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From the Townsend Letter
May 2015

Complete Diabetes Care Now that We Have TACT
by L. Terry Chappell, MD; T. Rae Neal, MSN, CNP; and Natallie Paphanchith, MSN, ACNP-BC
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Incidence and Cost
Diabetes is a growing epidemic in the US. According to the National Diabetes Statistics report for 2014, 21 million people in the US have been diagnosed with type 1 or type 2 diabetes. It is estimated an additional 8.1 million people are undiagnosed. The American Diabetic Association documented 86 million prediabetes diagnosis cases in 2012. Treatment and management of this disease is costly; the estimated annual cost of diabetes per year in the US is $245 billion.
More alarming than diagnosis and cost is the impact that diabetes has on our overall health and well-being. Diabetes was listed as the 7th leading cause of death in the US in 2010. When diabetes is controlled, we reduce the risk of coexisting diseases. Unfortunately, many patients remain with an elevated hemoglobin A1C. Uncontrolled diabetes leads to multiple micro- and macrovascular complications. Comorbidities secondary to diabetes include hypertension, hyperlipidemia, coronary artery disease, cerebral vascular accidents, chronic kidney disease, amputation, retinopathy, and neuropathy.1

Conventional Approach to the Treatment of Diabetes
Type 2 diabetes mellitus (T2DM) is clearly linked to obesity. As the obesity rates climb, so does the diagnosis. Eighty to ninety percent of patients diagnosed with type 2 diabetes are classified as obese. The International Diabetes Foundation was quoted, "Diabetes and obesity are the biggest public health challenges of the 21st century." The link is clear; obesity drives insulin resistance and an inflammatory response. Prolonged insulin resistance puts an extreme amount of stress on the pancreas. When resistance is accompanied by dysfunction of the pancreatic islet beta cells, that is what ultimately leads to the disease.2

Table 1
A dietary goal should be to minimize refined sugars and starches. Modern carbohydrate staples, such as potatoes, breads, and cereals, have a high glycemic index (GI) and a very strong link to chronic disease.3 Foods low on the GI scale such as sweet potatoes, winter squash, and beans help to stabilize blood glucose levels. This can be achieved with whole structured foods and lower GI. Clinical trials support low GI diets with greater fat content as more effective than low-fat diets at preventing complications associated with cardiovascular disease. Often a low fat diet contains the highest GI content, which leads to increased insulin resistance. Low GI diets improved whole body insulin sensitivity throughout the trials with no increase in LDL cholesterol.3 Whole rice and seeds decrease circulating levels of glucose, insulin, LDL cholesterol, and fructosamine, while refined sugar and high-fructose corn syrup lead to increased risk for T2DM. Large amounts of fructose result in insulin resistance and could accelerate the development of T2DM and associated complications. Avoiding processed foods is an important step in preventing and managing diabetes.4
Many options are available to treat diabetes. As discussed above, lifestyle modifications are the initial target for obesity. Nutritional planning, weight loss, and diabetic education are a top priority. However, despite efforts of diet and exercise, many patients will require additional therapies. There are multiple oral medications available. Metformin is the initial medication of choice if liver and kidney functions are stable. However, if the hemoglobin A1C remains elevated after 3 months of therapy, an additional agent may be selected. Treatment of diabetes has greatly changed in the last 10 years. Use of sulfonylureas, meglitinides, and alpha-glucosidase inhibitors are less common, as innovative medications are integrating to the market.
Emerging drug classifications include thiazolidinediones, DPP-IV inhibitors, GLP agonists, and SGLT2 inhibitors. If insulin resistance remains high and oral medications and injectable noninsulin medications are not effective in maintaining glycemic control, insulin may be added. Likewise, if chronic medical conditions arise and prevent the use of certain medications, a basal-bolus regimen of insulin may be more appropriate.

Goals of Treatment
As previously mentioned, treatment goals are targeted by the hemoglobin A1C. The A1C is a 3-month average of the patient's blood sugar. An A1C less than 5.7% is normal, prediabetic range is 5.7-6.4%, and diabetes is diagnosed if the A1C is greater than 6.5%. Once a patient is diagnosed with diabetes, The American Diabetes Association recommends an A1C goal less than 7%. However, many randomized trials that examined the effects of glycemic control did not include the frail elderly.5
Newer data points to higher health threats in the elderly population with tight glycemic control. The most common risk is severe hypoglycemia. Hypoglycemia can lead to increased falls, injury, trauma, and hospitalizations.6 Also, elderly patients are more likely to experience an adverse effect from their medications. The American Geriatric Society recommends the targeted A1C to be 8% in the elderly.7 However, the A1C target is controversial among various organizations. Ultimately, goals should have an individual approach and target.

