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Condition - Diabetes

By Dr Pieris Nicola PhD BSc (Hons) Dip ION

Diabetes (also known as diabetes mellitus) is a problem with controlling the levels of blood sugar (glucose), a fuel the body needs. It is estimated that up to one in 20 people in England has diabetes (diagnosed & undiagnosed).

When you eat a carbohydrate-containing food, your digestive system turns the carbohydrates into blood sugar. Some is used immediately and the rest is stored for later use in muscles, the liver, and fat cells. Insulin, a hormone made by the pancreas (a gland lying just behind the stomach), is needed to move glucose out of the bloodstream and into the cells. Some people cannot make insulin, or cannot make enough of it. In others, the insulin produced is not effective and the tissues cannot respond properly to insulin’s ‘open up for sugar’ signal. The end result is increased glucose in the blood. Over time, raised blood sugar levels can affect the small blood vessels in the kidneys, eyes and nerves, and also the larger blood vessels in the heart, brain and legs. 

There are two main types of diabetes known as type-1 and type-2. 

Type-1 diabetes, also known as juvenile-onset diabetes or insulin-dependent diabetes, is an auto-immune disease and occurs when the immune system, which normally fights harmful bacteria and viruses, attacks the insulin-producing cells of the pancreas. As a result, the pancreas is unable to produce enough insulin, and so there is a need to receive insulin by injection. 

Type-2 diabetes, also known as adult-onset diabetes or non-insulin dependent diabetes, accounts for approximately 90% of all diabetes, and occurs when the body does not produce enough insulin, or more commonly when your body’s muscle and liver cells do not respond adequately to normal insulin levels - doctors call this insulin resistance

Other types of diabetes or conditions related to diabetes include

Pre-diabetes.  This is when your blood sugar levels are higher than normal, but not high enough to be classified as diabetes. Reactive hypoglycaemia is considered by many to be a pre-diabetic condition and usually results from the overconsumption of refined carbohydrates high in the glycaemic index.

Gestational diabetes.  This occurs during pregnancy, resulting from changes in hormone levels.  

Secondary diabetes.  A form of diabetes that is secondary to other conditions such as pancreatic disease, Cushing’s, Acromegaly, etc.

Symptoms of diabetes 

The symptoms of diabetes may include the following: 

  • Excessive thirst.
  • Excessive appetite.
  • Frequent urination.
  • Unexplained weight loss.
  • Fatigue.
  • Blurred vision.
  • Craving for sweet foods.
  • Itching of the genital organs.
  • Frequent infections, including gum or skin infections, and vaginal or bladder infections. 

If you have pre-diabetes or gestational diabetes, you may not experience any of these symptoms, or you may experience some or all of the symptoms above.

Risk factors for type-1 diabetes 

  • Genes - Type-1 diabetes runs in families.
  • Viruses - Some scientists believe that enteroviruses, in particular the Coxsackie virus that causes mumps and German measles, may trigger type-1 diabetes.
  • Foods - Some studies suggest that early exposure to cow’s milk or products containing wheat raises the lifetime risk of developing type-1 diabetes in high-risk children.

 Risk factors for type-2 diabetes 

  • Weight. Being overweight and obese increases the chances of developing type-2 diabetes.
  • Increased waist circumference.
  • Physical inactivity. A lack of physical activity is associated with a greater risk of pre-diabetes and type-2 diabetes.
  • Dietary factors. The amount of calories in the diet derived from fat (especially saturated fats) is associated with type-2 diabetes. A diet with a high glycaemic load is also a risk factor, as is a low fibre diet.
  • Reactive hypoglycaemia.
  • Smoking.
  • Use of certain drugs, including oral contraceptives, thiazide diuretics, cortisone or phenytoin.
  • Race. Afro-Americans, Hispanics, Native American youth and Asian-Americans are at a greater risk.
  • Age. The risk increases with age and may be related to an age-related decrease in physical activity and increase in weight.
  • Gestational diabetes increases your risk of developing pre-diabetes or type-2 diabetes. Giving birth to a baby weighing more than nine pounds also increases your risk.
  • Polycystic ovary syndrome increases the risk of diabetes.

