Type 2 Diabetes Flashcards
Type 2 diabetes (T2DM)
Type 2 diabetes (T2DM) = chronic hyperglycaemia due to mild to significant insulin deficiency with or without insulin resistance
Signs and symptoms
- Polyuria (increased urination).
- Polydipsia (excess thirst).
- Polyphagia (excess hunger).
- Extreme fatigue. Blurry vision.
- Poor wound healing.
- Recurrent infections.
- Acanthosis nigricans.
- Obesity. Note: Non-obese T2DM rising (60–80% in Asian countries).
Complications
- Acute: Hyperosmolar hyperglycaemia.
- Macrovascular: Cardiovascular disease, hypertension, stroke. Elevated homocysteine.
- Microvascular: Retinopathy, neuropathy (peripheral, autonomic), nephropathy.
- Depression, periodontal disease. Alzheimer’s disease.
Causes and risk factors
- Strong family history.
- Ethnicity — Asian, African, and Afro-Caribbean.
- Advancing age > 45 years. Children < 17 ass. with obesity, inactivity, poor nutrition etc.).
- Diet — high GL diet (↑ blood glucose and insulin levels; ↑ LPS, ROS and NF-kB after a meal which ↑ inflammation), alcohol, high saturated fat / trans fat, low fibre (increasing GL and impacting microflora — see later), low antioxidants, HFCS (e.g., soft drinks).
- Nutrient deficiencies — vitamins C, E, B3, B5, B6, magnesium, chromium, zinc, omega-3.
- Obesity (increased waist:hip ratio).
- Reduced physical activity — exercise modulates inflammatory mediator expression involved in IR; increases GLUT4 expression; ↓ adiposity.
- High oxidative stress, e.g., from smoking, poor sleep, environmental toxins (phthalates, arsenic, BPA, PCBs).
- Chronic stress — ↑ glucose, lipid and inflammatory cytokines; increases BP. Leads to chronic low-grade inflammation.
- Mitochondria dysfunction — e.g., due to heavy metals, chemicals such as pesticides, drugs such as statins etc.). ↑ ROS, low ATP, ↓ GLUT 4 expression.
- Poor methylation (high homocysteine), hypertension, elevated triglycerides. Low adiponectin.
- Pre-diabetes, metabolic syndrome, gestational diabetes
Microbiome and T2DM
Gut dysbiosis can:
- Drive inflammatory processes (pro-inflammatory cytokines), modulate SCFA production and alter intestinal permeability.
- Cause metabolic endotoxaemia ↑ circulating LPS
Bifidobacterium, b faecalibacterium, akkermansia and roseburia are shown to be protective against TIIDM.
- Bifidobacterium ↑ glycogen synthesis, improves the translocation of GLUT4 and ↑ insulin-stimulated glucose uptake.
- Ruminococcus, fusobacterium, and blautia are associated with a higher risk of TIIDM.
- Low gut microbial diversity is common in T2DM
T2DM - Naturopathic goals
- Stabilise blood sugar levels (and monitor):
- Low GL meals, high fibre (especially fibre). Avoid refined carbohydrate snacks. Address stress.
- Reduce inflammation and boost antioxidants:
- Diet — avoid inflammatory foods / beverages.Increase flavonoid-rich foods (ensure adequate blue, purple and black plant foods; green tea etc.).
- Antioxidants (e.g., α-lipoic acid, ↑ glutathione etc.).
- Sleep hygiene; address environmental toxins. of oxidative damage
- GI health (e.g., address dysbiosis, endotoxaemia etc.).
- Correct macronutrient and micronutrient status:
- To improve glycaemic control, reduce complications and support the immune system.
- Magnesium, zinc, B vitamins, vitamins D, C and E, chromium etc.
- Optimise EFA status and ensure adequate protein with meals.
- Optimise insulin sensitivity and mitochondrial function:
- Nutrition, nutraceuticals and lifestyle factors incl. exercise.
- Gymnema sylvestre, bitter melon, Panax ginseng, fenugreek seeds, onions and garlic, cinnamon, silymarin. CoQ10.
T2DM - Nutritional support:
- Calorie restriction — ↑ skeletal muscle and liver insulin sensitivity.
- A low carbohydrate diet (LCD) — with more nuts shown to reduce weight, improve blood glucose, and regulate blood lipids.
- Reduced carbohydrates — increased protein, MUFAs, and fibre (slows down gastric emptying, slower release of glucose and, therefore, insulin response is lowered, reduces GL of meal).
- Low glycaemic index (GI) — more effective in controlling HbA1c and fasting blood glucose than a high GI diet, also shown to lower IL-6. Reduced post-prandial glucose = reduced insulin
T2DM - Low glycemic index (GI)
Foods to avoid
- Sucrose and fructose; fruit juices.
- Processed foods.
- Refined carbohydrates.
(bread, pasta, pastries etc.)
- High red meat (arachidonic acid).
- Food / drinks from plastic bottles.
- Large meals (over-eating).
- Non-calorific artificial sweeteners — signaling insulin release in the absence of glucose.
T2DM - Low glycemic index (GI)
Foods to incude
- Extra virgin olive oil.
- Green tea.
- Mixed nuts.
- Cinnamon.
- Omega-3 sources.
- Soluble fibre rich foods (> 50 g / day; whole grains, legumes, nuts, seeds etc.)
- Fibrous vegetables.
- Low GL fruits e.g., berries.
T2DM - Nutritional support
Chromium
T2DM - Nutritional support
Alpha-lipoic acid
T2DM - Nutritional support
Cinnamon
T2DM - Nutritional support
Magnesium
T2DM - Nutritional support
Vitamin D
T2DM - Nutritional support
Mioinositol
T2DM - Nutritional support
Biotin
T2DM - Nutritional support
EPA and DHA
T2DM - Nutritional support
Zinc
T2DM - Nutritional support
CoQ10
T2DM - Nutritional support
Berberine
Berberine:
- Decreases gluconeogenesis and facilitates GLUT4 translocation.
