Diabetes / Metabolic Syndrome

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Diagnostics and Treatment Protocol in Diabetes and Metabolic Syndromes

Standard medicine presents an often confusing diagnosis and treatment strategy to the patient. Below is a short summary of the current treatment and diagnostic guidelines in standard medicine. Complementary Medicine should integrate with these diagnostic findings and complement any prescription of drugs with the individualized herbal and nutrient therapies based on both standard lab findings and signs and symptoms. Today, instead of a more thorough diagnostic workup to address the findings of the strong variance in presentations of diabetes and Metabolic Syndromes, the guidelines have instead narrowed the diagnostic testing and analysis, for no other reason than to promote more drug sales, not to actually inform and benefit the patient with an individualized approach to care.

Standard testing for patients suspected of a type of diabetes includes the A1C test, a fasting plasma glucose test (FPG), and an oral glucose tolerance test (OGTT). Often these are initiated after an abnormal finding with a random plasma glucose test (RPG), but the blood sugar can be highly elevated in random sampling for a number of reasons besides a diabetic condition. The A1C index, or hemoglobin A1c, may be an unreliable diagnostic tool, though, as well, as variations in testing quality, and various health conditions seen with subsets of patients and individuals may alter the A1C level. For example, patients with chronic kidney disease, liver disease, and/or anemia, even undiagnosed conditions, could have elevated A1C unrelated to diabetes, and the chronic use of statin drugs may increase the A1C. Without a thorough and intelligent assessment, many patients may be started unnecessarily on drugs to treat diabetes. Even with blood tests such as the FPG, studies show a potential variance of glucose levels when the blood sample is tested in the same laboratory. Intelligent patients will make sure that their diagnosis is correct before starting problematic therapies with side effects. To review diagnostic criteria, this basic outline is presented by the National Diabetes Information Clearinghouse of the U.S. National Institutes of Health: http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/

If you are diagnosed as type I / IDDM, diagnosis is confirmed by a high random blood glucose of >200, or by 2 separate fasting blood glucose tests showing >140, and hyperglycemic symptoms, such as frequent urination, abnormal thirst, unexplained weight loss, and hunger without satiation. If there are few signs of chronic hyperglycemia, the patient may be monitored and assessed for an acute cause of hyperglycemia secondary to another cause, that may be resolved, thus sparing the patient the need for synthetic insulin. If the diagnostic workup for the hyperglycemia confirms a true case of Insulin Dependent Diabetes Mellitus, in this case insulin is prescribed and self-administered in a combination of fast and slow acting forms, with attention paid to current blood glucose levels, measured by placing a drop of blood on a measuring device, or now by devices that are implanted or use other technology than blood stick to measure blood sugar. This taking of insulin does not exempt the patient from the need to also control the blood sugar with careful attention to balanced intake of food, and attention to controlled utilization of body sugars, fats, and proteins by timely exercise patterns associated with intake of food. A number of protocols could reduce the amount of synthetic insulin needed in Type 1 Diabetes and lead to a better quality of life, and fewer complications over time.

Diagnosis of type II / NIDDM is often difficult, as the patient is often experiencing only mild symptoms. This diagnosis is confirmed also by 2 separate fasting glucose tests showing > 140, or by a hemoglobin A1c (HGbA1c) measure of >7.0 percent, or by an observed glucose tolerance test (OGTT). The common use of just the A1C measure (an advanced glycation endproduct or AGE), is now controversial, though, and there is worry that this strategy has been used just to increase medication prescription. The diagnosis is rarely clear in Diabetes Type II, and the doctor may need to monitor blood levels and adjust medications for a few months to control the disease, or first try a more conservative protocol with dietary changes, nutritional medicine, and exercise. A 2014 study from the Weill Cornell Medical College in New York, New York, U.S.A. found that statin drug use to lower cholesterol was associated with a modest increase in Hb A1C, and since most patients with a perceived risk of diabetes or Metabolic Syndrome are first prescribed statin drugs, the subsequent rise in A1C above 7.0 percent could be attributed to the statin use, not onset of diabetes. Studies have also made clear that patients diagnosed with Metabolic Syndrome increase their risk of advancing to a diabetic type 2 state 46 percent by taking statin drugs, by both increasing insulin resistance and by impairing the ability of the pancreas to secrete insulin effectively (Dr. Markku Laakso et al, Institute of Clinical Medicine, University of Eastern Finland and Kuopio University Hospital; Diabetologia; March 2015). In response, the American Diabetes Association revised their guidelines in 2015 to recommend statin prescription in diabetes and Metabolic Syndrome only with significant risk, not purely when LDL-cholesterol is high.

