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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 recent 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 β-3 fatty acid interventions that may 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, α-carotene, and β-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, β-carotene, along with lutein and zeaxanthin, has 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.
A range of different dietary approaches may help patients achieve T2D remission. Based on evidence from clinical trials, maintenance of weight loss appears to be the main driver of continued remission, and low carbohydrate diets have been demonstrated as being effective in facilitating weight loss. Evidence of effectiveness beyond two years is limited.9,10 The dietary approach should be one which the individual can maintain for the long term.9
IFM’s Cardiometabolic Food Plan is a tool that contains the resources and information for clinicians to work with patients to help them transition to healthier eating patterns that support cardiac and metabolic health. It is designed for patients at risk of or already diagnosed with cardiovascular disease or metabolic conditions, which share many underlying causes, including increased inflammation, insulin resistance, and stress. The plan has the following features:
- A modified Mediterranean diet, focusing on the heart-healthy elements
- A low glycemic impact
- Personalized, targeted calorie recommendations
- Blood sugar balancing
- High fiber, low simple sugars
- Balanced, quality fats
- Condition-specific phytonutrients
The Cardiometabolic Food Plan is just one of several therapeutic food plans available as part of IFM’s Toolkit.
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.11 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.11
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.12 The lifestyle intervention consisted of an aerobic training program along with a dietary plan for achieving a BMI of less than 25.12 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.13
Functional Medicine Considerations
Many functional and integrative clinicians have had patients with T2D who have lost that diagnosis as a result of sustained lifestyle modifications. Yet up until now, there was little recognition in the wider medical community that such change was possible and no established language to describe this phenomenon. In a sudden reversal of this longstanding trend, late last year, the American Diabetes Association convened an international expert group to officially recognize that such change was possible and propose new terminology to describe it. The result was a consensus report outlining the definition and clinical details of what the group termed diabetes remission. The report also recognizes the importance of lifestyle change as a primary cause of T2D remission, and its publication is at least in part the result of many years of ongoing clinical successes by functional medicine clinicians and others who focus on lifestyle change as the primary treatment for T2D. Read more here.
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. Learn more about cardiometabolic conditions and clinical applications that support your patient’s health journey at IFM’s upcoming Cardiometabolic Advanced Practice Module (APM). The module will help clinicians understand the physiology underlying cardiometabolic syndrome and cardiovascular disease, new approaches to effective assessments and treatments, and how to integrate these lifesaving tools into practice.
- 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: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: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: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: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:1016/j.jdiacomp.2016.07.027
- Sala-Vila A, Díaz-López A, Valls-Pedret C, et al. Dietary marine &omgega;-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:1039/d0fo03321a
- Johra FT, Bepari AK, Bristy AT, Reza HM. A mechanistic review of β-carotene, lutein, and zeaxanthin in eye health and disease. Antioxidants (Basel). 2020;9(11):1046. doi:3390/antiox9111046
- Brown A, McArdle P, Taplin J, et al. Dietary strategies for remission of type 2 diabetes: a narrative review. J Hum Nutr Diet. 2021;35(1):165-178. doi:1111/jhn.12938
- Dyson PA, Twenefour D, Breen C, et al. Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabet Med. 2018;35(5):541-547. doi:1111/dme.13603
- 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: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: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:1016/j.numecd.2017.06.009