Nutrinews

Recent health and nutrition information from Douglas Laboratories 2002
July/August/September
DIABETES: A NATIONWIDE EPIDEMIC
Fast Facts About Diabetes
Diabetes is becoming more widespread in the United States each year. Almost • 1 million new cases each year in everyone knows someone who has diabetes. An estimated 17 million people in the United States, 6.2 percent of the population, have diabetes mellitus - a serious, lifelong condition. Of those who are 20 years of age or older, 16.9 million or 8.6% have diabetes. People age 65 years or older account for 7 million cases of diabetes • In 1999, approximately 450,000 and represent 20.1 percent of all people in this age group. Fully one-third or about 5.9 million people have not yet been diagnosed and 11.1 million people have a confirmed older. This figure represents about19 percent of all deaths in the U.S. diagnosis of diabetes. Each year, about 1 million people age 20 and older are diag- for people that are 25 years of age nosed with diabetes. About 151,000 people less than 20 years of age have diabetes.
This represents 0.19 percent of all people in this age group. Approximately one in • Diabetes was the sixth leading every 400 to 500 children and adolescents has type 1 diabetes. Clinic-based reports cause of death listed on U.S. deathcertificates in 1999. and regional studies indicate that type 2 diabetes is becoming more common among • Diabetes is the leading cause of American Indian, African American, and Hispanic/Latino children and adolescents.
• Men: 7.8 million. 8.3 percent of all men have diabetes.
• Diabetes is the leading cause of • Women: 9.1 million. 8.9 percent of all women have diabetes.
treated end-stage renal disease,accounting for 43 percent of • Non-Hispanic whites: 11.4 million. 7.8 percent of all non-Hispanic whites
• Non-Hispanic blacks: 2.8 million. 13 percent of all non-Hispanic blacks have
amputations were performed eachyear among people with diabetes. diabetes. On average, non-Hispanic blacks are two times more likely to have diabetes than non-Hispanic whites of similar age.
THIS ISSUE
• Hispanic/Latino Americans: 2 million. 10.2 percent of all Hispanic/Latino
Gestational Diabetes.page 4 Americans have diabetes. On average, Hispanic/Latino Americans are Insulin Resistance Syndrome and 1.9 times more likely to have diabetes than non-Hispanic whites of similar age.
Hyperinsulinemia.page 4 Impaired Glucose Tolerance.page 5 Mexican Americans, the largest Hispanic/Latino subgroup, are two times more Complications of Diabetes.page 5 likely to have diabetes than non-Hispanic whites of similar age. Similarly, Preventive Measures.page 6 residents of Puerto Rico are two times more likely to have diagnosed diabetes Laboratory Testing and Diagnosis.page 7 than U.S. non-Hispanic whites. Sufficient data is not available to derive more Traditional Medical Treatments.page 7 Functional Medical Treatments.page 11 specific current estimates for other groups.
Alternative/Complementary Medical Treatments.page 13 continued on page 2
• American Indians and Alaska Natives who receive
U.S. Population (Men/Women) Affected By Diabetes
care from the Indian Health Service (IHS): 105,000,
15.1 percent of American Indians and Alaska Natives receiving care from IHS have diabetes. At the regional level, diabetes is least common among Alaska Natives (5.3 percent) and most common among American Indians in the southeastern United States (25.7 percent) and in certain tribes from the Southwest. On average, American Indians and Alaska Natives are 2.6 times more likely to have diabetes than non-Hispanic whites of similar age.
• Asian Americans and Native Hawaiian or other Pacific
Islanders: Prevalence data for diabetes among Asian
Americans and Native Hawaiians or other Pacific Islanders are limited. Some groups within these popula- tions are at increased risk for diabetes. For example, data Mortality from Diabetes
collected from 1996 to 2000 suggest that Native In 1999, approximately 450,000 deaths occurred among Hawaiians are 2.5 times more likely to have diagnosed people with diabetes that were 25 years and older. This figure diabetes than white residents of Hawaii of similar age. represents about 19 percent of all deaths in the United States • Overall, the risk for death among people with diabetes is about two times that of people without diabetes. However, the increased risk associated with diabetes is greater for younger people (3.6 times for people 25 to 44 years of Editor In Chief . Andrew D. Halpner, Ph.D.
age versus 1.5 times for those 65 to 74 years old) and Assistant Editor . Michael Traficante women (2.7 times for women 45 to 64 years old versus Technical Advisors/Contributors: .
• Diabetes was the sixth leading cause of death listed on U.S. death certificates in 1999. This is based on the 68,399 death certificates in which diabetes was listed as the underlying cause of death. Diabetes was listed as a contributing cause of death on an additional 141,265 death certificates. However, many decedents with diabetes Contact Us:
NutriNews Inquiries
do not have the disease entered on their death certificate; only about 35 to 40 percent have it listed anywhere on the Phone: (412) 494-0122 • Fax: (412) 278-6804 certificate and only about 10 to 15 percent have it listed Email: nutrinews@douglaslabs.com
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Toll-Free: 866-856-9954Email: douglaslaboratories@on.aibn.com High Risk Factors for Diabetes
View back issues of NutriNews online at www.douglaslabs.com The experts suggest that adults 45 years and older be tested for diabetes. If their blood glucose is normal at the first test, they When we eat, the pancreas is supposed to automatically should be tested at 3-year intervals. People under age produce the right amount of insulin to move glucose from blood 45 should be tested if they are at high risk for diabetes. These into our cells. In people with diabetes, however, the pancreas either produces little or no insulin (type 1), or the cells do not • Being more than 20 percent above ideal body weight or respond appropriately to the insulin that is produced (type 2).
having a body mass index (BMI) of greater than or equal Glucose builds up in the blood, overflows into the urine, and to 27. BMI is the ratio of weight in kilograms to height in passes out of the body. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose.
A relative lack of glucose going to the muscles results in fatigue, • Having a mother, father, brother, or sister with diabetes.
which causes many to seek medical care. There are three main • Being African American, Alaska Native, American types of diabetes, they are: Type 1 Insulin Dependant Diabetes, Indian, Asian American, Hispanic American, or Pacific Type 2 Non-insulin Dependant Diabetes and Gestational (Pregnancy) Diabetes. Of the three types, type 2 is by far the most • Giving birth to a baby weighing more than 9 pounds or common and the most amenable to comprehensive treatment.
