Current Non-Drug Therapies

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Non-drug Therapies: Introduction

From ancient times until the discovery of insulin in the 1920's, nutritional therapy was the only available means of treating diabetes. The availability of a broad and ever-increasing array of drugs to treat diabetes has led to an unfortunate de-emphasis of proper nutritional counseling and exercise. Although every discussion of diabetes therapy begins with a statement that dietary modification with weight loss is the first line of defense, patients and physicians alike often skip over this recommendation and head directly for medication. Indeed, weight loss through proper nutrition and exercise is hard work, and ultimately most of us struggle to maintain our ideal body weight. Despite this, diet and exercise can truly benefit almost all patients, even with relatively modest degrees of weight loss. The goals of therapy include the maintenance of near normal blood glucose levels, which help reduce diabetic complications such as nephropathy, retinopathy, neuropathy, and cardiovascular disease. Weight loss through diet and exercise can also lower cholesterol levels and blood pressure, thereby reducing the risk of cardiovascular disease commonly associated with diabetes. It is recommended that every patient with diabetes meet periodically with a nutritionist who specializes in diabetes to develop a diet that meets his or her specific needs.

Dietary Therapy

Type 1 Diabetes:

The goal of dietary therapy for most patients with type 1 diabetes is normalization of blood glucose levels. For children with type 1 diabetes, attention must be paid to providing sufficient calories and insulin to allow normal growth and development. Patients with type 1 diabetes are prone to wide swings in blood glucose, and therefore should eat regularly paced meals with similar caloric content, timed properly with their particular insulin preparation. More frequent injections and the use of rapid-acting insulins allow for increased flexibility in meal content and timing. As patients learn more about their diabetes, they can make subtle adjustments to their insulin regimen that allows them to compensate for changes in their diet on a meal-to-meal basis.

Type 2 Diabetes:

In the United States, most patients with type 2 diabetes are obese, and the goals of dietary therapy are primarily directed at weight loss. It is important for patients and physicians to understand that even a modest reduction of 10-20 lbs. can dramatically improve insulin sensitivity (the body's ability to use its own insulin effectively), glucose and cholesterol levels, and blood pressure, regardless of starting weight. In order to achieve this through dietary therapy, patients are started on diets that are usually 250-500 calories less than their typical diets. Even this limited decrease in caloric intake is difficult for many patients.

Specific Dietary Recommendations:

Carbohydrates

Patients with diabetes often believe that their blood sugar levels directly reflect the amount of sugar that they consume in their diet. They therefore reason that simply avoiding sugary foods should keep their blood sugar under control, and they are subsequently disappointed and frustrated when this does not prove to be the case. Blood glucose comes from a variety of sources, including dietary sugar (usually eaten in the form of complex carbohydrates such as rice and breads) in addition to the natural production of sugars that occurs all the time through normal bodily metabolism. The increase in blood glucose levels that follows the ingestion of carbohydrates varies depending on the individual and the specific type of carbohydrate eaten (fruit versus starch, for example), but most nutritionists who specialize in diabetes recommend that attention be paid to the total amount of carbohydrate, rather than the specific type.

Protein

According to current guidelines, diabetic patients should eat roughly the same amounts of protein as non-diabetic patients. Patients with significant kidney disease, however, should restrict their protein intake modestly.

Fat

More patients with diabetes will die from cardiovascular disease, especially heart attack and stroke, than any other cause. While diabetes itself is a risk factor for these complications, part of the risk is attributable to high levels of fat in the blood. Combined with the need for weight loss in most patients with type 2 diabetes, this represents a good reason to reduce fat intake. Specific recommendations include cutting saturated and polyunsaturated fats (such as lard) each to less than 10% of total caloric intake. Monounsaturated fats, such as olive and canola oils, can make up 10-15% of the diet.

