Diagnosis and Possible Reversal of Pre-Diabetes
Early And Accurate Diagnosis is Critical
Commentary by Mona Morstein, ND
The medical diagnosis of pre-diabetes (PD) includes both standard evaluations, as well as a unique naturopathic test. The goal of early and accurate diagnosis is to determine if the patient is in a mild, moderate, or severe state of pre-diabetes. Early and accurate diagnosis helps determine how aggressive the treatment needs to be, and how much damage PD may have already caused the body.
PD is often associated with metabolic syndrome, which is defined similarly by various organizations. The basic definition based on the American Heart Association (AHA)/Updated National Cholesterol Education Program (NCEP) consists of having three or more of the following traits:
..Elevated waist circumference (men >40 inches; women >35 inches; lower for Asian populations)
..Hypertriglyceridemia (>150 mg/dl)
..Reduced HDL (men <40 mg/dl; women <50 mg/dl)
..Hypertension (>130/85 mmHg)
..Fasting hyperglycemia (>100 mg/dl)
Not all pre-diabetic patients have metabolic syndrome; however, simply having a fasting glucose level of 101–125 mg/dl can identify a patient as pre-diabetic. When I have a patient with a pre-diabetic glucose number, I reflex to a more comprehensive analysis of glucose regulation, which is justified in scientific literature. The Oral Glucose Tolerance Test is a standard lab test consisting of having a patient fast 12 hours, get a fasting glucose level, and then drink 75–100 g of a glucose drink, with repeated glucose blood draws over the next one, two, and three hours. I have personally adapted this test to a different format. I have patients fast for 12 hours and then test their fasting glucose and insulin levels. I then have them eat—preferably at a local fast food restaurant—one pancake with syrup and one hash brown. This gives the patient 100 g of refined sugar and grain carbohydrate, as well as saturated fat—the two top food groups that initiate insulin resistance. I am more interested in seeing what actual food does to people than just a glucose drink. I then have the patient return to the clinic 1.5 hours after eating for a second blood draw of glucose and insulin. Some other naturopaths at my clinic have patients get postprandial draws of one, two, and three hours, but I find that is very difficult for many patients, and it is time-consuming. For my interpretation of the patient’s condition, it also does not seem to help more than the solo 1.5-hour postprandial reading.
Insulin levels are vital for understanding how much insulin resistance is occurring. How much insulin that is secreted, analyzed in combination with glucose levels, gives the clinician a very accurate way of determining if the patient’s insulin resistance and pre-diabetes status is mild, moderate, or severe.
I also do a comprehensive CMP/CBC, including TSH/FT3/FT4, vitamin D (25OHVD), ferritin (to check for early liver inflammation indicating fatty liver), and A1C. It might be wise to also include fibrinogen to check on blood clotting risk, HS-CRP to analyze inflammation, and homocysteine to check for L-methylfolate bioavailability.
The initial physical exam should include vitals, heart/lung evaluation, thyroid exam, search for skin tags or acanthosis nigricans, height, weight, waist circumference with BMI, body fat percentage (via scale such as Tanita or Bio-Impedance device), foot exam including edema/pulses/lesions/neuropathy (using standard monofilament check), and abdominal exam to check for hepatomegaly.
The patient should be instructed to fill out a week-long diet diary to track eating habits, accurately recording everything she/he eats and drinks for all meals/snacks. Bowel movement frequency, symptoms, and sleeping habits should also be recorded.
Regarding the treatment of pre-diabetes, some clinicians fail to emphasize the importance of sleep in this patient population. Several well-designed studies, including a recent one this year from the Journal of Clinical Endocrinology,1 have clearly demonstrated that lack of sleep causes insulin resistance and weight gain. Sleep directly affects the two main hormones that regulate human appetite: leptin and ghrelin. Leptin is made in the adipocytes and instructs a person to eat less food. When a person gets enough sleep, it raises leptin levels, which decreases the desire to eat. Conversely, low amounts of sleep lower leptin levels and can thus cause increased appetite. Ghrelin is another appetite hormone made in the stomach. Opposite to leptin, ghrelin tells the brain to eat more food. When people don’t get enough sleep, ghrelin levels increase and people crave high carbohydrate foods.
Less sleep also causes an increase in cortisol output at night, which can cause hyperglycemia and initiate insulin resistance, another factor in abdominal weight gain and developing pre-diabetes and diabetes. Lastly, sleep is also needed for growth hormone (GH) to be fully secreted. Adult patients with low GH secretion are insulin resistant, due to several not wholly understood factors.
If a patient presents with PD symptoms and has sleep problems, a sleep study should be performed. Instituting sleep hygiene is a necessary aspect of pre-diabetes treatment and includes turning off most lights in the house so melatonin output can be enhanced; establishing the same bedtime routine each night; not watching disturbing TV shows or even news at night before bed, which may cause mental/emotional upset; spending some time reading before bed to initiate sleep; ensuring the mattress and room temperature is conducive to the patient’s body; addressing problems such as partner snoring or restless legs that may be interrupting the patient’s sleep; urging the use of a continuous positive airway pressure (CPAP) if apnea is diagnosed; dealing with hormonal imbalances thaymay be causing sleeping problems, such as elevated nighttime cortisol, or menopausal night sweats; using guided relaxation DVDs (or other stress relaxation techniques) to help induce sleep; and recommending occasional sleep aids, but avoiding nightly addiction to them.
References
1 Nedeltcheva AV, Kessler L, Imerial J, Penev PD. Exposure to recurrent sleep restriction in the setting of high caloric intake and physical inactivity results in increased insulin resistance and reduced glucose tolerance. J Clin Endocrinol Metab. 2009 Sep; 94(9):3242-51. Epub 2009 Jun 30.
http://www.naturalmedicinejournal.com/pdf/NMJ_OCT09_CR.pdf
http://www.depsyl.com/
http://back2basicnutrition.com/
http://bionutritionalresearch.olhblogspace.com/
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