Type 1 Diabetes
• Having blood pressure at or above 140/90 millimeters of Type 1 diabetes was previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes. Type 1 • Having abnormal blood lipid levels, such as high density diabetes develops when the body's immune system destroys lipoprotein (HDL) cholesterol less than 35 mg/dL or pancreatic beta cells, the only cells in the body that make the triglycerides greater than 250 mg/dL.
hormone insulin that regulates blood glucose. The pancreas • Having abnormal glucose tolerance when previously then produces little or no insulin. Someone with type 1 diabetes needs to take insulin daily to live. This form of diabetes usually strikes children and young adults, who need several insulin What is Diabetes?
injections a day or an insulin pump to survive. Type 1 diabetes Diabetes mellitus is a group of diseases characterized may account for 5 to 10 percent of all diagnosed cases of by high levels of blood glucose resulting from defects in insulin diabetes. Risk factors for type 1 diabetes include autoimmune, production, insulin action, or both. Diabetes can be associated genetic, and environmental factors. Symptoms of type 1 with serious complications and premature death, but people diabetes usually develop over a short period, although beta cell with diabetes can take steps to control the disease and lower the destruction can begin years earlier. Symptoms include increased thirst and urination, constant hunger, weight loss, Diabetes is a disorder of metabolism - the way our bodies blurred vision, and extreme fatigue. If not diagnosed and use digested food for growth and energy. Most of the food we treated with insulin, a person can lapse into a life-threatening eat is broken down into glucose, the form of sugar in the blood.
diabetic coma, also known as diabetic ketoacidosis.
Glucose is the main source of fuel for the body. Type 2 Diabetes
After digestion, glucose passes into the bloodstream, where The most common form of diabetes is type 2 diabetes. type it is used by cells for growth and energy. For glucose to get into 2 diabetes was previously called non-insulin-dependent diabetescells, insulin must be present. Insulin is a hormone produced by mellitus (NIDDM) or adult-onset diabetes. About 90 to 95 per- the pancreas, a large gland behind the stomach. cent of people with diabetes have type 2. This form of diabetes usually develops in adults age 40 and older and is most common in adults over age 55. A rapid increase in the younger gestational diabetes, impaired glucose tolerance, physical population is now being seen. What was once a traditional inactivity, and race/ethnicity. African Americans, Hispanic/ "middle-age" onset disease has now infiltrated the young adult Latino Americans, American Indians, and some Asian and even the adolescent age group. This alarming increased Americans and Pacific Islanders are at a particularly high risk rate in younger patients has sparked the attention of the for type 2 diabetes. Type 2 diabetes is increasingly being medical industry to actively begin educational outreach pro- diagnosed in children and adolescents.
grams to increase awareness in both patients and providers. Gestational Diabetes
About 80 percent of people with type 2 diabetes are over- Gestational diabetes is a form of glucose intolerance that weight. Type 2 diabetes is often part of a metabolic syndrome is diagnosed in some women during pregnancy. Gestational that includes obesity, elevated blood pressure, and high levels diabetes occurs more frequently among African Americans, of blood lipids. Unfortunately, as noted above, 25% of children Hispanic/Latino Americans, and American Indians. It is also and adolescents are now overweight and type 2 diabetes is more common among obese women and women with a family history of diabetes. During pregnancy, gestational diabetes When type 2 diabetes is diagnosed, the pancreas is usually requires treatment to normalize maternal blood glucose levels producing enough insulin but the body cannot use the insulin to avoid complications in the infant. Though it usually disap- effectively, a condition called insulin resistance. The body senses pears after delivery, the mother is at increased risk of getting this lack of effectiveness and frequently increases its production type 2 diabetes later in life. After pregnancy, 5 to 10 percent of insulin erroneously to regulate elevated blood glucose levels.
of women with gestational diabetes are found to have type 2 After several years of overproduction, or hyperinsulinism, insulin diabetes. Women who have had gestational diabetes have a production decreases. The result is the same as for type 1 diabetes; 20 to 50 percent chance of developing diabetes in the next 5 glucose builds up in the blood and the body cannot make effi- to10 years. Other specific types of diabetes result from specific cient use of it as a main source of fuel. The excess genetic conditions (such as maturity-onset diabetes of youth),glucose in the blood stream is then converted to storage energy, surgery, drugs, malnutrition, infections, and other illnesses.
i.e. fat. Via production of glycerides then triglycerides, excess Such types may account for 1 to 5 percent of all diagnosed glucose metabolites are sent to the adipocyte to be saved for a rainy day - that frequently never comes for many patients.
Insulin Resistance Syndrome and Hyperinsulinemia
The symptoms of type 2 diabetes develop gradually. They The term "insulin resistance" describes a condition of the are not as sudden in onset as in type 1 diabetes. Some people reduced sensitivity of a cell to the action of insulin. Insulin must have no symptoms. Symptoms may include fatigue or nausea, bind "effectively" to the cell receptor as one of the first steps in frequent urination, unusual thirst, weight loss, blurred vision, appropriate glucose metabolism. If insulin is less than effective frequent infections, and slow healing of wounds or sores. Fully at the receptor, glucose levels tend to rise signaling a "need" for a third of diabetics are walking around undiagnosed by the more insulin. The body responds by secreting excessive insulin, best health care industry on the planet! In my opinion, the at times reaching 4-5 times the expected physiologic level. This screening parameters set forth by the American Diabetic secondary hyperinsulinemia can have a deleterious effect on Association are only fueling this missed opportunity to uncover the pancreas as it tries in vain to keep up with this excessive diabetes at the earliest stage. I will discuss my recommendations demand. The pancreas begins to fail and sets the stage for type for improved screening later in this newsletter.
2 diabetes. Eager physicians are quick to prescribe a first- Type 2 diabetes is associated with older individuals (until or second-generation diabetic medication, betting on the recently), obesity, family history of diabetes, prior history of pancreas to produce even more insulin and further hastening death rates about 2 to 4 times higher than adults without diabetes.
the demise of the pancreas beta cells. This insulin resistance or Stroke - The risk for stroke is 2 to 4 times higher among
insensitivity leads to glucose intolerance and dysglycemia.
Insulin Resistance Syndrome (IRS) also referred to as Syndrome High blood pressure - About 73 percent of adults with
X or Metabolic Syndrome refers to a set of metabolic abnormalities.
diabetes have blood pressure greater than or equal to 130/80 IRS is associated with glucose intolerance, abnormally low HDL mmHg or use prescription medications for hypertension.