Differentiation between Diabetes Type II and Metabolic Syndrome is still unclear as well, and hampers effective design of treatment protocol. The NIH has stated that the use of A1c index alone is not sufficient to diagnose and monitor diabetes, and recommends that blood sugar levels, triglyceride levels, and C-reactive protein levels be monitored also and analyzed as well when making these diagnoses. Unfortunately, this advice is often ignored. To better understand A1c, which is an advanced glycation endproduct (AGE), another article on this website, under Practitioners / Treatment Protocols, offers a more detailed look at current scientific findings. In Type 2 Diabetes, a problem exists of insulin resistance and subsequent increased insulin production to offset this problem. Simply stimulating increased insulin secretion will not solve this problem, but has been the strategy for decades. Finally drugs were created to decrease insulin resistance, but these do come with some alarming adverse side effects over time. If standard medications to increase insulin production and utilization are ineffective, this patient may, in time, need to inject insulin also. An insulin inhaler is being developed successfully for this type of patient and may be on the market soon. Often, this type of diabetes is successfully controlled, and the patient taken off of medication, if weight is reduced and dietary/exercise patterns are successfully developed, showing that a more holistic attention to metabolic health can resolve Type 2 Diabetes. Weight loss is recommended for many patients, but if weight loss is difficult, you must consider balancing of the hormonal system and improved inflammatory regulation to gain success in losing weight. For many patients, though, the fatty accumulation accompanying Type 2 Diabetes and Metabolic Syndrome is not very evident, outwardly. Many patients will experience a type of obesity, or upset of the regulation of fatty stores, that affects their organs more than their skeletal muscle.

The problem with this treatment strategy for diabetes type 2 / Metabolic Syndrome of utilizing an insulin inhaler, is that for most of these patients the true problem is not a deficiency of insulin, but rather resistance to insulin at the receptors. While taking insulin may be an acute relief of symptomatic insulin dysfunction, the potential for problems, as well as the failure to address the overall metabolic disorder, will be a big problem for the patients. Individualized diagnosis and a patient-centered approach, rather than an assembly-line attitude, is extremely important in this field. Utilizing an integrative approach with a more holistic physician, such as a Licensed Acupuncturist, or TCM physician, is the sensible and conservative approach to solving these problems and giving each individual patient the best chance to restore a healthy metabolism.

Dietary and exercise regimens are the most direct way for patients to proactively help their body manage blood sugars in all of these disorders. These regimens need not be complicated or time consuming, and can easily be incorporated into anyone's busy lifestyle. In 2015, the guidelines of the American Diabetes Association clarified the importance of exercise and activity by stating that diabetic patients, as well as those with Metabolic Syndrome, should limit the time that they spend in sedentary sitting or lying to periods of less than 90 minutes, getting some activity in their routines more often to decrease risk of diabetes and to manage blood sugars and metabolism. This means that even at work, one must get up at least every hour and a half and perform some simple exercise to properly help the body to regulate blood sugars and metabolism. Unfortunately, for most patients, diet and exercise are important, but are not enough for a high degree of success by themselves, and research in Complementary Medicine is coming up with proof and guidelines for simple and effective therapies that should be added to these diet and lifestyle regimens. These regimens must also be understood by the patient, and individualized to each patient, and a Complementary Medicine physician, such as a knowledgeable Licensed Acupuncturist and herbalist, can help with this understanding and individualizing of protocol. Before describing dietary/exercise patterns, let me give you some final pieces of information you may want to know to fully assess the diabetic condition. This information, like much of the above information, may be too much to digest at this time, but will be of value to you later, to understand therapy and thus to achieve piece of mind and a sense that you are in control of your disease. Diabetes, more than any other disease is disease where the patient must assume full responsibility for the understanding and maintenance of the disease. Complete reliance on doctors and medications will lead to a poorly controlled disease, acceptance of symptoms that are worse than they need to be, and a sense of frustration and hopelessness as a person with an illness that seems to control and detract from your life. If you fully understand the disease and become comfortable with a diet/exercise pattern that works, you will be able to feel secure and lead a normal life.

Three types or classes of diabetes mellitus (DM) have been recognized. The above descriptions constitute the first class. Also in this class are cases of diabetes secondary to (as a result of) other diseases, such as malnutrition, pancreatic cancer, hormonal disorders such as pheochromocytoma and Cushing's syndrome, and drug induced diabetes as commonly occurs with tuberculosis medications, estrogen therapies, dilantin, and corticosteroid use. In recent years, the chronic use of statin drugs and atypical antipsychotics, tow heavily prescribed drugs, have also been proven to increase the risk of developing diabetes. A second class of secondary DM occurs sometimes in pregnancy due to the high levels of estrogen or relative excess of estrogen due to progesterone deficiency. This type is diagnosed by an oral glucose challenge test and can be successfully controlled during the pregnancy, often resolving after the birth. This type also occurs in other hormonal imbalances with deficient progesterone and relative excess of estrogen, which we see in PMS syndromes, irregular menstrual patterns, and menopausal states. The third class of secondary DM is impaired glucose tolerance (IGT), with fasting blood glucose levels in the normal range of <140, but abnormal OGTT (oral glucose tolerance test), which means that the blood glucose is observed to be too high (140-200) up to 2 hours after eating, but is well controlled after that. Symptoms are mild in these patients, but risk of developing coronary heart disease and diabetes mellitus in the future is still great, and some attention must be paid to diet to insure a healthy aging process. This third type of Diabetes Mellitus is very prevalent, but few patients have this explained to them, even though simple strategies with herbal and nutrient medicines to help with postprandial sugar metabolism, and just a little aerobic exercise after eating, would control and resolve this type of diabetes effectively. With any of these disorders, an intelligent patient will seek greater understanding and treatment with Complementary and Integrative Medicine (CIM) to avoid future health problems, as well as to feel better in the present.

