Case Study Excerpt: Treating Type 2 Diabetes with Lifestyle Medicine

Patient Information:

Sonya is a 46-year-old woman who works as the head baker at a bakery she owns with her husband in Providence, Rhode Island. After their wedding in the spring of 2013, Sonya and her husband, Leo, moved to Providence to open a wedding cake shop, a lifelong dream of Sonya’s.

Social History:

• Non-smoker
• Drinks alcohol socially

Vital Signs:

• Height: 5’7”
• Weight: 215 lbs
• BMI: 33.7
• Total cholesterol: 200
• HDL cholesterol: 50
• Blood pressure systolic: 129 mm Hg
• Blood pressure diastolic: 78 mm Hg
• Non-fasting glucose: 250 mg/dL

Medications:

• Metformin

Health Concerns:

• Diabetes
• Elevated blood pressure
• Anxiety

Practitioner Perspective: Mona Morstein, ND

Dr. Morstein is a naturopathic doctor that specializes in diabetes care. To reduce blood sugar spikes, Dr. Morstein said she believes Sonya would benefit from a low-carb diet. Physical activity is key to glucose regulation, but beginning exercise can be daunting for many patients. Dr. Morstein said she would recommend that Sonya start with daily walks and later incorporate light strength training.

First Visit

The first visit with Sonya would be 90 minutes. Prior to the visit, Dr. Morstein would send Sonya a comprehensive intake specifically tailored to patients with diabetes. At the beginning of the appointment, Dr. Morstein would review the intake and address questions such as,

• What were the results from your latest lab tests? 
• How controlled is your diabetes?
• Do you have a glucose meter? 
• Have you had your eyes examined for signs of diabetic retinopathy? 
• Have you had a microalbuminuria test? 
• Do you have any numbness or tingling? 

Dr. Morstein would ask these questions to identify early signs of diabetes complications because they can start even in the prediabetes phase.

After addressing the basics, Dr. Morstein would try to understand Sonya's lifestyle habits better. She would ask about exercise, stress levels, family history, and experiences with medications. Sufficient sleep is also important for glucose regulation, so Dr. Morstein would discuss Sonya’s sleep quality.

Then, Dr. Morstein would order lab work, including tests for complete blood count (CBC), a comprehensive metabolic panel (CMP x 14), high-sensitivity C-reactive protein (hs-CRP), lipids, gamma-glutamyl transferase (GGT), C-peptide, and ferritin. Dr. Morstein always tests for ferritin because it’s generally one of the first labs that detects signs of fatty liver disease, which is common in patients with diabetes. She’d also test Sonya’s A1C, thyroid, and urine for any kidney problems. In addition, Dr. Morstein would test Sonya’s vitamin D3 levels if she expected a deficiency, as vitamin D helps maintain glucose control. Depending on Sonya’s sleep quality, Dr. Morstein may also consider testing her for obstructive sleep apnea.

At the end of their visit, Sonya would go home with a diet diary. In this diary, Dr. Morstein would ask her to record the specifics of everything they eat and drink, including the brands of the products, for one week. She would also have her record her blood sugar several times a day. She would instruct Sonya to test her fasting glucose when she wakes up and again 1.5 hours after breakfast, lunch, and dinner.

Care Plan

One week later, Sonya would have her second treatment visit with Dr. Morstein. During this appointment, Dr. Morstein would recommend that Sonya eat a low-carb diet. When working on diet changes with her patients, Dr. Morstein would focus on the foods she can eat as opposed to foods she can’t. She would provide Sonya with a reference sheet that includes low-carb options, recipe books, and alternatives for bread, pancakes, pasta, and other carbheavy foods. According to Dr. Morstein, informing patients about how to make common meals with fewer carbohydrates allows for more fluidity in their diet so they can adhere to it in the long-term.

In addition to changing Sonya’s diet, Dr. Morstein would encourage her to exercise daily with a routine that includes both cardio and strength training. Dr. Morstein would also encourage Sonya to get at least seven hours of quality sleep each night and discuss methods to reduce her stress levels.

As for supplements, Dr. Morstein always suggests that her diabetic patients take a tablet that she specially formulated for people with diabetes, which includes ingredients like zinc, chromium, vanadium berberine HCL, alpha lipoic acid, N-acetyl cysteine (NAC), Gymnema sylvestre, curcumin, bilberry, and green tea. In addition, if Sonya were deficient in any nutrients, Dr. Morstein would prescribe the corresponding supplements to help. Dr. Morstein also puts all her patients with diabetes on a high-quality multivitamin mineral and high omega three fish oil product.

Case Considerations

Exercise is one of the most important aspects of glucose control, but for many patients, it’s difficult to schedule into their daily lives. Because Sonya already had a relationship with walking from when she had gestational diabetes, Dr. Morstein would encourage her to begin walking again. She would suggest Sonya walk two miles daily in around 40 minutes. According to Dr. Morstein, walking would not put much strain on Sonya’s body, and she could easily schedule it into her daily routine by walking to work or the store. Dr. Morstein would later encourage Sonya to include strength training into her exercise routine, providing her with resources for online workouts, such as a ten-minute kettlebell session. Dr. Morstein also would explain to Sonya that there are many other free workout videos online that help patients conveniently exercise at home.

To reduce Sonya’s snacking, Dr. Morstein would tell Sonya to eat three large and filling meals each day. That way, she wouldn’t be as hungry while baking and would be less tempted to snack on her leftovers.

If Sonya continued to have uncomfortable side effects from her metformin, Dr. Morstein would suggest switching to a GLP-1 inhibitor, which Dr. Morstein's patients seem to tolerate better.

Long-Term Goals

In the long-term, Dr. Morstein would like to see Sonya with an A1C of less than six, fasting glucose below 100 and a postprandial of no more than 125, and at a healthy weight.

To achieve this, Dr. Morstein would come from a non-confrontational, non-judgmental point of view. She would focus on Sonya’s positive behavioral changes to motivate Sonya to continue to improve her diabetes management. Instead of scaring Sonya with possible diabetes complications, Dr. Morstein would work with her as a team and take it step by step.

About the Expert

Mona Morstein, ND, has been a practicing naturopathic physician for more than three decades. She is recognized as an expert on prediabetes and diabetes and also treats conditions involving reproductive, thyroid, and adrenal hormones. She authored Master Your Diabetes: A Comprehensive, Integrative Approach to Both Type 1 and Type 2 Diabetes, an in-depth, evidence-based book for both patients and physicians. Morstein is the founder and executive director of the Low Carb Diabetes Association. In 2012, Morstein received the President’s Award from the American Association of Naturopathic Physicians in honor of her comprehensive work for the naturopathic profession.

Editor's note: This article is an excerpt from the e-book, Treating Type 2 Diabetes with Lifestyle Medicine. To read more, click here.