- ↓ expression of proinflammatory genes (incl. that which is LPSinduced) e.g., TNF-alpha, IL-1beta, IL-6. Berberine ↓ hs-CRP.
- ↑ AMPK activity of islet cells = insulin secretion.
- Modulates the microbiome — a likely anti-diabetic mechanism. Thought to reduce circulating LPS load (a factor associated with insulin resistance).
- These mechanisms are similar to metformin.
Although metformin = vitamin B12 and folate malabsorption and can hence ↑ homocysteine
T2DM - Nutritional support
Other natural approaches
- Support gut microbiome (‘5R programme’, comprehensive stool testing). Lactobacullus acidphillus for 4 weeks has been shown to preserve insulin sensitivity.
- Reishi mushroom — ganoderic acids increase insulin secretion and decrease cellular resistance to insulin.
- Milk thistle — 600 mg for 6 months shown to significantly reduce fasting glucose. Improves liver function; protective role against NAFLD (associated with metabolic syndrome).
- Exercise — increase physical activity; mix of aerobic, strength / resistance and flexibility. Aiming for at least 30 minutes daily.
Type 1 diabetes mellitus (T1DM)
Type 1 diabetes mellitus (T1DM) = a generally autoimmune condition characterised by pancreatic beta-cell destruction and absolute insulin deficiency.
T1DM - Signs and symptoms
- Similar to T2DM but are more severe and faster in onset.
- Profound symptoms can develop in days or weeks.
- DKA presentation at diagnosis is common: Nausea, vomiting, abdominal pain, dehydration and shortness of breath.
- ED, anxiety and depression.
- Hypoglycaemia (< 3.5 mmol / L):
Often due to missing meals, over exercising and excess antidiabetic medication e.g., insulin.
DKA can be fatal.
- T1DM increases risk of other AI diseases (20%–25% have thyroid antibodies) e.g., Grave’s, Hashimoto’s, AI gastritis (5–10%), coeliac disease (4%)
Autoimmunity of T1DM
- Approximately 90% of individuals develop T1DM due to autoimmune destruction of beta-cells.
- Occurs in genetically susceptible individuals and is marked by the presence of circulating autoantibodies to islet cells.
- Activation of auto-aggressive T-helper (Th) cells and macrophages are proposed. Growing evidence to suggest altered Th1 / Th2 balance is key.
Autoantibody-negative T1DM
Lack measurable autoantibody responses, autoantibody false negatives or have rare monogenic diabetes.
T1DM - Causes and risk factors
- Genetics: 30–70% in identical twins. Polymorphisms: (HLA)-DR / DQ gene increase susceptibility.
- Stress — e.g., serious life events.
- Viral infections — Coxsackievirus B, rotavirus, mumps virus, and cytomegalovirus. EBV may be implicated. ‒ Viruses can cause direct cytolytic destruction of beta-cells or by promoting autoimmunity.
- Obesity — the prevalence of obesity in T1DM is increasing! A 10% increment in weight was associated with a 50–60% increase in risk of T1D before the age of 3 years.
- Early nutrition — introducing gluten < 4 months old and cow’s milk < 12 months encourages gut dysbiosis in infants.
- Caesarean delivery. Breastfeeding confers protection.
- Nitrates — N-nitroso compounds (damaging to β-cells). Found in smoked and cured meats.
- Vitamin D deficiency — low levels are often seen in pre-diabetic children with autoantibodies.
- Omega-3 deficiency — promoting inflammation. Supplementation suppresses inflammatory cytokines
Gut microbiome and T1DM:
T1DM - Glucose monitoring
Glucose monitoring: In clinical practice, clients / families can experience increased stress in relation to managing the disease and glycaemic control.
- T1DM requires regular accurate glucose monitoring to avoid hypo- and hyperglycaemic episodes. Education is paramount.
- Continuous glucose monitoring devices have made it easier to understand and manage glucose levels. For example:
– Dexcom®: A slim sensor continuously monitors glucose, alarm alerts and app to view readings, graphs and trends.
– Freestylelibre ®: Small sensor on skin, scanning device to get current glucose reading, tracking reports and app.
T1DM - Naturopathic approach
- Many of the T2DM naturopathic goals apply in T1DM, but note that insulin will always be needed in T1DM.
- Support blood glucose balance — low GI meals, avoid high refined carbohydrate snacking, alcohol, concentrated sugars (fructose) and nitrates. Increase high-fibre foods.
- Restore nutrient deficiencies (e.g., vitamin D, omega-3).
- Optimise GI health (e.g., digestion, microbiome).
- Reduce stress, support exercise and sleep.
- Reduce inflammation associated with AI disease.
Remove allergenic triggers e.g., gluten, cow’s milk
T1DM - Early intervention (‘honeymoon period’)
Early intervention (‘honeymoon period’):
- Early intervention may help to delay or reverse beta cell damage.
- Combine strict glycaemic control and immune modulation to protect β-cell function during this period.
- Exercise — a case control study revealed that the honeymoon period is 5 times longer in men who exercise.
- Niacinamide and epicatechin may help with immune modulation and reduce immune-mediated damage to B-cells.
Green tea
‒ Epicatechin — the polyphenols exhibit antiviral activity against rotavirus and enterovirus.
T1DM - Nutritional suport
Alpha-lipoic acid
T1DM - Nutritional suport
EPA and DHA
T1DM - Nutritional suport
Vitamin D
T1DM - Nutritional suport
Vitamin C