Research is uncovering a wide variety of therapies in Complementary Medicine that will help to regulate specific metabolic dysfunctions as well as to resolve underlying health problems causing these dysfunctions. For example, if your diabetes involves impaired glucose tolerance, herbs such as Crepe Myrtle, American Ginseng, and a type of cinnamon bark used in Chinese medicine, have all been proven to increase postprandial glucose assimilation, meaning that they will help your body to restore a normal circulating blood glucose quicker after you eat. Coupled with sensible dietary and exercise routines, such as avoidance of high glycemic, or simple carbs, increased consumption of complex carbohydrates, and a little aerobic excercise following the meal, the patient should be able to control the postprandial blood sugars well, avoiding the consequences of impaired glucose tolerance down the road. With attention to research and individualized assessment, the Complementary Medicine physician is able to individualize a treatment protocol, and integrate it with standard care, to achieve the best possible medical treatment. Many patients diagnosed with diabetes fall into this category and may not need pharmaceutical treatment.

There is mounting evidence that improved gastrointestinal function and health, and a healthier Biome, may also resolve obesity and diabetes. The latest surprise with Diabetes Type 2 and Metabolic Syndrome is the effect of a resolution in some patients that received a gastric bypass surgery. This baffling phenomenon was researched with laboratory animals, and the researchers found that a dramatic increase in intestinal function occurred when bypass surgery was performed, accounting for a 54 percent increase in the dietary sugars used. What this tells us is that perhaps poor function of the intestines is involved in Diabetes Type 2, and improvement in the healthy function of the intestines could help alleviate the poor utilization of dietary sugars. Once again, a holistic approach that helps restore intestinal function, with such dysfunction often seen with Metabolic Syndrome as a comorbidity, may significantly help solve these problems. Restoring the health and function of the small intestine membrane as well as the large intestine biota is an essential part of any holistic protocol.

In 2015, the American Diabetes Association updated their guidelines for diagnosis and treatment of diabetes to reflect current research findings, and noted that different ethnic groups presented variances with diabetic risk and BMI (body mass index, or weight-to-height ratio, an estimate of body fat in tissues). For instance, for obese or overweight Asian Americans, the average point of concern was lowered to 23 kg/m2 to indicate that this population is at increased risk for diabetes at lower BMI levels. Also, the guideline goals for blood pressure were changed in diabetes and Metabolic Syndrome from a diastolic of 80 to a diastolic of 90 in patients with significant cardiovascular risk, reflecting the fact that this prior blood pressure guideline only served to place millions of patients unnecessarily on hypertension medications, and did not reflect actual risks from hypertension.

Clarifying the individualized diagnosis with Type II Diabetes

If you are diagnosed with type II NIDDM or IGT, your diagnosis may not be clear and you may want to monitor your laboratory results and acquaint yourself with drug regimens. Normal values of pertinent chem levels are:

  • fasting glucose: 80-130 mg/dL ( perhaps even higher in chronic cases) (updated in 2015)
  • glycohemoglobin: 5.5-8.5% (A1c index) (an average optimal level is considered below 7.0) (an average optimal level for children was revised in 2015 to below A1c of 7.5)
  • creatinine: .0-1.4 mg/dL
  • lipids (cholesterol): total serum: 450-850 mg/dL
  • cholesterol: 120-210 mg/dL, 20-30% HDL and 60-70% LDL
  • triglycerides: <160 mg/dL
  • total FA (fatty acids): 190-240 mg/dL
  • folate: 2-20 mg/mL
  • Vit B12: 200-900 mg/L
  • CRP: <1mg/dL or <10mg/L (c-reactive protein from the liver)
  • A1C: >6.5 may be used as an additional marker, but read below to understand how this marker can be misused in diagnosis; this is an advanced glycation endproduct (AGE), and more information on this subject is available elsewhere on this website