Complementary Treatment Options and Lifestyle Measures
Complementary, alternative, integrative, or comprehensive, whatever term you choose, these additional approaches to medicine offer many options for the prevention and treatment of T2DM. The California Institute of Integral Studies and Integrative Medicine presented a paradigm shift in our health-care system at the International Congress for Clinicians in Complementary and Integrative Medicine in 2013.8 Collaborative practice and interaction between disciplines will provide valuable insight toward a new health-care model. It is estimated that as much as 40% of adults use complementary and alternative medicine (CAM), with up to 34% of those patients having a chronic disease. These figures are meaningless when disclosure of CAM use is often withheld due to potential conflict with other providers.9
Personal responsibility is essential for prevention and management of diabetes. Awareness of recommended caloric intake and ideal body weight prevent the buildup of excess body fat, which can lead to cellular insulin resistance. Maintaining ideal body weight and modifying the diet to include important nutrients, limit less beneficial ingredients, and eliminate harmful options will lead to improved glycemic control.4 Organic pollutants also accumulate in adipose tissue and carry destructive consequences. Sorbitol accumulation caused by environmental exposure leads to cell death and contributes to diabetic complications.4 Weight loss and detoxification will improve insulin sensitivity and glucose tolerance. Losing as little as 5% of body fat can lead to marked improvement in glycemic control and a reduction in the incidence of T2DM by up to 50%.10
Gaby also identified a gluten-free diet as delaying or preventing the development of T2DM due to the preservation of beta cells. Vegan diets improve glycemic control. Coffee is associated with a decreased risk of developing T2DM. Oolong tea is associated with a mean decrease in plasma glucose concentrations. This could be due to reducing iron absorption, which improves glycemic control. Modest increases in body iron stores have an adverse effect on glucose metabolism. Iron depletion enhances glucose utilization. Phlebotomy treatments have effectively reduced iron concentration to vegetarian levels and caused a 40% increase in insulin sensitivity.4 Deferoxamine, an iron chelating agent, was used in poorly controlled DM patients with elevated ferritin levels to improve blood glucose and HbA1C levels.4
Increased dietary fiber from legumes, carrots, artichokes, peaches, strawberries, and grapefruit can improve glycemic control. Obtaining fiber from food is preferred. If supplementation is necessary, unprocessed wheat bran or apple fiber is recommended. Legumes have an ability to flatten blood sugar response over 4 hours, when eaten at breakfast.4
The temperature and manner in which food is cooked plays a role in the development of diabetes. The advanced glycation end products (AGE) remain in food after the cooking process. These products cause modifications in protein structure, which promote inflammation.4 Less AGE formation results from cooking techniques using water at low temperatures for a longer period of time. An emphasis on boiling, poaching, and stewing over frying, broiling, and roasting can decrease AGE by up to 50%. AGE products play a role in the pathogenesis of insulin resistance and DM complications.4

Table 2

Consuming raw fats such as sesame, coconut, avocado, flaxseed, and olive oil help to reduce HbA1C. Esposito and associates found that a low-carb Mediterranean diet effectively reduced HbA1C, achieved diabetes remission, and delayed the need for medications.11 Harokopio at the University of Athens found that eating plenty of olive oil, fish, and whole grains was more effective at slowing the progression of T2DM than a low-fat diet. The key factor in the Mediterranean diet is that more than 30% of daily calories are from fat. Olive oil is high in oleic acid and monounsaturated content, providing antioxidant and anti-inflammatory properties.12
Mind-body medicine, recognized by the National Center for Complementary Medicine, includes yoga, tai chi, and meditation. These techniques are used to influence the mind-body connection. Movement, breathing, meditation, and chanting can be used to achieve lifestyle changes and stress relief, and allow inner focus. The American Diabetic Association recommends 150 minutes a week of moderate to intense physical activity. These mind-body activities can be considered moderate exercise.13 No real improvement in glycemic control was seen, but beneficial effects on behavior, mood, stress, and quality of life were identified as positive outcomes.13 Because chronic stress has been implicated as a risk factor for the development of T2DM and we know that stress-induced inflammatory cytokines could be the cause of this finding, it is easy to see how daily practice in mind-body medicine would have a positive effect.4 Significant improvements have been documented with daily yoga training. Reduced fasting blood sugar and postprandial levels, better glycemic control, and stable autonomic control are possible with daily yoga training.9

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