). A 1991 study found that an average daily intake of 24.2 grams (about one ounce) of fish to be associated with a significantly lower incidence of glucose intolerance. Furthermore, the likelihood of death was found to be lower in those consuming fish compared to those who did not eat fish. Other studies have found a low prevalence of both type I and type II diabetes in cultures consuming cold-water fish on a regular basis, suggesting that omega-3 fatty acids may offer protection against the development of diabetes. Because fish oil supplements may contain high levels of oxidized fat, and can adversely affect antioxidant status, we recommend obtaining omega-3 fatty acids from either fresh fish or flax-seed oil. Two 3.5 ounces of fish per week or one tablespoon of flax-seed oil daily should suffice for most diabetics. Diabetes Care 1995, 18;8:1160-7 Arzneimittel Forschung 1995, 45;8:872-4
Vanadium (100 mg daily): Early studies investigating the effects of vanadium have shown it to have the ability to normalize blood glucose levels in animals with type I and type II diabetes. In a recent study, researchers at Albert Einstein College of Medicine in New York compared the effects of oral vanadyl sulfate (100 mg daily) in moderately obese diabetics and nondiabetic individuals. The results showed improvements in both liver and skeletal muscle insulin sensitivity in people with diabetes. Blood lipid levels and oxidation were also reduced, suggesting that vanadium may also help to reduce the risk of atherosclerosis, a frequent complication of diabetes. Diabetes 1996, 45;5:659-66
L-Carnitine (1 mg per 2.2 lbs of body weight): L-Carnitine is required by the body to properly metabolize fat. In studies involving diabetics given carnitine, blood fat levels (cholesterol & triglycerides) dropped between 25 and 39 percent in only ten days. In larger doses (1 gram daily by injection), carnitine has also proven effective in reducing the pain associated with diabetic neuropathys. Int J Clin Pharmacol Res 1995, 15:9-15 Nutr Rep Internat 1984, 29:1071-9
Alpha lipoic acid (400-600 mg daily): Alpha Lipoic Acid (ALA), a powerful natural antioxidant, has been shown to improve diabetic neuropathies and reduce pain in several studies. Free Radical Bio Med 1995, 19:227-50

Herbal Remedies

Gymnema extract (200 mg twice daily): Gymnema, a plant native to the tropical forests of India, has been shown to improve blood glucose control in type I and type II diabetics. In one study involving 27 type I diabetics on insulin therapy, Gymnema extract was shown to lower insulin requirements and improve blood glucose control. In a second study involving 22 patients with type II diabetes on oral hypoglycemic agents, all subjects given Gymnema extract demonstrated improved blood glucose control, 21 of the subjects were able to reduce their drug dosage, and 5 of the subjects no longer required drugs to maintain blood sugar control. There were no side effects reported in either study. The intriguing thing about Gymnema is that when it's given to healthy volunteers, blood sugar levels are not effected. The herb appears to work only if pancreatic function is impaired. J Ethnopharmacol 1990, 30:281-94 J Ethnopharmacol 1990, 30:295-305
Bitter melon (2 oz. fresh juice daily): Bitter melon is a green cucumber-like fruit that has been used extensively in folk medicine as a remedy for diabetes. Clinical trials, as well as experimental models, have established the blood sugar lowering action of this fruits juice or extract. Bitter melon contains several compounds that have been shown to have anti-diabetic properties. For best results, ingest two ounces of fresh juice daily (juice extractor). Bitter melon is available at most Asian grocery stores. J Ethropharmacol 1986, 17:277-82 Phytotherapy Res 1993, 7:285-89
Fenugreek seeds (15-25 grams twice daily): Significant anti-diabetic effects have been noted in clinical and experimental studies using fenugreek seeds. In one study, a 50-gram dose of defatted fenugreek seed powder given to a group of type I diabetics resulted in significant reductions in fasting blood glucose levels and glucose tolerance test results. Additionally, there was also a 54 percent reduction in 24-hour urinary glucose excretion as well as significant reductions in cholesterol and triglyceride values. Similar results have also been noted in studies involving type II diabetics. Eur J Clin Nutr 1988, 42:51-54
Bilberry extract (80-160 mg three times daily): Bilberry extract has been used to treat diabetic retinopathy in France since the mid 1900's. Flavonoids contained in the extract provide numerous benefits to people with diabetes such as increased intracellular concentration of vitamin C, reduction in the breakage of small blood vessels, and protection from oxidative damage. Specifically, Bilberry flavonoids have an affinity for the blood vessels of the eye and the retina, and have been shown to improve circulation to those areas. In clinical trials, Bilberry extract has been shown to exert several positive effects in conditions of diabetic retinopathy, macular degeneration, cataract, retinitis pigmentosa, and night blindness. Arch Med Int 1985, 37:29-35
Ginko biloba (50-80 mg three times daily): A common complication of diabetes is peripheral vascular disease, a condition in which blood flow is reduced to the tissues in the arms, legs fingers and toes. Ginko has been used successfully to treat vascular insufficiency in the brain as well as intermittent claudication, a circulatory disease of the lower extremities. Ultrasound measurements have demonstrated increased blood flow through limbs in patients using Ginko. In studies involving animals, Ginko extract has been shown to prevent diabetic retinopathy, suggesting a beneficial effect in humans as well. Arzneim-Forsch 1984, 34:716-21 Fortschr Med 1987, 105:397-400
Ginseng (100-200 mg daily): In an 8-week double-blind controlled study involving 36 type II diabetics, ginseng was found to improve mood and psychophysiological performance, and to reduce fasting blood glucose levels. Improvements in glycosylated hemoglobin levels were also noted in patients supplemented with a 200 mg dose of ginseng. Diabetes Care 1995, 18:1373-75

Physical Medicine

Acupuncture: Acupuncture is a procedure in which needles are inserted into specific points on the skin. Acupuncture may bring relief to diabetics suffering from painful neuropathies, as it has been shown in clinical trials to trigger the release of endorphins, the body's own natural painkillers.
Biofeedback: Biofeedback is a technique that helps a person become more aware of and learn to deal with the body's response to pain. This therapy focuses on relaxation and stress-reduction techniques. Guided imagery is a relaxation technique that some professionals who use biofeedback practice. With guided imagery, a person thinks of peaceful mental images, such as ocean waves. A person may also include the images of controlling or curing a chronic disease, such as diabetes.

Additional Information

National Diabetes Information Clearinghouse (NDIC)

This organization provides information about diabetes to people with the disease and their families, health care professionals, and the general public. The NDIC answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations, as well as government agencies to coordinate resources about diabetes. Publications produced by the clearinghouse are reviewed carefully for scientific accuracy, content, and readability. They may be reached via e-mail at ndic@info.niddk.nih.gov