Alcohol In general, recommendations on limiting alcohol intake to two drinks per day for men (one for women) apply similarly to people with diabetes and those without. There are specific issues to remember with diabetes, however. Alcohol cannot be broken down to glucose, and it also inhibits glucose production by the liver. This means that if a person taking insulin or a sulfonylurea drinks alcohol without food, hypoglycemia can result. For people with Pancreatitis. No Alcohol intake, is the rule!

Exercise

Almost all patients with diabetes should be exposed to the beneficial effects of exercise, and exercise should be a prominent component of the weight loss program for most people with type 2 diabetes. In this sense, there is little difference between recommendations for people with and without diabetes. There are several specific issues, however, that need to be addressed in diabetics wishing to increase their level of physical exertion.

Patients with active diabetic retinopathy should not participate in exercises involving straining or heavy lifting since these activities can provoke eye damage. Patients should also be aware that nerve damage caused by high blood sugar levels can lead to a loss of sensation in the feet, with a subsequent increased risk of blistering and ulceration. Patients with progressive heart damage from high blood sugar should be warned about the risk of sudden heart failure and death.

For all of these reasons, people with diabetes should consult with their physicians prior to embarking on an exercise program. Once an exercise program is begun, the patient with diabetes must pay attention to proper shoe selection to minimize blistering. Swimming, bicycling, and other non-weight-bearing exercises are preferable to running or treadmill activities. Patients taking insulin, especially those with type 1 diabetes, need to have access to carbohydrate-based snacks in case their blood sugar level falls. Ultimately, individual patients need to learn what their body's metabolic responses to varying degrees of exertion will be, and to take appropriate steps to avoid both high and low blood sugar levels. Patients should remember to drink plenty of fluids to replace body water lost through respiration and sweating. Despite these caveats, exercise is recommended for virtually all patients with diabetes. With few exceptions, exercise is expected to improve metabolic control directly (by enhancing glucose uptake into active muscles) and by causing weight loss. Similarly, exercise leads to decreases in cholesterol and blood pressure both of which benefit the overall health status of patients with type 1 and type 2 diabetes.

Pancreas transplantation

A healthy pancreas, transplanted into a type 1 diabetic, will produce insulin and, in effect, cure the disease. It is important to note that transplantation will not cure type 2 diabetes, as a new source of insulin does not solve the problem of insulin resistance in body tissues.

Like heart, lung, and liver transplant recipients, patients who receive a new pancreas must take immunosuppressive drugs to prevent rejection of the foreign organ. These drugs can cause side effects ranging from fatigue to life-threatening infections. Cadaveric donors supply most of the pancreases used in transplant operations. Some centers are performing transplants using partial organs from living relatives of the patient.

The first pancreas transplant in a diabetic patient was performed nearly 35 years ago. Many early procedures were unsuccessful. However, recent improvements in surgical technique and immunosuppression regimens have dramatically improved results. A review of pancreas transplantations in the 1990s shows that over 90% of patients are alive one year after the operation. In over 80% of cases, the transplanted pancreas was able to regulate blood sugar levels. These patients required no supplemental insulin or other diabetic drugs.

Most pancreas transplants are performed in diabetic patients who also need a kidney transplant. These two procedures can be performed simultaneously, although some doctors place the new kidney first, followed by the pancreas. The American Diabetic Association recommends that pancreas transplants be reserved for patients with end-stage kidney disease who also need a new kidney. They do accept the practice of pancreas-only transplants, providing the following three criteria are met:

1. The patient experiences frequent metabolic complications from their diabetes (e.g., hypoglycemia, hyperglycemia, ketoacidosis).

2. The patient has significant difficulty with the administration of insulin shots.

3. Insulin administration has failed to prevent metabolic complications.

The reason pancreas transplantation is not done more often is because the surgical death rate (albeit low) and the risks of lifelong immunosuppression weigh heavily on the minds of doctors who know that judicious use of insulin will keep almost all diabetics in check. Given the efficacy of insulin, in other words, it is hard to justify exposing patients to these risks. There is also a shortage of donor organs, as is true for all solid organ transplantation therapy.