Managing diabetes 

An important part of managing all types of diabetes includes maintaining a healthy weight and controlling blood sugar levels, through dietary changes and lifestyle intervention.  Supplying additional key nutrients may also help support blood sugar levels within a normal healthy range.

Nutritional considerations 

  • Magnesium. Diabetes is the most common disorder associated with magnesium deficiency, and is thought to result from an increased loss of magnesium in the urine of diabetics. Magnesium deficiency may worsen insulin resistance and impair insulin secretion.
  • Manganese. Manganese is a trace mineral that helps support normal blood sugar levels.
  • Zinc. Low blood levels of zinc are common in diabetics, and this is likely to be the result of an increased loss of zinc in the urine. Zinc plays an important role in the synthesis, storage and secretion of insulin. Zinc also plays a key role in antioxidant defence. Insufficient amounts of zinc could result in an increase in free radical production. Free radicals may bring about, or worsen, some of the complications of diabetes.
  • Chromium. Chromium is a trace element that may be deficient in diabetics. Chromium may help to maintain normal insulin sensitivity and support the function of the pancreatic cells that produce insulin.
  • Biotin. Biotin may help support normal glucose metabolism and insulin sensitivity.  The results of a double-blind study of 447 overweight to obese type-2 diabetics, who were also on oral medication, suggested that the combination of chromium and biotin may have a significant positive impact on glucose regulation. The results were published in the journal Diabetes/Metabolism Research and Reviews.
  • Vitamin B5 (Pantothenic acid). Patients with diabetes have been shown to have a greater level of pantothenic acid in their urine compared to healthy persons.
  • Vitamin B6. Low blood concentrations of vitamin B6 have been observed in patients with type-1 and type-2 diabetes.
  • Vitamin B12.  Abnormal B12 metabolism is frequently seen in diabetics. B12 deficiency produces symptoms similar to diabetic neuropathy.
  • Vitamin C. An imbalance between our antioxidant defences and the production of free radicals is defined as oxidative stress. Oxidative stress has been associated with insulin resistance, type-2 diabetes, and the progression of long-term diabetic complications. Vitamin C is a major antioxidant that may help to reduceoxidative stress. Diabetes is characterised by high blood sugar levels. Prolonged high blood sugar sets in motion a destructive chain reaction that can damage blood vessels. Scientists in Italy and Hungary found that this damage continues even when blood sugar is controlled by insulin and other drugs. Recently, researchers at theHarold Hamm Oklahoma Diabetes Center, USA and theUniversity Hospital of Coventry and Warwickshire, UK, showed that combining vitamin C with insulin, in type-1 diabetic patients, halts this destructive chain reaction.  Finally, vitamin C may help to reduce the accumulation of a sugar-like substance, called sorbitol, in the cell. Sorbitol accumulation has been associated with diabetic complications, including damage to the small blood vessels of the eye.
  • Vitamin D. Studies suggest that mild vitamin D deficiency may be linked to diabetes.
  • Vitamin E. Diabetes is associated with increased levels of highly reactive molecules, including free radicals. When these reactive molecules attack lipids within cell membranes or lipoproteins, they initiate a chain reaction called lipid peroxidation. Elevated lipid peroxidation has been observed in atherosclerosis, a major cause of death in diabetics. Vitamin E is a fat-soluble vitamin that helps protect against free radical damage to lipids, by halting the chain reaction of lipid peroxidation.
