Lifestyle strategies for prediabetes reversal

Photo Cred: Bonnie Kittle/Unsplash

By Kellie Blake, RDN, LD, IFNCP

Prediabetes is reversible most of the time, so I’m always surprised when a patient has been told their blood sugar isn’t yet high enough to address. While prediabetes isn’t classified as a disease itself, it certainly leads to serious health consequences like heart disease, diabetes, and stroke when left untreated.

This public health crisis is seemingly overlooked. As reported in the Journal of the American Board of Family Medicine, only 23 percent of patients with undiagnosed or diagnosed prediabetes are provided with treatment such as medication or lifestyle modification counseling by their primary provider. While it’s estimated that 88 million Americans have prediabetes, only 16 percent of them, according to the Centers for Disease Control and Prevention, are aware.

Technically, prediabetes can be diagnosed when fasting blood sugar is 100 to 125 milligrams/deciliter, HgbA1c is 5.7 to 6.4 percent, or two-hour oral glucose tolerance test blood sugar is 140 to 199 milligrams per deciliter. However, as integrative providers, we know the earlier we intervene, the better the outcome. When I see a patient with a fasting blood sugar above 95 milligrams/deciliter, a HgbA1c above 5.4 percent, or a fasting insulin level above eight mcIU/mL, I initiate clinical measures.

Lifestyle modification for the prevention of diabetes and cardiovascular complications in those with prediabetes is well-documented. In the Finnish Diabetes Prevention Study reported in Diabetes Care, participants with impaired glucose tolerance received either intensive nutrition counseling and resistance training or general nutrition and exercise guidance. The intensive therapy group lost more weight and had much improved lipid and glucose parameters when compared to the general group. In addition, the intensive therapy group had a 58 percent reduced risk of developing type 2 diabetes. Likewise, the Diabetes Prevention Program, as reported in Diabetes Care, showed intensive lifestyle modification produced a 58 percent reduction in diabetes incidence in those with prediabetes.

Exercise is a very important component for those with prediabetes. In one randomized, controlled trial reported in the Journal of Diabetes Research, participants with prediabetes were assigned to a 12-month lifestyle intervention group with no exercise, a supervised exercise program group focused on strength training, or a supervised exercise program group focused on cardiovascular training. The researchers found the participants in both exercise groups experienced significant decreases in visceral and subcutaneous fat tissue, but also had higher reductions in fasting glucose when compared to the control group. In addition, the exercise groups had fewer participants transition to diabetes as compared to the control group. While both cardiovascular and strength training improved outcomes, only the strength training group experienced an increase in muscle mass, which is extremely important in disease prevention and aging.

Time-restricted feeding is also showing benefit for those with prediabetes. In one clinical trial published in Cell Metabolism, male participants with prediabetes were assigned to an early time-restricted feeding schedule of 6 hours versus a 12-hour time-restricted feeding schedule. After five weeks the participants crossed over to the opposite group. The researchers found the participants experienced more improvement in insulin sensitivity, blood pressure, oxidative stress, appetite, and β cell responsiveness when they were in the early time-restricted feeding group.

Prediabetes is pervasive, so it’s always on my radar as a dietitian. Instead of waiting for full-blown disease to develop, I help my patients aim for optimal blood sugar and insulin levels with a variety of nutrition and lifestyle-related strategies. When it comes to nutrition for prediabetes, there are many options. While the diabetes prevention trials have mostly focused on a lower-fat diet, the Mediterranean diet, low carbohydrate diet, intermittent-fasting, and the ketogenic diet are likely also very effective for diabetes prevention. I like to focus on a whole-foods, plant-based approach with time-restricted feeding and nutritional supplements as appropriate. I tailor the meal plan to the patient making it a more sustainable option. When patients are more compliant over time, long-term outcomes are improved.

Case Study

My patient Jane is a 57-year-old female referred by her ophthalmologist due to prediabetes, obesity, and inflammation. Jane had three corneal transplants with poor results due to underlying medical issues and mycotoxin infection and her provider had encouraged her to make some nutrition and lifestyle-related changes.