(high density lipoprotein) cholesterol and/or high triglyceride levels, high blood pressure and upper body obesity. All of these Blindness - Diabetes is the leading cause of new cases of
factors are independent risk factors for coronary heart disease blindness among adults 20 to 74 years old. Diabetic retinopathy (CHD). CHD develops from a direct effect of insulin that stimu- causes from 12,000 to 24,000 new cases of blindness each year.
lates lipogenesis in arterial tissue and enhances the growth of Kidney disease - Diabetes is the leading cause of treated
arterial smooth muscle promoting atherosclerosis. Increased end-stage renal disease, accounting for 43 percent of new insulin levels decrease fibrinolysis, increasing the risk for coro- cases. In 1999, 38,160 people with diabetes began treatment nary thrombosis. Insulin also increases the hepatic production of for end-stage renal disease, and a total of 114,478 people with triglycerides and lowers production of HDL (good cholesterol).
diabetes underwent dialysis or kidney transplantation.
High blood pressure may also be caused from the elevated Nervous system disease - About 60 to 70 percent of peo-
insulin's effect on renal sodium reabsorption. Weight loss is a ple with diabetes have mild to severe forms of nervous system major benefit to those with Insulin Resistance Syndrome. High damage. The results of such damage include impaired sensa- dose vitamin E has been reported to improve insulin resistance in tion or pain in the feet or hands, slowed digestion of food in the type 2 diabetic patients. Zinc, selenium and vitamin C have been stomach, carpal tunnel syndrome, and other nerve problems.
associated with decreasing oxidative stress in diabetic patients.
Severe forms of diabetic nerve disease are a major contributing Impaired Glucose Tolerance
Impaired glucose tolerance (IGT) and impaired fasting Amputations - More than 60 percent of non-traumatic
glucose (IFG) are considered to be pre-diabetic conditions, and lower-limb amputations in the United States occur among studies suggest that they may be reversible. IGT results from people with diabetes. From 1997 to 1999, about 82,000 Insulin resistance covered in the above section. non-traumatic lower-limb amputations were performed each IGT is a condition in which the blood glucose level is year among people with diabetes. elevated (between 140 and 199 milligrams per deciliter or Dental disease - Periodontal or gum diseases are more
mg/dL in a 2-hour oral glucose tolerance test), but is not high common among people with diabetes than among people with- enough to be classified as diabetes.
out diabetes. Among young adults, those with diabetes are IFG is a condition in which the fasting blood glucose level is often at twice the risk of those without diabetes. Almost one third elevated (between 110 and 125 mg/dL after an overnight fast), of people with diabetes have severe periodontal diseases but is not high enough to be classified as diabetes.
with loss of attachment of the gums to the teeth measuring Among U.S. adults 40 to 74 years of age, 16 million (15.6 percent) have IGT and 10 million (9.7 percent) have IFG.
Complications of pregnancy - Poorly controlled diabetes
before conception and during the first trimester of pregnancy can Complications of Diabetes
cause major birth defects in 5 to 10 percent of pregnancies and Heart disease - The leading cause of diabetes-related
spontaneous abortions in 15 to 20 percent of pregnancies.
deaths is heart disease. Adults with diabetes have heart disease Poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, Blood pressure control - Controlling blood pressure can
posing a risk to the mother and the child.
reduce cardiovascular disease (heart disease and stroke) by Other complications - Uncontrolled diabetes often leads to
approximately 33 to 50 percent and can reduce microvascular biochemical imbalances that can cause acute life-threatening disease (eye, kidney, and nerve disease) by approximately events, such as diabetic ketoacidosis and hyperosmolar (non- 33 percent. In general, for every 10 millimeters of mercury ketotic) coma. People with diabetes are more susceptible to (mmHg) reduction in systolic blood pressure, the risk for any many other illnesses, and once they acquire these illnesses they complication related to diabetes is reduced by 12 percent.
often have a worse prognosis than people without diabetes. Control of blood lipids - Improved control of cholesterol
For example, they are more likely to die with pneumonia or and lipids (for example, HDL, LDL and triglycerides) can reduce influenza than people who do not have diabetes. cardiovascular complications by 20 to 50 percent.
Preventive Measures
Preventive care practices for eyes, kidneys, and feet -
Detection and treatment of diabetic eye disease with laser Research studies in the United States and abroad have therapy can reduce the development of severe vision loss by an found that lifestyle changes can prevent or delay the onset of estimated 50 to 60 percent. Comprehensive foot care programs type 2 diabetes among high-risk adults. These studies included can reduce amputation rates by 45 to 85 percent. Detection people with IGT and other high-risk characteristics for developing and treatment of early diabetic kidney disease can reduce the diabetes. Lifestyle interventions included diet and moderate- development of kidney failure by 30 to 70 percent.
intensity physical activity (such as walking for 2 1/2 hours eachweek). For both sexes and all age and racial and ethnic groups, Appropriate nutritional supplementation - Adding
the development of diabetes was reduced 40 to 60 percent adequate amounts of high grade nutritional supplements shown during these studies that lasted 3 to 6 years.
to be of benefit in diabetes may help improve daily glucose control, stabilize carbohydrate metabolism and prevent Studies have also shown that medications have been further complications from diabetes due to the glycosylated end successful in preventing diabetes in some population groups. In products caused by elevated glucose levels.
the Diabetes Prevention Program, a large prevention study of people at high risk for diabetes, people treated with the drug Routine exercise - low glycemic index diet - Routine
metformin reduced their risk of developing diabetes by 31 percent.
exercise directly helps improve glucose metabolism by increasing Treatment with metformin was most effective among younger, the activity of glucose transport protein, independent of the heavier people (those 25 to 40 years of age who were 50 to 80 action of insulin. Combined with an appropriate low glycemic pounds overweight) and less effective among older people diet, exercise has been shown to be nearly twice as effective as and people who were not as overweight. There are no known a leading anti-diabetic medication. A recent study was halted methods to prevent type 1 diabetes. Several clinical trials are prematurely due to the profound superior benefit of diet and exercise over the prescription medication. It would behoove practitioners and clinicians caring for diabetic patients not to Glucose control - Research studies in the United States and
underestimate the significant impact that diet and exercise has abroad have found that improved glycemic control benefits on diabetes morbidity. Too often health care providers neglect people with either type 1 or type 2 diabetes. In general, for this all important aspect of care and education. If you are not every 1 percent reduction in results of A1C blood tests, the risk proficient at providing a quality educational experience for of developing microvascular diabetic complications (eye, your diabetic patients, please refer them to a facility that can kidney, and nerve disease) is reduced by 40 percent.
implement this critical component of their total care plan.