  • Vitamin K. A study, led by Sarah Booth, director of the Vitamin K Research Laboratory at Tufts,and published in the journal Diabetes Care, showed that vitamin K could reduce the risk of insulin resistance in older men. Insulin resistance is a primary cause of type-2 diabetes.
  • Homocysteine and oxidative stress. Increased homocysteine levels and increased generation of free radicals are associated with type-2 diabetes. Vitamins B6, B12 and folic acid may help to support homocysteine levels within a normal healthy range; and antioxidants help to mop-up free radicals.
  • Alpha-lipoic acid. This is an antioxidant that, according to scientific studies, may have a positive effect on insulin sensitivity. A meta-analysis of clinical trials of alpha-lipoic acid in diabeticpatients, reported in the leading journal Diabetic Medicine, showed a significant positive impact on the symptoms of diabetic neuropathy.
  • Acetyl-L-carnitine. Mitochondria are the energy-producing structures inside our cells. Emerging evidence supports the hypothesis that both insulin resistance and hyperglycaemia, which are prominent features of type-2 diabetes, are caused by mitochondrial dysfunction. A study by researchers from the Institute for Brain Aging and Dementia at the University of California, Irvine, reported in the journal Diabetologia, that the combination of alpha-lipoic acid and acetyl-L-carnitine works synergistically to improve mitochondrial function, and much more effectively than the use of either in isolation.
  • Fish oil. Diabetes is a risk factor for cardiovascular disease. Long-chain omega-3 fatty acids (including EPA and DHA) may help support cardiovascular health and reduce the risk of cardiovascular disease. Studies have also suggested that low-grade inflammation throughout the body, including the fatty tissue, may play an important role in many diseases, including the development of type-2 diabetes. Further, inflammation may contribute to insulin resistance, an early step in the development of type-2 diabetes. Omega-3 fatty acids may help support anti-inflammatory processes. Fish oil is a good source of omega-3 fatty acids. 
  • Fermented soy products. The incidence of type-2 diabetes is lower in Asian populations compared with those in Western countries. A possible reason for this is the consumption of fermented soy products in the traditional Asian diet, which contain soy phytoestrogens (isoflavones). The beneficial effects of soy isoflavones may be related to improved glucose control and insulin resistance.
  • Quercetin. Harvard researchers have found an over-abundance of immune cells, called mast cells, in the fat tissue from obese and diabetic mice and humans, compared with fat tissue from people with a normal weight. Their research also showed that stabilising mast cells may help fight obesity and control blood sugar levels. Quercetin is a type of plant-based chemical, also known as a flavonoid, which may help to support mast cell integrity.
  • Ginkgo biloba helps support healthy blood flow in peripheral areas including fingers and toes.
  • Fenugreek. Steroid saponins, flavonoids and galactomannan fibre are plant-based chemicals that may help reduce blood sugar, serum cholesterol, and serum triglyceride levels. The amino acid, 4-hydroxyisoleucine, has been shown to stimulate insulin secretion, and reduce insulin resistance. Fenugreek is a good source of steroid saponins, flavonoids, galactomannan fibre, and 4-hydroxyisoleucine.
  • Cinnamon. Polyphenols are beneficial active components found in plants with antioxidant effects. Polyphenol type-A polymers may help to improve insulin sensitivity and support healthy blood sugar levels in type-2 diabetics. Cinnamon is a rich source of polyphenol type-A polymers.

