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Many patients with cardiometabolic syndrome or diabetes are at increased risk for related health concerns, including vision impairment, renal dysfunction, podiatric concerns, and dental disease. Current care guidelines for these patients often highlight glycemic control, but research indicates that this metric may not be delivering the health outcomes patients want. Going beyond a singular focus on glycemic control may be necessary to help patients achieve the health outcomes they find most meaningful.
A functional medicine approach can help control glycemic indices, and it may also help reduce many related health issues. In particular, using dietary change as a first-line treatment has shown success in reversing diabetes. In Kristine Burke, MD’s, practice , not only did 75% of program participants enjoy normalization of their A1c and blood sugar numbers, many were also able to taper off and eventually stop their diabetes medication(s). Watch her describe the diabetes reversal program:
A 2016 analysis found that diabetic retinopathy and associated vision impairment have been increasing steadily around the world, despite a focus on glycemic control.1 Renal failure and neuropathy also showed no improvements.1 This is despite the increased focus on glycemic control, now supported by a variety of clinical guidelines.2 The worldwide prevalence of diabetes is estimated to increase to 700 million by 2045, with approximately 160 million of those individuals projected to have comorbid diabetic retinopathy.3
The current focus on glycemic control is costly and is generally not fully supported by the literature. A joint Canadian-US study estimated the annual cost of hypoglycemia resulting from tight glycemic control in older adults was $65,497,849 in Canada and $509,214,473 in the US.2 In a review, Mayo Clinic researchers found that tight glycemic control did not meet its endpoints: it did not lower the risk of progression to dialysis, renal transplant, blindness, neuropathy, all-cause mortality, or stroke.2 Further, tight glycemic control in the frail elderly may lead to hypoglycemia and dementia4 and may create (as well as treat) episodes of neuropathy.5
While medications can normalize glucose numbers, this approach may not address other complications that diabetes can engender. Research suggests that diet-based approaches have greater success, including ?-3 fatty acid interventions that research suggests can successfully reduce retinopathy.6 A 2021 study evaluating the dietary intake of patients with type 2 diabetes found that plasma levels of carotenoids were significantly lower in patients with diabetic retinopathy as compared to diabetic patients with no vision impairment and the control group.7 Dietary intake of several nutrients including zeaxanthin, lycopene, ?-carotene, and ?-carotene were markedly lower in the patients with diabetic retinopathy, suggesting a potential connection between carotenoids and the progression of retinopathy.7 As a precursor to vitamin A, ?-carotene along with lutein and zeaxanthin have been shown to attenuate oxidative stress in ocular tissue in all populations, and in diabetic patients, it may slow the progression of cell apoptosis and mitochondrial dysfunction and reduce inflammation.8 Supplementation of these nutrients through increased intake of orange, red, and yellow foods and/or vitamins may be a therapeutic target to consider.
Exercise and Lifestyle Considerations
At least for some patients, exercise and nutrition interventions may outperform medications. In a 2020 study published in The Lancet, researchers found that intensive lifestyle intervention led to significant weight loss at 12 months and was associated with diabetes remission in over 60% of participants and normoglycemia in over 30% of participants.9 Study participants were aged 18-50 years, had a short diabetes duration (?3 years), and had a BMI of 27.0 kg/m2 or more. The intensive lifestyle intervention comprised a total diet replacement phase, in which participants were given specially formulated, low-energy diet meal replacement products followed by gradual food reintroduction combined with physical activity support and a weight-loss maintenance phase involving structured lifestyle support. The authors say that the provision of this lifestyle intervention could allow a large proportion of young individuals with early diabetes to achieve improvements in key cardiometabolic outcomes, with potential long-term benefits for health and well-being.9
In another recent study, reduction in glucose-lowering medications was achieved by 47 participants (73.5%) in the lifestyle group compared to only nine participants (26.4%) in the standard care group.10 The lifestyle intervention consisted of an aerobic training program along with a dietary plan for achieving a BMI of less than 25.10 In a separate study, participants with poor glycemic control who undertook a multidisciplinary lifestyle regimen enjoyed significant improvements in hemoglobin A1c, BMI, waist circumference, and blood pressure up to two years after study completion.11
IFM provides clinicians with tools to help their patients adopt healthy lifestyle practices, such as eating more high-quality foods that are rich in phytonutrients and increasing physical activity. For more information, read the additional IFM-authored articles below.
- Leasher JL, Bourne RRA, Flaxman SR, et al. Global estimates on the number of people blind or visually impaired by diabetic retinopathy: a meta-analysis from 1990 to 2010. Diabetes Care. 2016;39(9):1643-1649. doi:10.2337/dc15-2171.
- Rodríguez-Gutiérrez R, Montori VM. Glycemic control for patients with type 2 diabetes mellitus: our evolving faith in the face of evidence. Circ Cardiovasc Qual Outcomes. 2016;9(5):504-512. doi:10.1161/CIRCOUTCOMES.116.002901.
- Teo ZL, Tham Y-C, Yu M, et al. Global prevalence of diabetic retinopathy and projection of burden through 2045: systematic review and meta-analysis. Ophthalmology. 2021;128(11):1580-1591. doi:10.1016/j.ophtha.2021.04.027.
- Boulin M, Diaby V, Tannenbaum C. Preventing unnecessary costs of drug-induced hypoglycemia in older adults with type 2 diabetes in the United States and Canada. PLoS One. 2016;11(9):e0162951. doi:10.1371/journal.pone.0162951.
- Abdelhafiz AH, McNicholas E, Sinclair AJ. Hypoglycemia, frailty and dementia in older people with diabetes: reciprocal relations and clinical implications. J Diabetes Complications. 2016;30(8):1548-1554. doi:10.1016/j.jdiacomp.2016.07.027.
- Sala-Vila A, Díaz-López A, Valls-Pedret C, et al. Dietary marine ?-3 fatty acids and incident sight-threatening retinopathy in middle-aged and older individuals with type 2 diabetes: prospective investigation from the PREDIMED trial. JAMA Ophthalmol. 2016;134(10):1142-1149. doi:1001/jamaophthalmol.2016.2906.
- Shalini T, Jose SS, Prasanthi PS, Balakrishna N, Viswanath K, Reddy GB. Carotenoid status in type 2 diabetes patients with and without retinopathy. Food Funct. 2021;12(10):4402-4410. doi:10.1039/d0fo03321a.
- Johra FT, Bepari AK, Bristy AT, Reza HM. A mechanistic review of ?-carotene, lutein, and zeaxanthin in eye health and disease. Antioxidants (Basel). 2020;9(11):1046. doi:10.3390/antiox9111046.
- Taheri S, Zaghloul H, Chagoury O, et al. Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol. 2020;8(6):477-489. doi:10.1016/S2213-8587(20)30117-0.
- Johansen MY, MacDonald CS, Hansen KB, et al. Effect of an intensive lifestyle intervention on glycemic control in patients with type 2 diabetes: a randomized clinical trial. JAMA. 2017;318(7):637-646. doi:10.1001/jama.2017.10169.
- Sbroma Tomaro E, Pippi R, Reginato E, et al. Intensive lifestyle intervention is particularly advantageous in poorly controlled type 2 diabetes. Nutr Metab Cardiovasc Dis. 2017;27(8):688-694. doi:10.1016/j.numecd.2017.06.009.