Laboratory Testing and Diagnosis
The committee recommended that the OGTT not be used. An American Diabetes Association expert committee has Testing for Diabetes During Pregnancy
recommended a lower fasting plasma glucose (FPG) value to The expert panel also suggested a change in the testing for diagnose diabetes. The new FPG value is 126 milligrams per diabetes during pregnancy, stating that women at low risk for deciliter (mg/dL) or greater, rather than 140 mg/dL or greater.
gestational diabetes do not need to be tested. This low-risk This recommendation was based on a review of the results of more than 15 years of research. This research showed that a fasting blood glucose of 126 mg/dL or greater is associated with an increased risk of diabetes complications affecting the eyes, nerves, and kidneys. When diagnosis was based on a blood glucose value of 140 mg/dL or greater, these complica- • Not members of a high-risk ethnic group tions often developed before the diagnosis of diabetes. The experts believe that earlier diagnosis and treatment can prevent All women who are not in the low-risk category should be or delay the costly and burdensome complications of diabetes. tested for gestational diabetes during the 24th to 28th weeks of pregnancy. The testing procedure requires drinking a glucose The prior criteria for diagnosing diabetes relied heavily on drink and measuring blood glucose one hour later. If the blood performing an oral glucose tolerance test (OGTT). In this test, glucose value is 140 mg/dL or greater, the woman should be the person must come in fasting, drink a glucose syrup, and have a blood sample taken 2 hours later. This complicated pro- cedure made detection and diagnosis of diabetes a difficult and Traditional Medical Treatments
cumbersome process, and the expert committee recommended • In order to survive, people with type 1 diabetes must have that it be eliminated from clinical use. The change to using fast- insulin delivered by a pump or injections.
ing plasma glucose for determining the presence of diabetes • Many people with type 2 diabetes can control their blood will make detection and diagnosis of diabetes more routine. The glucose by following a careful diet and exercise program, fasting value can be easily obtained during routine physician losing excess weight, and if needed taking oral visits, in clinics at the place of employment, and other situations.
medication. It is important to strive to educate patients Currently, about 5 to 6 million adults in the United States have about the beneficial nutritional and physiological aspects diabetes but do not know it. The simpler testing method of of treatment. Many times these treatments are overlooked measuring fasting glucose should help identify these people so by the medical profession, or minimal time is spent on these recommendations in lieu of writing a prescription Diabetes can be detected by any of three positive tests. To medication as a first line treatment.
confirm the diagnosis, there must be a second positive test on a • Traditional physicians may treat people with diabetes with several medications to control their cholesterol and blood • A casual plasma glucose level (taken at any time of day) pressure in an effort to prevent premature cardiac and of 200 mg/dL or greater when the symptoms of diabetes • Among adults with diagnosed diabetes, about 11 percent • A fasting plasma glucose value of 126 mg/dL or greater. take both insulin and oral medications, 22 percent take • An OGTT value in the blood of 200 mg/dL or greater insulin only, 49 percent take oral medications only, and 17 percent do not take either insulin or oral medications.
Insulins
Insulin products available and defined according to derivation, onset*, peak, and duration** of action. Route of administration is also shown.
Duration
Preparation
Manufacturer
*Onset is always for the SC route. All times are approximate.
**Maximum occurs between these times; actual effect may last longer.
Insulins listed are available in a concentration of 100 Units/mL; Humulin R, in a concentration of 500 Units/mL for SC injection only, is available by prescription from Lilly for insulin resistant patients who are hospitalized or under close medical supervision.
1Recombinant (using E. coli).
2Recombinant (using S. cerevisiae).
3Recombinant human insulin analogue (using E.coli).
The various insulins and oral medications for type 2 generation sulfonylureas. Diabinase or chlorpropamide, was diabetes are listed in the table titled "Insulins." one the newer sulfonylureas, which like its first-generation Classes of diabetic medications
cousins, has some major drawbacks when treating diabetes.
This class has a tendency to put weight on patients and also Physicians have five different "classes" of oral prescription cause low blood sugar levels. Low blood sugar, called hypo- drugs which can be used to treat type 2 diabetes and injectable glycemia, occurs when the blood glucose falls below a certain insulin. Several of these oral medications have just been recently level and causes several symptoms. Signs of hypoglycemia include mental confusion, dizziness, loss of consciousness and Sulfonylureas
others. This is precisely the opposite effect that we wish to see.
The long standing class of drugs, the sulfonylureas, have We want people with diabetes to lose those unnecessary been the mainstay of the oral medications for many years.
pounds, not accumulate more! Insulin has at times been necessary Sulfonylureas have been used for the treatment of to treat patients with type 2 diabetes. Naturally, patients would type 2 diabetes since the 1950's. Acetohexamide (Dymelor), not prefer this type of treatment due to the invasive nature of Tolbutamide (Orinase) and Tolazamide (Tolinase) were all first- daily injections, so the oral agents are more popular when they work to lower blood glucose levels. The sulfonylureas also drugs as they do not cause weight gain like the sulfonylureas, increase insulin levels by directly stimulating release. There are nor do they increase cardiovascular risk profiles. Metformin currently seven of them to choose from, of which the latest three causes the liver and the muscle to utilize glucose better. In the to come to market are called "second generation" sulfony- muscles, metformin causes glucose to get into the cells more lureas. These latest "offspring" are glyburide (Micronase, easily to be metabolized. It also causes the liver to slow down Glynase and Diabeta), glipizide (Glucotrol, Glucotrol XL) and production of glucose. Glucophage was introduced in the spring the youngest brother glimepiride (Amaryl). Sulfonylureas of 1995 and has been shown to lower triglyceride levels, as well stimulate more insulin release, however many times the insulin as total and LDL cholesterol levels. It also causes a rise in the levels are already elevated, thus compounding the problems good cholesterol levels (HDL cholesterol) with a slight loss that are associated with increased insulin levels. The newer prescriptions for type 2 diabetes are: The benefits of this medication however have their costs.
Acarbose (Precrose) an [alpha-glucosidase inhibitor]
People taking the medication report bloating, nausea, cramps, abdominal fullness and diarrhea as the unpleasant side effects.