Another important marker for diabetic or metabolic disorder is the A1C index, or glycosylated hemoglobin A1C, a surrogate marker for blood glucose levels. A1C is the first important Advanced Glycation Endproduct (AGE) that is identified with metabolic disorder and indicates a problem with insulin metabolism at the cellular level (you may read my article on AGEs under the For Practitioners section on this website). The National Diabetic Association has stated that the A1C marker alone should not be used to diagnose and treat metabolic syndrome, or Diabetes type 2. The marker, which reflects chronic changes in red blood cell hemoglobin receptors in response to advanced glycosylation endproducts, which are molecules made up of sugars, fats and proteins that are abnormal to our physiology, was introduced as a diabetic marker in 1976, but not utilized in standard diagnosis until certain new diabetic medications reflecting insulin resistance therapy were introduced onto the market. A1C is proportional in most cases to the average glucose concentration over the previous 4-12 weeks, although many researchers find that it reflects average blood glucose in most patients for the last 2-4 weeks. The American Diabetes Association in 2010 finally added A1C greater than 6.5% as an additional laboratory value useful in the diagnosis of diabetes, but again cautioned that A1C should not be the only diagnostic value that is used, and could indicate other metabolic problems not addressed by standard diabetes medication. The American Diabetes Association recommends that A1C be below 7.0% for most patients, and that medicating patients with an A1C between 6.5% and 7.0% may engender more risk than benefit.

In 2014, experts at the University of Bergen, in Norway, conducted a large study to see if stress and mood disorder altered the A1C index in patients with type 1 diabetes. The findings clearly showed that while overall anxiety and depression were not correlated with levels of A1C, that diabetes-specific emotional stress was. An increase of 0.5 on a scale measuring this distress was associated with a 0.6 change in the A1C (PMID: 25149027). This outcome clearly showed that a more proactive and informed diabetic regimen, with less stress and fear used to encourage more drug use, was very important to the diabetic patient. As the patient is faced with the potential for diabetes, prescription of statin drugs may raise the A1C, and various diabetic drugs to lower the A1C may increase obesity and cardiovascular risk. As the A1C rises, this may be due to the overall treatment stress. This scenario adds a high degree of diabetes-related stress to the treatment regimen. Integration of Complementary Medicine with greater attention to diet, lifestyle and overall holistic health would greatly aid the patient to achieve a better outcome. In 2012, researchers at the University of Otago Dunedin School of Medicine, in New Zealand, found that shorter sleep duration in young adults was also highly associated with increased A1C index, and that many patients in their early 30s may be diagnosed with diabetes and started on problematic drugs based on the A1C level alone, instead of being counseled on sensible lifestyle and dietary issues and help with improved sleep quality and stress reduction (PMID: 22068028).

Two patients with the same average blood sugar can have A1C levels that differ by as much as 3 percentage points, and the range of levels generally found in healthy patients is 4-5.9%. Higher than expected A1C index can be seen in people with certain types of anemia, in which the red blood cell life span is longer due to abnormal shape of red blood cells, or decreased removal of old red blood cells by the spleen. This could occur with Vitamin B12 or folate deficiency, or other causes. A1C index should not be measured when there is a change of diet or pharmacological treatment in the last 6 weeks, according to standard guidelines, but this is often ignored. Also, patients with chronic abnormal blood loss, abnormal shape of red blood cells (e.g. sickle cell anemia), or other more rare disorders, may show a higher than normal A1C when there is no real diabetic disorder. Careful diagnosis should be insisted upon, and the time should be spent to give each patient an accurate complete diagnosis before starting drug therapy. Since newer diabetic medications may force the A1C index down just 1.0 - 1.5 points, this may not really be meaningful, depending on the individual. Restoring a healthy A1C index with an holistic treatment protocol may be much more beneficial than blocking biological processes to bring this lab value down, and time will tell whether these newer medications actually afford a better long-term outcome, or just better immediate lab results.

Of these, fasting glucose and triglyceride levels are initially important to monitor as these show the extent of pancreatic and liver involvement, with high triglycerides pointing to a liver problem, and requiring a different medication strategy and lifestyle change. In Metabolic Syndromes and diabetes type 2 both of these also may refer to a problem with an important organ that has been acknowledged only in recent years, our fat cells. Glycohemoglobin count will point to a protein imbalance and the carrying of sugar as a principal problem. Creatinine count will point to kidney problems. Lipid counts will point to liver and cardiovascular dangers, and folate and B12 levels will point to a need to aid cell differentiation in the presence of enzyme deficiencies. CRP levels indicate chronic inflammatory states and liver dysfunction. Many doctors will not evaluate all of these levels, and thus it is important that the patient demand attention to all of these. Bringing these findings to a Complementary and Integrative Medicine physician, such as a Licensed Acupuncturist and herbalist, or a Naturopathic Doctor, allows these integrative physicians to design individualized protocols to address these specific needs in treatment.