Jane is five foot two and initially weighed 200 pounds. She reported a usual body weight of 165 pounds until she began taking prescription steroids. She had prolonged use of proton-pump inhibitors, antibiotics, and non-steroidal anti-inflammatory drugs and while she had cut down from two packs per day, she was still smoking six to 10 cigarettes per day. Jane was diagnosed with chronic obstructive pulmonary disease, rheumatoid arthritis, chronic pain, and hypertension and she stated she could no longer work due to her chronic medical conditions.

Her initial lab work indicated inflammation with c-reactive protein of 4.1mg/L, inadequate vitamin D level of 36.1ng/mL, and prediabetes with fasting blood sugar of 159mg/dL and fasting insulin of 41.2 mcIU/mL. Her food diary indicated three meals and two snacks daily with late night eating being problematic. She craved chocolate and avoided dairy products, but her diet was high in processed foods and sugar. Initial medications included berberine, quercetin with bromelain, blood pressure medication, a bronchodilator, a corticosteroid, and prescription eye drops. Jane had very minimal physical activity due to her breathing problems and chronic pain.

The initial plan for Jane included:

1. An anti-inflammatory, low-glycemic, gluten-, grain-, and dairy-free meal plan with moderate intake of high-quality fat. Jane was to focus on consuming 10 servings of vegetables per day with half of those being leafy greens. She was limited to one serving of fruit per day and no starchy vegetables for the first four weeks.
2. Time restricted feeding. Jane was to eat within an eight-hour window daily and avoid late-night snacking. She woke later in the day, so her eating window was 10 a.m. to 6 p.m.
3. Stress management practice of meditation. Ten minutes immediately upon waking and 10 minutes in the afternoon. In addition, restorative yoga daily for at least 10 minutes.
4. Exercise by walking on the treadmill or outside after every meal for at least 10 minutes.
5. Continue the berberine to target blood sugar, quercetin with bromelain to target digestion, and add in vitamin D3/K2 5,000 international units daily to improve vitamin D level, and omega-3 2,000 milligrams daily to target inflammation.
6. Complete smoking cessation.

After six weeks, Jane had lost 23 pounds and reported she had much more energy. She said she still had stiff, sore joints, which kept her from doing more exercise, but she was walking for 10 minutes three times per day most days. She said one of the most important effects of her lifestyle change involved being able to sleep through the night. She was following the meal plan closely and reported she was really enjoying eating a variety of greens every day. Her bowel movements were regular every morning and she was practicing meditation once daily. She was still struggling to quit smoking but continues working toward her goal of cessation. Jane’s fasting blood sugar was down to 105 milligrams/deciliter and her fasting insulin had decreased to 14mcIU/mL.

Jane’s follow up goals included continuing with the meal plan and previous goals, but she was educated to meet with a fitness professional to begin strength training at least twice per week.

The diabetes prevention trials have shown that weight loss and exercise interventions are successful in preventing diabetes development in up to two thirds of prediabetes cases during and for several years after the intervention. In addition, there is sustained risk reduction when compared to control groups. However, after 15 years, most participants in these trials did develop diabetes for several reasons. So, while Jane had amazing results in the short-term, if these lifestyle strategies are not lasting, she will likely go on to develop full disease. This is the importance of personalization, routine testing, and frequent reevaluation of the plan to promote current and future success.

References

American Diabetes Association. Diagnosis. Retrieved from: https://www.diabetes.org/a1c/diagnosis

Diabetes Prevention Program (DPP) Research Group (2002) The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282458/

Finnish Diabetes Prevention Study Group (2003) The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/14633807/

Guess, N. D. (2018) Dietary Interventions for the Prevention of Type 2 Diabetes in High-Risk Groups: Current State of Evidence and Future Research Needs. Nutrients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163866/

Mainous, A. G. (2016) Prediabetes Diagnosis and Treatment in Primary Care. Journal of the American Board of Family Medicine. Retrieved from: https://doi.org/10.3122/jabfm.2016.02.150252

Sutton, E. F. (2018) Early Time-Restricted Feeding Improves Insulin Sensitivity, Blood Pressure, and Oxidative Stress Even without Weight Loss in Men with Prediabetes. Cell Metabolism. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/29754952/

U.S. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/diabetes/basics/prediabetes Accessed 03/11/2021

Yan, J. (2019) Effect of 12-Month Resistance Training on Changes in Abdominal Adipose Tissue and Metabolic Variables in Patients with Prediabetes: A Randomized Controlled Trial. Journal of Diabetes Research. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/31737686/