The alpha-glucosidase inhibitors such as Acarbose are best They do, however, usually go away after several days. Patients used to treat the elevated glucose levels which occur after with kidney problems or congestive heart failure are not to take eating in diabetic patients. This medication is better for this medication, nor are any patients with liver problems.
carbohydrate intolerance and is better than sulfonylureas which Alcohol and binge drinking are not to be mixed with metformin.
can promote a rapid drop in glucose levels causing low blood It should not be taken within 48 hours after any tests which use sugar and magnify other medical problems. This drug was iodine as the contrast material such as an IVP or CT scan. released for use in 1996 but was used prior to this in Canada and in Europe. Glyset is the newest of the AGI's.
Troglitazone (Rezulin) a [thiazolidinedione]
Ascarbose interferes with an enzyme called alpha- One of the newest medications for diabetes is a thiazo- glucosidase in the small intestine. This enzyme is responsible for lidinedione called Troglitazone or Rezulin, which was taken off breaking down various ingested sugars in the small intestine. If the market just after its debut. This medication was the first they are not able to be broken down, they cannot be absorbed medication which worked directly on insulin resistance. Rezulin and the blood glucose level is less likely to rise abnormally after increases the effect of insulin, but not the actual release of the eating. This blocks glucose uptake from the small intestine but hormone. The term "insulin sensitizer" has been used in the carries with it some pretty unfriendly side effects. Excessive literature to describe how it works. The medication causes gas and flatulence, diarrhea and abdominal pain make it a glucose to be metabolized through the muscle when insulin is questionable drug to use without the fear of a social "accident." effective. A side effect of this medication is that it may increase Elevated liver function test can also occur with Ascarbose.
cholesterol levels and may cause severe liver damage, which Particular care must be taken as a hypoglycemic event must be eventually caused the FDA to request its withdrawal from the treated with oral tablets or gel due to the absorption blocking market. Significant weight gain was also seen in patients activity in the small intestine. Patients with inflammatory bowel taking Rezulin with Glyburide. This pill was used in patients problems, such as irritable bowel disease, ulcers and colitis who have type 2 diabetes and are taking insulin. The benefit should also refrain from this alternative treatment. Patients with and potential importance of this medication was that patients kidney problems should also look elsewhere for type 2 medication.
taking insulin shots may be able to discontinue their insulin when taking Troglitazone. Troglitazone is now unavailable and Metformin (Glucophage) a [biguanide]
the newer thiazolidinediones (Avandia and Actos) hope to have The biguanids, like metformin, are improved diabetic all the benefits with less side effects as their predecessor.
Repaglinide (Prandin) a [meglitinide]
also available for physicians to prescribe. The FDA is continually Repaglinide (Prandin) is a benzoic acid derivative that is a looking at newer agents which are under development. The blood glucose lowering agent. It will be used as first line therapy increased emphasis that the Diabetes Control and by doctors in conjunction with diet and exercise. Diet and Complications Trial has placed on diabetes undoubtedly will exercise can frequently improve diabetes symptoms dramatically, stimulate more and more prescription drug development in the however, it has always been fraught with frustration due to lack area of oral treatments for diabetes mellitus.
of compliance of patients' willingness to participate in an The newer insulins have a faster time of action and help to aggressive enough program to make a change. In some cases, keep the after-meal glucose levels from rising too high. They are repaglinide was used together with metformin to help keep generally used in the type 1 diabetic but also have uses in the blood glucose levels down to the normal range. Prandin causes patient with type 2 diabetes. Somewhere around 29% of type 2 increased release of insulin by the beta cells. The insulin is diabetics are treated with insulin. This is a sad fact since with dependent on glucose and levels fall as the glucose levels go adherence to diet, a good exercise routine and increased down. It works very quickly, then just as quickly quits working to knowledge of the mechanics of diabetes, insulin could be avoided.
minimize side effects. This has been shown to be particularly Insulin tells the liver to stop producing glucose and start useful in diabetic patients with kidney problems. Prandin mag- using it. In addition, insulin tells the muscles to suck in glucose nifies the normal response of increased insulin in response to and start burning it for fuel. Insulin can also tell the fat cells to eating a meal. As the glucose level rises after eating, insulin is take in glucose, but this occurs to a lesser amount. Insulin released and causes unlocking of the gates to the cells so dosage and timing will have profound effects on the blood glucose can go from the blood stream into the cell itself.
glucose levels. Too much and the blood glucose level falls and Repaglinide is welcomed as it has minimal hypoglycemic side hypoglycemia can occur. Too little insulin and there is not effects. Weight gain has been associated with repaglinide, enough to drive the glucose into the cells that need it. Insulin cansimilar to the sulfonylureas. Other less common side effects be used in type 2 diabetics with or without some of the oral include lowering of platelets, lowering of white cells, and medications. Usual doses of insulin are given two times a day, increased liver enzymes. This medication is best taken three morning and evening to try to keep the glucose levels at a near times each day with meals. People with kidney or liver problems normal range. Eating pushes up the glucose your body needs to should refrain from using this medication. deal with. Exercise burns up glucose and can cause hypo- Benefits of the newer therapeutics
glycemia if too much insulin is given or too little food is eaten.
The biguanides (Metformin or Glucophage) are not associ- The delicate balance between multiple factors, food intake, energy ated with weight gain as are traditionally the sulfonylureas.
expenditure, medication dosages, illness, and stress all interact Acarbose (Precose), which is an alpha-glcosidase inhibitor, to raise or lower the levels of glucose in the blood. What is targets the after-eating increase in glucose or post-prandial universally accepted, is that the more closely the blood glucose hyperglycemia. Precose is particularly good in patients whose levels stay in the normal range the less systemic effects diabetes glucose levels increase rapidly after eating a meal high in will have. If close attention is paid to balancing energy output carbohydrates. The combination therapeutics are of benefit to with food intake, along with a nutritionally sound vitamin and patients that are resistant to taking multiple medications as are mineral intake, the type 2 diabetic patient will have a good the newer extended release versions of the above medications.
chance of keeping the levels of glucose in the correct range.
Insulins, new and old - Lispro (Humalog)
Insulin has its side effects and that is why many diabetics are motivated to avert the need for insulin injections.