Dietary factors 

  • Choose healthy fats. Diets rich in mono and polyunsaturated fats can help lower the risk of diabetes and heart disease. Good choices of healthful fats include olive oil; the fats in avocados, nut and seeds; and cold-water oily fish (salmon, herring, mackerel, sardines and anchovies). Studies have linked a high consumption of nuts to a reduced risk of diabetes, and research suggests that a walnut-rich diet may boost diabetic heart health. Walnuts are a rich source of the plant omega-3 fat, alpha-linolenic acid (ALA), and the science so far suggests that ALA improves vascular tone, heart rate, blood lipid levels, blood pressure, inflammatory responses, and reduces hardening of the arteries.  Flax seeds are also a good source of ALA.
  • Eat a diet lower in saturated fats.
  • Avoid trans fats.  These increase the risk of diabetes and heart disease. These are found in traditional stick margarines, packaged and baked goods, fried foods in fast-food restaurants, and any product that lists “shortening or hydrogenated or partially hydrogenated oil” as one of its ingredients (read the food labels).
  • Limit red meat and avoid processed meat. People who regularly eat red meat have approximately 20% greater risk of type-2 diabetes than those who rarely or never eat red meat. It is possible that the high iron content of red meat reduces insulin’s effectiveness or damages insulin-producing cells. Eating processed meats can also increase your risk of diabetes. Avoid smoked or cured meats. Good-quality lean meat and grass-fed meat in moderation is fine.
  • Alcohol. High alcohol consumption could increase the risk of type-2 diabetes, whilst moderate consumption may reduce the risk, possibly by increasing the efficiency of insulin. However, if you are a non-drinker, don’t feel obliged to start drinking. You can get similar benefits by losing weight, exercising and eating healthily. If you choose to drink a small amount, do so in moderation and always with a meal.
  • Avoid diabetic specialty foods. There is no evidence that such foods offer any benefit for diabetics.
  • Lower dietary glycaemic load or overall dietary glycaemic index:

            i.              Choose whole grains and products made from whole grain flours. There’s a growing body of evidence that a diet rich in whole grains can help reduce the risk of diabetes and keep your appetite under control. Examples of whole grains are brown rice, wild rice, millet, oats, quinoa, rye, bulgur and corn grits. Products made from whole grains include whole-wheat bread, wholegrain crackers, sprouted wheat or rye breads, whole rye bread.

          ii.              Avoid refined carbohydrates and sugary drinks.  Avoid refined carbohydrates (white rice, white bread, white pasta and many breakfast cereals), sugary drinks and fruit juice. These have a high glycaemic index, which means they cause rapid and greater increases in blood sugar levels, and this may increase the risk of developing type-2 diabetes. Check food labels for the following sugars and avoid: sucrose, fructose, maltose, dextrose, polydextrose, corn syrup, maple syrup, molasses, sorbitol, and maltodextrin. There is mounting evidence that sugar contributes to inflammation, elevates blood fats (triglycerides), reduces good (HDL) cholesterol, and increases insulin resistance, all of which are risk factors for diabetes.

        iii.              Increase consumption of fruits, legumes (beans, peas, and lentils), nuts and seeds, and non-starchy vegetables such as lettuce and other leafy greens, artichoke, asparagus,bean sprouts, broccoli, bok choy, cabbage, cauliflower,celery, cucumber, eggplant, okra, onion, sprouts, squash (cushaw, summer, crookneck, zucchini) etc. Eat root vegetables (potatoes, carrots and beets) and fruits with other foods and not on their own which will also help to control blood sugar levels.

        iv.              Include protein at each meal.  This helps decrease your hunger between meals. Nuts, seeds, beans, tofu, fish, poultry or free-range eggs, and organic wholemilk yogurt (the fat content of “wholemilk” reduces the glycaemic index) are healthier protein choices.

          v.              Try to eat small frequent meals throughout the day, and avoid skipping meals, especially breakfast.

Lifestyle factors 

Making a few lifestyle changes can dramatically lower the chances of developing type-2 diabetes, and can also be beneficial if you have pre-diabetes. 

1.      Stay active.  The combination of excess weight and physical inactivity makes tissues resistant to insulin, which can snowball into diabetes. Regular exercise improves insulin sensitivity, reduces total serum cholesterol and triglycerides, and increases HDL (good) cholesterol. It also helps you to control weight and use up glucose as energy.  Choose activities you enjoy, and do them regularly. Walking is a good start. Do it as often as you can. Cycling or walking to work, or walking up the stairs instead of taking a lift, can be helpful. Findings from the Nurses' Health Study and Health Professionals' Follow-up Studysuggest that walking briskly for half hour every day reduces the risk for type-2 diabetes by 30%. Similarly, a more recent study, The Black Women’s Health Study, showed that brisk walking for more than five hours per week was associated with a reduced type-2 diabetes risk. Finally, a study reported in the journal Diabetes Care, showed that breaks in sedentary (primarily sitting) time may provide beneficial metabolic effects that may positively influence the risk of type-2 diabetes.

