DIABETES MELLITUS
STEPHEN HOLT, M.D. LLD(Hon.) ChB., PhD, ND, FRCP (C) (Internal Medicine), FRCP (C) (Gastroenterology) MRCP (UK), FACP, FACG, FACN, FACAM, OSJ

Introduction
Diabetes mellitus affects approximately 6% of the US population and its occurrence is increasing in incidence at an alarming rate. Many of the 16 million Americans who have diabetes are unaware of its presence and even more individuals lack sufficient education to deal with the lifestyle adjustments that are required to manage or prevent this disease. Diabetes mellitus is a common cause of premature death or disability and its progression results in accelerated aging of the body. More than 90% of all cases of diabetes mellitus are of the Type 2 form (maturity onset diabetes). The economic burden of diabetes mellitus, together with some disenchantment about allopathic treatments for this disorder, has led to a growing interest in potentially safer and gentler management options that are presented by alternative medicine. The objective of this short article is to review non-allopathic options for the potential management of Type 2 diabetes mellitus, accepting that research in this area is emerging, but it is incomplete.

Understanding Diabetes Mellitus
Diabetes mellitus is a common disease in which excessive levels of blood glucose (sugar) occur. In simple terms, diabetes is generally due to the absence or lack of effective functioning of insulin. Two common types of diabetes are described. The first type (Type 1 diabetes mellitus) has been called “juvenile onset diabetes” where there is damage to the cells in the pancreas that secrete insulin. This type of diabetes occurs from a lack or absence of insulin and it tends to occur in young people, as the name suggests.
The second, but main type of diabetes (Type 2 diabetes), is commonly called “maturity onset diabetes” (MOD). Type 2 diabetes is much more common than Type 1 diabetes and it accounts for more than 90% of all known cases of diabetes. This type of diabetes is often associated in its early phases with a resistance to insulin. Insulin may be present in early forms of Type 2 diabetes but it is not able to do its job of driving glucose into cells. Type 2 diabetes is the type of diabetes that is most relevant to our understanding of the abnormalities of body chemistry (metabolic disturbances) that cause Syndrome X. The metabolic Syndrome X is the variable combination of obesity, hypertension and hypercholesterolemia, linked by an underlying resistance to insulin. While maturity onset (Type 2) diabetes occurs most often in mature people, a striking increased occurrence in this type of diabetes in children has been experienced in recent years. This disorder has been called maturity onset diabetes of the young (MODY), a strange label!
Each type of diabetes can cause similar medical complications. These complications include cardiovascular disease, nerve damage (neuropathy), eye disease (retinopathy) and kidney disorders. One cannot completely separate Type 1 and Type 2 diabetes and some overlap exists between these disorders. There is a third type of diabetes called the Gestational Diabetes that occurs somewhat temporarily in pregnancy. Gestational Diabetes involves insulin resistance and research has characterized it to have much in common with Syndrome X. Diabetes is a heterogeneous (multifactorial) disease.

Fiber and Diabetes
Diabetes mellitus is the oldest dietary fiber deficiency disease described in humans. In 1979, my colleagues and I described the physiological effects of soluble fiber on the absorption of glucose and model compounds in humans (Holt S et al, Lancet, 1, 639-9, 1979). In acute dosing with soluble fiber, the rate of sugar absorption was slowed and blood glucose tolerance curves tended to flatten. This research forms the basis of an understanding of what is popularly termed “the Glycemic Index”. Thus, soluble fiber was able to smooth the absorption and delay the metabolic incorporation of ingested glucose into the body.
More definitive studies in recent times have shown the ability of extracts of soluble oat fiber ( beta glucans) to significantly lower blood glucose levels following meals and reduce blood cholesterol levels in a favorable manner ( lower LDL, lower triglycerides, with a tendency to raise HDL). Beta glucans function to control body chemistry that is altered by insulin resistance and diabetes mellitus. Diabetes mellitus is often associated with multiple risk factors for cardiovascular disabilities and deaths, such as obesity, hypertension and high blood cholesterol. Extracts of soluble oat fiber (beta glucans) have an increasing role to play in controlling these risk factors. Enhanced intake of both soluble and insoluble dietary fiber is a grossly underestimated natural option that will improve diabetic control and health in patients with both Type 1 and Type 2 diabetes.