A faster acting form of insulin called Lispro (Humalog) is Hypoglycemia, weight gain, and faster disease occurring in the blood vessels are all potential side effects of insulin therapy. It I personally prefer chromium polynicotinate for supplemen- is clear that close supervision by a health care provider trained tation in both diabetes and overweight patients. Recommended in diabetes is essential when it comes to insulin treatment. Close dosages are up to 1000 micrograms daily divided with meals monitoring by self-administration of glucose testing is critical to (200 mcg with breakfast, 400 mcg at lunch and 400 mcg at follow the effects of the treatment.
dinner). These doses are sufficient to promote the 200 mcg absorption that the body needs on a daily basis. The deficiency Functional Medical Treatments
of chromium in the diet has lead some researchers to state Alternative therapies are treatments that are neither widely that we would need to consume in excess of 12,000 calories taught in medical schools nor widely practiced in hospitals.
per day to get the required amount of chromium from dietary Alternative treatments that have been studied to manage only sources.
diabetes include acupuncture, biofeedback, guided imagery, Magnesium - Magnesium may alter both insulin secretion
and vitamin and mineral supplementation. The success of some and the biological activity of insulin. Scientists believe that a alternative treatments can be hard to measure. Critics of deficiency of magnesium interrupts insulin secretion in the pan- natural-based therapies are quick to state that many alternative creas and increases insulin resistance in the body's tissues.
treatments remain either untested or unproven through Evidence suggests that a deficiency of magnesium may con- traditional scientific studies, however many of these studies do tribute to certain diabetes complications and co-morbidities exist and are overlooked by those who do not desire to see a such as insulin resistance, glucose intolerance and hyperinsu- benefit exist. The traditional "double-blind" placebo controlled linemia. Low magnesium levels are associated with diabetic clinical study relates a given single treatment to a specific patients that have experienced diabetic ketoacidosis. In patients desired outcome. Frequently, natural-based treatments require with type 2 diabetes, research has demonstrated that clinical descriptive studies for evaluation due to the nature of the magnesium improves cellular uptake of glucose by insulin.
treatments' effects on multiple organ systems and the overall Vanadium - Vanadium is a compound found in tiny
amounts in plants and animals. Early studies showed that Chromium - In the early 1970's, Dr. Walter Mertz, then
vanadium normalized blood glucose levels in animals with type director of the US Department of Agriculture's Human Nutrition 1 and type 2 diabetes. A recent study found that when people Research Center, discovered that simple forms of chromium are with diabetes were given vanadium, they developed a modest poorly absorbed (typically less than 2% of the amount con- increase in insulin sensitivity and were able to decrease their sumed) and do not potentiate insulin activity like biologically insulin requirements resulting in improved glucose levels.
active chromium. Dr. Mertz isolated a chromium compound Although not completely understood, vanadium is thought to from Brewer's yeast that had a strong activating effect on enhance the number of insulin receptors on cell membranes and insulin. He discovered that this "active" chromium was com- improve the binding of insulin to these receptors and/or plexed with several amino acids and the B-vitamin niacin and increase the glucose transport proteins within the cell called this chromium complex: "Glucose Tolerance Factor" or membrane. Improved utilization of glucose in the cells prevents "GTF." Dr. Mertz concluded that niacin was the key to chromium's excess glucose from being converted to triglycerides and biological activity. Neither niacin by itself nor the common ultimately stored as fat. Dosages of 10-100 mg. of Vanadyl chromium picolinate complex had any significant effect on Sulfate have been shown to be beneficial in type 2 diabetes. glucose metabolism. Dr. Mertz concluded that the niacin-bound chromium, called "polynicotinate" or "nicotinate" was the Garcinia Cambogia (Hydroxycitric Acid) - Hydroxycitric
biologically active form of chromium that potentiates Acid (HCA), the active ingredient in Garcinia Cambogia, is a rare organic acid similar to the citric acid found in citrus fruits such as oranges and lemons, but it has several unique proper- Fenugreek - Fenugreek is a compound that may improve
ties. HCA has been shown to reduce appetite and inhibit fat glucose levels by decreasing the absorption of glucose by the small production without stimulating the central nervous system like intestine. It is thought that Fenugreek delays gastric emptying due many of the OTC weight loss and prescription diet medications.
to its high level of soluble fiber. Fenugreek was also shown HCA is extracted from the rind of the fruit of the Garcinia to decrease both total cholesterol levels and triglyceride levels in Cambogia tree where it has been used for seasonings and as a diabetic patients. Defatted Fenugreek seed powder has been food preservative by the people of Southeast Asia. HCA blocks shown to produce a 25 percent drop in fasting blood glucose a key enzyme responsible for the production of fat from leftover measurements, 24 percent drop in elevated total cholesterol levels, glucose that is not being used immediately for energy. When 32 percent decrease in LDL levels, and a 37 percent decrease in carbohydrates are consumed they are broken down into glu- cose and sent throughout the body. Excess glucose that is not Biotin - Biotin deficiency has been implicated in glucose
immediately needed for energy or metabolism is stored in the intolerance and dysglycemia. Biotin has been shown to improve body's liver and muscles as glycogen. Glycogen can be rapidly glucose metabolism without increasing the output of insulin from utilized if needed from this storage depot in the liver and mus- the pancreas. Biotin is thought to work via an increase in the cle, but there is only so much room to store this "immediate backup" form of energy fuel. The glucose in excess of that needed B Vitamins - Vitamin B6 is involved in inhibiting the
for liver and muscle glycogen storage is transformed into a glycosylation of proteins known to cause tissue damage from longer term depot of energy fuel (i.e. triglyceride and fat). The excessive blood glucose levels and high tissue concentrations of conversion of unused, or excessive glucose, is aided by an glucose. B1 is involved with carbohydrate metabolism in the enzyme called ATP-citrate lyase. HCA temporarily inhibits the Krebs cycle and may prevent complications of diabetes like activity of this enzyme thus decreasing fat production from carbo- hydrate metabolism. In addition it promotes biochemical changes in the liver that promote fat burning and glycogen storage. Conjugated Linoleic Acid (CLA) - Conjugated Linoleic Acid
or CLA has an effect similar to the prescription diabetic agents Gymnema Sylvestre - Gymnema Sylvestre is a compound
called thiazolidinediones. These compounds activate certain that was shown to reduce glucose in the urine nearly 70 years receptors that promote both glucose tolerance and lessen ago. It was subsequently shown that Gymnema had a blood glucose lowering effect when there was residual pancreatic function, but had no affect on animals lacking pancreatic Alpha-Lipoic Acid - Alpha-Lipoic Acid has been demon-
function. Studies beginning again in 1981 showed that strated to improve insulin sensitivity. The mechanism may be by Gymnema lowered blood glucose levels and raised serum increasing the activity of glucose transport proteins in patients insulin levels during an oral glucose tolerance test. Further with type 2 diabetes.