2.      Maintain a healthy weight. Excess weight is the single most important cause of type-2 diabetes. Being overweight increases the risk for developing type-2 diabetes more than seven fold. Obese people are up to 80 times more likely to develop diabetes than those of average weight. The Diabetes Prevention Program (DPP) was a major multicentre clinical research study that examined the effects of weight loss and increased exercise on the development of type-2 diabetes among non-diabetic men and women with increased blood sugar levels. The DPP results showed that people at risk for developing diabetes can prevent or delay the onset of diabetes by losing a modest amount of weight through diet and exercise. DPP participants assigned to weight loss and exercise reduced their risk of developing diabetes by 58% during the study compared to the group assigned to usual care. Indeed, the benefits persisted even when the programme ended i.e. the risk of diabetes was reduced over 10 years. Similar results have been seen in both a Finnish study of exercise, weight loss and dietary changes, and a Chinese study of exercise and dietary changes.  Waist circumference is strongly correlated with visceral fat (the fat wrapped around internal organs in your tummy), which is thought to be more dangerous than the fat just under the skin. This is because visceral fat may actually be fuelling inflammation throughout the body, which may play important roles in the development of insulin resistance and diabetes. So if you are apple-shaped, with fat stored on your tummy, you may be at a greater risk of diabetes than pear-shaped people, with fatter hips and thighs. Research has also associated obesity with inflammation. A recent study published in the Journal of Clinical Endocrinology & Metabolism showed that obese people with either type-2 diabetes or pre-diabetes had high levels of inflammatory blood cells. After weight loss associated with gastric band surgery, the scientists found up to an 80% reduction in pro-inflammatory blood cells, and many patients were able to significantly reduce their diabetic medications. They concluded that modest weight reduction reverses some of the adverse inflammatory changes seen in obese people with diabetes.

3.      Control stress levels. The hormones produced by the body in response to chronic stress may prevent insulin from working properly. Practise relaxation techniques including yoga, meditation, or breathing exercises, prioritise your tasks, and stay positive.

4.      Stop smoking. Smokers are approximately 50% more likely to develop diabetes than non-smokers, and heavy smokers have an even higher risk. Smoking also increases your risk of various diabetic complications, including heart attacks, stroke, nerve damage, and kidney disease. Diabetic smokers are three times more likely to die from cardiovascular disease than age-matched diabetic non-smokers, according to the American Diabetes Association.

5.      Avoid PCBs and pesticides. Diabetes may be linked to environmental pollution according to a study from Stanford University, which found that a pesticide-derivative (Heptachlor epoxide) and polychlorinated biphenyls or PCBs were associated with a greater risk of type-2 diabetes.

6.      Take care of your feet. Diabetics are prone to poor circulation, especially affecting the legs and feet, as well as nerve damage in the feet. This increases the risk of various foot complications, which can become quite serious if left untreated. Wash your feet daily, in lukewarm water. Check your feet for blisters, cuts, sores, redness or swelling.

7.      Take care of your teeth. Diabetes may increase the risk of gum infections. Brush and floss your teeth at least twice a day, and pay regular visits to your dentist.

8.      Regular medical check-ups are important to ensure blood sugar levels are controlled and also to reduce the risk of long-term diabetes-related complications.

9.      Have a good night’s sleep. Scientists at the University of Chicago, writing in the journal PNAS, have discovered that a component of your nocturnal sleep, known as slow-wave sleep, is vital to helping your body regulate sugar levels and reduce the risk of diabetes, by improving insulin sensitivity.

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