Type 2 Diabetes

Question 1

Type 2 diabetes (T2DM)

Answer 1

Type 2 diabetes (T2DM) = chronic hyperglycaemia due to mild to significant insulin deficiency with or without insulin resistance

Question 2

Signs and symptoms

Answer 2

• 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).

Question 3

Complications

Answer 3

• Acute: Hyperosmolar hyperglycaemia.
• Macrovascular: Cardiovascular disease, hypertension, stroke. Elevated homocysteine.
• Microvascular: Retinopathy, neuropathy (peripheral, autonomic), nephropathy.
• Depression, periodontal disease. Alzheimer’s disease.

Question 4

Causes and risk factors

Answer 4

• 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

Question 5

Microbiome and T2DM

Answer 5

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

Question 6

T2DM - Naturopathic goals

Answer 6

1. Stabilise blood sugar levels (and monitor):

• Low GL meals, high fibre (especially fibre). Avoid refined carbohydrate snacks. Address stress.

2. 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.).

3. 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.

4. 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.

Question 7

T2DM - Nutritional support:

Answer 7

• 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

Question 8

T2DM - Low glycemic index (GI)

Foods to avoid

Answer 8

• 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.

Question 9

T2DM - Low glycemic index (GI)

Foods to incude

Answer 9

• 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.

Question 10

T2DM - Nutritional support

Chromium

Answer 10

Question 11

T2DM - Nutritional support

Alpha-lipoic acid

Answer 11

Question 12

T2DM - Nutritional support

Cinnamon

Answer 12

Question 13

T2DM - Nutritional support

Magnesium

Answer 13

Question 14

T2DM - Nutritional support

Vitamin D

Answer 14

Question 15

T2DM - Nutritional support

Mioinositol

Answer 15

Question 16

T2DM - Nutritional support

Biotin

Answer 16

Question 17

T2DM - Nutritional support

EPA and DHA

Answer 17

Question 18

T2DM - Nutritional support

Zinc

Answer 18

Question 19

T2DM - Nutritional support

CoQ10

Answer 19

Question 20

T2DM - Nutritional support

Berberine

Answer 20

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

Question 21

T2DM - Nutritional support

Other natural approaches

Answer 21

• 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.

Question 22

Type 1 diabetes mellitus (T1DM)

Answer 22

Type 1 diabetes mellitus (T1DM) = a generally autoimmune condition characterised by pancreatic beta-cell destruction and absolute insulin deficiency.

Question 23

T1DM - Signs and symptoms

Answer 23

• 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%)

Question 24

Autoimmunity of T1DM

Answer 24

• 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.

Question 25

Autoantibody-negative T1DM

Answer 25

Lack measurable autoantibody responses, autoantibody false negatives or have rare monogenic diabetes.

Question 26

T1DM - Causes and risk factors

Answer 26

• 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

Question 27

Gut microbiome and T1DM:

Answer 27

Question 28

T1DM - Glucose monitoring

Answer 28

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.

Question 29

T1DM - Naturopathic approach

Answer 29

• 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

Question 30

T1DM - Early intervention (‘honeymoon period’)

Answer 30

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.

Question 31

T1DM - Nutritional suport

Alpha-lipoic acid

Answer 31

Question 32

T1DM - Nutritional suport

EPA and DHA

Answer 32

Question 33

T1DM - Nutritional suport

Vitamin D

Answer 33

Question 34

T1DM - Nutritional suport

Vitamin C

Answer 34