studies revealed that Gymnema improved both glycosylated Citrus Aurantium - Citrus Aurantium is a member of the
hemoglobin and glycosylated plasma proteins, two indicators citrus family frequently called "Orange Bitters." The metabolic of long term glucose control. Further studies in 1990 promoted effect stems from an active alkaloid effect that stimulates the the concept of beta cell repair/regeneration of the exocrine sympathetic nervous system thus increasing metabolism. pancreas as an effect of Gymnema causing an improved level Omega-6 Fatty Acids - Omega-6 Fatty Acids like black
of glucose homeostasis. Cholesterol levels, triglyceride levels currant seed oil or evening primrose oil may aid in the reversal and free fatty acid levels have all been shown to be lowered by of nerve damage due to diabetic neuropathy.
Coenzyme Q10 - CoQ10 or ubiquinone is a key compo-
transport and decreasing the requirements on insulin. Vanadyl nent of the energy producing mitochondria, and is critical in the Sulfate also aids in the synthesis of muscle mass and the ability production of cellular energy known as ATP. The specific action of CoQ10 and diabetes is not known, however, increased Selenium - Selenium is a trace element that works closely
metabolism via increased ATP production corresponds with with glutathione peroxidase and vitamin E to prevent damagea greater need for glucose as a substrate for cellular energy from free-radicals. Low levels of selenium are associated withproduction. A 36 - 59 percent positive response in diabetics has poor immune function, acceleration of cardiovascular disease, been reported with CoQ10 supplementation. Some have shown and has been implicated in certain cancers. that CoQ10 stimulates insulin production and has been shown Zinc - Zinc is a trace mineral involved in a majority of
to reduce fasting blood glucose levels and ketone bodies by enzymatic reactions throughout the body. Zinc is required for proper activity and function of insulin and in the production of Green Tea - Green tea has been shown to increase insulin. It is believed that many people in the U.S. are at least
metabolism by increasing 24h Energy Expenditure (EE) and a mildly zinc deficient, however severe zinc deficiency is very decreasing the 24h Respiratory Quotient (RQ). Green tea has rare. Poor wound healing and immune dysfunction is worri- been demonstrated to significantly reduce food intake, body some for diabetic patients and increased zinc intake can help weight, blood cholesterol and triglycerides.
improve wound healing and promote effective immunity. Folic Acid (Folate) - Folate is involved in glucose metabolism
Vitamin C - Vitamin C is transported into cells with the help
and is a critical factor in the metabolism of homocysteine.
of insulin. Insulin dysfunction can affect this transport and Folate must be activated to 5-MTHF (5-Methyltetrahydrofolate) a relative decrease in intracellular vitamin C can occur. Low for effective action. Up to 25 percent of the population lack the intracellular vitamin C levels have been implicated in poor enzyme required for this activation and should take 5-MTHF wound healing, dysfunctional immunity and increased capillary permeability. Increased vitamin C intake in diabetic patients is B-12 - B-12 is involved in carbohydrate metabolism and recommended to offset these intracellular deficits.
is helpful in preventing and/or slowing the progression of Manganese - Manganese is used for activating enzymes
involved with glucose metabolism and is involved as a cofactor Niacin - Niacin is an essential component of Glucose
in a number of enzymes important in energy production and Tolerance Factor (GTF), and its association with chromium is antioxidant defense such as superoxide dismutase.
critical to effective insulin activity.
Alternative/Complementary Medical Treatments
Vitamin E - Vitamin E has been shown to be helpful in
Acupuncture - Acupuncture is a procedure in which a prac-
preventing complications of diabetes by preventing the titioner inserts needles into designated points on the skin. Some oxidation of glycosylation products that cause tissue damage Western scientists believe that acupuncture triggers the release of throughout the body. Vitamin E has been associated with the body's natural painkillers. Acupuncture has been shown to improving the flexibility of the cell membrane and increasing offer relief from chronic pain and is sometimes used by people utilization of glucose. Vitamin E has also been recommended with neuropathy, the painful nerve damage caused by diabetes. for preventing complications of diabetic retinopathy and Biofeedback - Biofeedback is a technique that helps a
person become more aware of and learn how to deal with the Vanadyl Sulfate - Vanadyl Sulfate improves and maintains
body's response to pain. This alternative therapy emphasizes proper blood glucose balance by increasing the rate of glucose relaxation and stress-reduction techniques. Guided imagery is a relaxation technique that some professionals use in biofeed- • Demonstration that antihypertensive drugs called ACE back. With guided imagery, a person thinks of peaceful mental (angiotensin-converting enzyme) inhibitors prevent or images, such as ocean waves. A person may also include the delay kidney failure in people with diabetes. images of controlling or curing a chronic disease, such as • Promising results with islet transplantation for type 1 diabetes. People using this technique believe their condition can diabetes reported by the University of Alberta in Canada.
A nationwide clinical trial funded by the NIH and the Additional information on alternative therapies for diabetes
Juvenile Diabetes Research Foundation International is To learn more about alternative therapies for diabetes currently trying to replicate the Canadian studies. treatment, contact the National Institute of Health's Office of • Evidence that people at high risk for type 2 diabetes can Alternative Medicines Clearinghouse at (888) 644-6226. The lower their chances of developing the disease through diet National Diabetes Information Clearinghouse collects resource information on diabetes for the Combined Health Information • Evidence that high quality nutritional supplementation Database (CHID). CHID is a database produced by health- may augment various dysfunctional biochemical path- related agencies of the Federal Government. This database ways restoring them to a more homeostatic balance.
provides titles, abstracts, and availability information for health information and health education resources.
Future Treatments for Diabetes
In the future, it may be possible to administer insulin through Recent Advances in Diabetes Management
inhalers, a pill, or a patch. Devices are now available In recent years, advances in diabetes research have led to (GlucoWatch) that allow a 12 hour monitoring of glucose levels better ways to manage diabetes and treat its complications.
through skin diffusion after a single daily calibration.