Antioxidants and Omega 3 fatty acids
Antioxidants of many types may benefit an individual with diabetes mellitus because many of the consequences or complications of diabetes are due to oxidative stress on the body, or the generation of free radicals. In diabetes and Syndrome X, cross- linking of sugar and protein causes advanced glycation end products which, in turn, damage vital organs. In this circumstance, antioxidant compounds such as vitamins C, E, beta-carotene, selenium and co-enzyme-Q10 and many plant or animal antioxidant compounds (phytonutrients, phytoantioxidants) can exert a major beneficial effect, by “mopping” up free radicals. Of particular interest is the dietary supplement alpha lipoic acid (thioctic acid). This antioxidant plays a specific role in glucose oxidation and it is accessible to both water and fat components of the body. Furthermore, alpha lipoic acid may improve the body’s sensitivity to insulin and it has been used in the prevention of complications of diabetes and liver damage.
Much interest has focused on the omega 3 fatty acid EPA (eicosapentonic acid) because of its vital role in balancing favorable eicosanoid production in the body and exerting beneficial effects in common cardiovascular diseases. The acid EPA is readily converted to DHA, which is found in large amounts in cell membranes, especially in the nervous system and EPA is an effective inhibitor of the genesis of “undesirable” forms of eicosanoids from arachidonic acid. For these and other reasons, EPA must be considered the emperor of fatty acids and it has an underestimated role in the management of diabetes mellitus and Syndrome X (see “Combat Syndrome X, Y and Z…, Holt S..
Evidence has accumulated that the active omega 3 fatty acid, EPA can favorably affect the PPAR (receptor complex), which is involved in insulin action, carbohydrate metabolism and lipid chemistry. Thus, EPA has emerged as a very important way of combating insulin resistance through its beneficial regulation of certain components of the PPAR receptor. EPA (found in fish oil) appears to be a natural and powerful antidote to insulin resistance and it is emerging as a first line option for Syndrome X, with its cardinal components of glucose intolerance, hypertension, hyperlipidemia and obesity. I am particularly impressed by the use of coenzyme Q10 combined with relatively high doses of EPA in the management of diabetes complicated by cardiovascular disease (a very common combination of disabilities).

Many Natural Substances for Diabetes Mellitus
The word diabetes means “siphon” and water soluble vitamins and several minerals are excreted in abundance by diabetic individuals. An adequate intake of vitamins and minerals is mandatory in the management of diabetes. While elements such as chromium and vanadium are known to assist the function of insulin, emerging research shows that the adequate dietary intake of calcium and magnesium is important for control of blood glucose and insulin receptor function. The role of adequate mineral intake in diabetes is underexplored. Soy foods are very valuable in the management of diabetes mellitus and their value has been wrongly impugned by the “meat and dairy lobby”. Soy has a low glycemic index, soy protein lowers blood cholesterol and isoflavones are powerful antioxidants. Soy protein is handled efficiently by the kidneys which are a common target of attack in diabetes mellitus. Several herbs or botanicals have been proposed as potential “treatments” for diabetes mellitus and there is no doubt that some plant compounds have a significant effect on lowering blood sugar, but there mechanism of action remains poorly understood. Popular botanicals used to induce a hypoglycemic effect include bitter melon (Momordica charantia), fenugreek (Trigonella foenum-graecum), garlic (Allium sativum), corosolic acid (Lagerstroemia speciosa or Punica granatum), stevia (Stevia rebaudiana) and Gymnema sylvestre. I believe that the more potent botanical extracts should only be used under the supervision of a health care practitioner, because of potential serious drug interactions with medication.
Of particular interest is the use of fermented barley extracts (GlycoX) which have been shown to reduce blood sugar by up to 63% and blood cholesterol by about 21% in individuals with Type 2 diabetes mellitus. Several other botanicals have been proposed as potential treatments for glucose intolerance and some possess the added advantage of cholesterol control. Examples of these other botanicals include: Tinospora cordifolia, Pterocarpus marsupium, Azadirachta indica, Ficus racemosa, Aegle marmelose, syzygium cumini, Cinnamonum tamala, Atriplex halimu, Vaccinium myrtillus, Korean ginseng, Opuntia ficus, Ocimum sanctum and Silybum marianum.

Diabetes Prevention
While the prevention of Type 1 diabetes is still problematic, there are clear emerging guidelines on lifestyle modification including dietary interventions for weight control and exercise that can be useful in the prevention of diabetes. In recent times, the American Diabetes Association has revised its guidelines on the management of Type 2 diabetes by stressing the role of diet and exercise in management, as the first line options. Drug therapy for Type 2 diabetes including oral hypoglycemic drugs and insulin sensitizing drugs are regarded increasingly as a “Backup plan”. Syndrome X or the metabolic syndrome is amenable to dietary interventions and lifestyle adjustments.
Complex dietary supplements can provide Syndrome X nutritional factors and can promote healthy blood glucose, healthy blood cholesterol, healthy immune function, healthy digestive function, antioxidant effects, inhibition of carbohydrate absorption and a useful adjunctive role in the control of calorie intake by the induction of satiety (the feel-full weight loss trick). The dietary and lifestyle changes that prevent diabetes can also improve the control of diabetes. Public education is a key initiative in the combat against the constellation of problems that are associated with the development, progression or worsening of the alarming increase in Syndrome X, a forerunner of Type 2 diabetes mellitus that affects 70 millions Americans. This constellation underlies the number one cause of death and disability in western society-cardiovascular disease, including stroke and heart attack.

Conclusion
Diabetes mellitus is part of the killer combination of diseases that account for most deaths and premature loss of life or disability. The combat against these problems has to be a multi-pronged approach where first line options involve simple lifestyle issues, particularly nutrition, rather than the premature prescription of drugs which have questionable cost or benefit versus risk profiles. Syndrome X and its consequences are the most important public health initiatives for this new millennium.
Resources
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