Researchers continue to search for the cause or causes of • The development of a quick-acting insulin analog. diabetes and ways to prevent and cure the disorder. Scientists • Better ways to monitor blood glucose and for people with are looking for genes that may be involved in type 1 or type 2 diabetes to check their own blood glucose levels. diabetes. Some genetic markers for type 1 diabetes have been • Development of external insulin pumps that deliver insulin identified, and it is now possible to screen relatives of people with type 1 diabetes to see if they are at risk.
• Laser treatment for diabetic eye disease that reduces the The Diabetes Prevention Trial - Type 1 (DPT-1) identifies relatives at risk for developing type 1 diabetes and treats them with an oral form of insulin in the hope of preventing type 1 • Successful transplantation of kidneys and the pancreas in diabetes. In the same study, researchers recently completed people whose own kidneys fail because of diabetes. a separate trial in which they found that low-dose insulin • Better ways of managing diabetes in pregnant women, injections do not prevent type 1 diabetes in relatives of people thus improving chances of successful outcomes. • New drugs to treat type 2 diabetes and better ways to Transplantation of the pancreas or insulin-producing beta manage this form of diabetes through weight control. cells offers the best hope of cure for people with type 1 • Evidence that intensive management of blood glucose diabetes. Some pancreas transplants have been successful.
reduces and may prevent development of diabetes However, people who have transplants must take powerful drugs to prevent rejection of the transplanted organ. These drugs are costly and may eventually cause other health problems.
Newer less immunogenic modifications are under development.
sity exercise, and lost 5 to 7 percent of their body weight.
Scientists are working to develop less harmful drugs and better Participants randomized to treatment with metformin reduced methods of transplanting beta cells to prevent rejection by the their risk of getting type 2 diabetes by 31 percent.
body. Using techniques of bioengineering, researchers are also Several new drugs have been developed to treat type 2 trying to create artificial beta cells that secrete insulin in response diabetes. By using the oral diabetes medications now available, to increased glucose levels in the blood.
many people can control blood glucose levels without insulin In 1996, NIDDK launched its Diabetes Prevention Program injections. Many people have been able to reduce their (DPP). The goal of this research effort was to learn how to prescription medications, avoid prescription medications and prevent or delay type 2 diabetes in people with impaired avoid insulin by using high grade nutritional supplements glucose tolerance (IGT), a strong risk factor for type 2 diabetes.
designed for use in glucose dysfunction. Many patients are very The findings of the DPP, which were released in August fearful, and therefore quite motivated, of allowing their 2001, showed that people at high risk for type 2 diabetes could condition to worsen to the point of needing insulin. I have sharply lower their chances of developing the disease through experienced a multitude of patients in my clinic that are drug diet and exercise. In addition, treatment with the oral diabetes free with sustained normalization of their Hgb-A1-C levels with drug metformin also reduced diabetes risk, though less dramat- appropriate daily supplementation and lifestyle modification.
ically. The same study was halted early due to the profound Studies are under way to determine how best to use nutritional positive impact of diet and exercise versus metformin.
supplements, prescription medications and combinations of Participants randomly assigned to intensive lifestyle intervention both to manage type 2 diabetes. Medical intervention regarding reduced their risk of getting type 2 diabetes by 58 percent. On obesity and weight management is also a key factor in the average, this group maintained their physical activity at 30 minutes per day, usually with walking or other moderate inten- Did you know that EVERY 24 HOURS
Did you also know:
in America:
• 65% of people with diabetes die from heart disease • 2,700 people are diagnosed with diabetes
• People with diabetes have the same cardiovas- • 1,200 people die from diabetes
cular risk as if they had already had a heart attack • 180 amputations are performed because
• Recent statistics show there are currently more than • 120 people begin treatment for end-stage
• Centers for Disease Control estimate that by the year 2050, the prevalence of diabetes will increaseby 165% • 75 people lose their eyesight because
• Diabetes kills more people every year than AIDS or breast cancer - one American dies from diabetesevery three minutes References and Further Reading
Ornish, MD, Dean, Love & Survival: The Scientific Basis for the Healing Power ofIntimacy (HarperCollins 1997).
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Reaven GM, Brand R, Chen Y, Insulin resistance and insulin secretion are determi- Pritikin, Nathan, The Pritikin Program for Diet & Exercise (Grosset & Dunlap 1979).
nants of oral glucose in normal individuals. Diabetes 1993; 42: 1324-32 Pritikin, Robert, The New Pritikin Program: The Premier Health & Fitness Program for Murray, M. and Pizzorno, J. Encyclopedia of Natural Medicine, 1997, Prima the '90s (Simon & Schuster, Inc. 1990).
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Sapolsky, R, Why Zebras Don't Get Ulcers, W.H. Freeman and Company, NY McCully, K, MD, The Homocysteine Revolution, Keats Publishing, CN Alterman, MD, Seymour L., How to Control Diabetes (Ballantine Books 1997).
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K, M. Nutr. & Diet, The Glucose Revolution, 1999, Marlowe and Company, NY Balch, MD, James F., Prescription for Nutritional Healing 2nd Edition (Avery Paolisso G., Sgambato S, Pizza G., Improved insulin response and action by chronic magnesium administration in aged NIDDM subjects. Diabetes Care. 1989;12(4):265-272 Resources
Garrison R, Somer E. Nutrition Desk Reference, 3rd ed. New Canaan, Conn; KeatsPublishing; 1995 National Diabetes Information Clearinghouse
1 Information Way
Blostein-Fujii A, DiSilvestro RA, Frid D, Katz C, Malarkey W., Short-term zinc supple- mentation in women with non-insulin-dependent diabetes mellitus: effects on plasma 5-nucleotidase activities insulin-like growth factor I concentrations and lysoprotein oxi-dation rates in vitro. Am J Clin Nutr. 1997;66(3):639-642 National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
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Weil, MD, Andrew, Spontaneous Healing (Alfred A. Knopf, Inc. 1995).
Pizzorno, ND, Joseph, TOTAL WELLNESS: Improve Your Health By Understanding The Centers for Disease Control and Prevention
Body's Healing Systems (Prima Publishing, 1996).
McDougall, MD, John A., The McDougall Program: Twelve Days to Dynamic Health(Penguin Group 1990).
Department of Veterans Affairs
www.va.gov/health/diabetes
McDougall, MD, John A., The McDougall Program for Maximum Weight Loss(Penguin Group 1994).
Health Resources and Services Administration
www.hrsa.gov
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Kamen, PhD, Betty, The Chromium Connection: A Lesson in Nutrition (Nutrition Juvenile Diabetes Research Foundation International
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