A major health concern worldwide is the continued increase of people with prediabetes and diabetes. There are estimates of more than 470 million people developing prediabetes by the year 2030, and each year 5-10 percent of people with prediabetes will progress to diabetes mellitus.  With proper detection and treatment of prediabetes the onset of diabetes can be delayed and even prevented.  ​

Prediabetes can be reversed with the proper nutrition, weight loss, exercise and healthy lifestyle as we have discussed in previous posts.  Additional factors in reversing prediabetes are prescription medications, supplements and meditation.  

Metformin
Metformin is the primary prescription medication recommended for treatment of prediabetes.  Metformin was recommended by the American Diabetes Association Standards of Medical Care in 2013 and is still recommended in the latest 2016 edition.  Check out the ADA 2016 recommendations and more information on preventing diabetes: 2016 ADA Recommendations.  
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The ADA suggests metformin therapy for prevention of type 2 diabetes should be considered in those with prediabetes, especially in those with BMI (Body Mass Index) >35, those aged <60 years, and women with prior gestational diabetes mellitus.  Additionally, metformin has been shown to be safe long-term as well as have secondary health benefits such as reductions in body mass index (BMI) and light density lipoprotein cholesterol (LDL) or bad cholesterol.   

Vitamin D
Some studies have suggested that vitamin D helps prevent the progression of prediabetes to diabetes, however, a recent study showed that vitamin D 20,000 IU per week for five years, did not prevent progression from prediabets to diabetes. This study came from the journal of clinical endocrinology.

The reasoning behind the importance of vitamin D supplementation originally came from studies such as those published by the Journal of Endocrinology from 1988.  These studies suggested that vitamin D deficiency in experimental animals leads to reduced insulin secretion which may be restored with vitamin D supplementation.  

​More recently, studies with vitamin D supplementation for improving glucose tolerance or prevention of Type II Diabetes, have not shown very positive results (Journal of Clinical Endocrinology Metabolism 2014).   One reason may be that the effect of vitamin D on glucose metabolism is small, and that the duration of the published studies where short term.

Because type II diabetes develops gradually over many years through a prediabetic stage, it is possible that an effect of vitamin D supplementation on prevention of type II diabetes may take years to become evident.  In short, if you do have a vitamin D deficiency it is important to discuss the best way to increase your level with your primary physician.  Vitamin D deficiency is detected in the blood and your physician can recommend the correct supplemental dosage based on your lab results.  

Vitamin K1

​Those with pre diabetes have blood sugar levels that are higher than normal but not yet high enough to be considered full onset diabetes.  Vitamin K1, also known as phylloquinone, has been shown to provide beneficial effects on blood sugar and insulin health in prediabetics.  

A 4 week study showed that those who took 1000mcg of vitamin K1 significantly increased insulin sensitivity and improved blood sugar control compared to the placebo group. Blood samples were studied to measure osteocalcin, a hormone that is thought to affect blood sugar health.  Osteocalcin is a protein hormone found in bone that depends on vitamin K1 for production.  Basically, by getting enough vitamin K1 in your diet, more osteocalcin can be produced in the body helping to release insulin from the pancreas and prevent diabetes.  Additionally, osteocalcin administration in mice has been shown to decrease fat pad mass and serum triglyceride levels.  

Foods that contain vitamin K1 include kale, spinach, mustard greens, collard greens, swiss chard, broccoli, brussel sprouts and asparagus just to name a few.  There are vitamin K supplements that are available as well.  Many of these include vitamin K1 and K2.  Vitamin K also helps support healthy bones and arteries.  

Meditation

The final section in this three part series on reversing prediabetes is about the benefits of meditation.  I recommend beginning with an easy 10 minutes per day.  There are easy to use meditation apps like Headspace and Stop, Breathe & Think that will help teach and guide you through the basics.  

Meditation will help you to relax and deal with stress in a new way.  At times, life stresses us all out! However, for those with prediabetes or diabetes, stress presents additional problems.  Stress can directly effect blood glucose levels.  Also, we are more likely to participate in behaviors that are unhealthy when we are stressed. We may tend to eat more high-carbohydrate foods like chips and cookies, or sit on the couch and watch TV instead of exercising. 
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Research studies suggest that regularly practicing meditation helps people reduce their response to stress by slowing heart rate, lowering blood pressure, reducing oxygen intake, and changing the brain waves to a more relaxed state. Controlling your response to stress is also likely to lower blood glucose levels. Regular meditation will help you think clearly before acting. You will be able to handle stress more easily and make better decisions.  

There are so many ways to get started meditating.  As I mentioned above, meditation apps are an easy and inexpensive way.  Also, youtube has several guided meditation videos.  Take a look at these youtube channels; The Honest Guys and Jason Stephenson.  Take an extra 10 minutes or so out of your day to focus on yourself, it is well worth it!

Cheers to your health!

I will continue where we left off from the last post on Prediabetes.  In order to reverse prediabetes, you must focus on decreasing body fat and improving your insulin sensitivity.  Before reading this post, I highly suggest you read the previous post Part I Prediabetes-A Reversible Disease.    I will discuss my recommendations on how to do this by using four categories;  diet, exercise, vitamins and supplements and stress reduction.   In this Part II section, I will discuss Diet and Exercise.  In Part III I will go over vitamins, supplements and stress reduction.  

Note: Please discuss with your physician or nutrition and training specialist, in regards to your particular medical conditions and health goals prior to making any changes in your current regimen.  

When patients are initially diagnosed with prediabetes or diabetes, their doctors may place them on medication to lower their blood sugar.  They will also discuss with them changing their diet and exercise habits or lack their of.  When patients come to me for an evaluation, I will ask them about their daily nutrition and exercise habits.  The extent of what most people know is that they need to lower their sugar and carbohydrate intake, lose weight and exercise more. This is a good start, however, many are confused and have no idea how to go about making these life altering changes.  

Diet 
​The last several decades have seen diet fads come and go.  A major diet craze, and one that is still quite popular, is the low fat and low calorie diet.  This diet is based on the old USDA food pyramid idea that every calorie and gram of fat is alike.  Ingrained in most Americans, is to eat less high fat foods regardless of the type of fat because it contains at least twice as many calories and eat more carbohydrates like cereals, breads and pasta because they contain less calories.  Recent research studies have proven that this is NOT true and in prediabetic and diabetic patients, higher carbohydrates are known to raise overall blood sugar levels.  

 In my experience, cutting calories and fat may help you lose weight in the short term but this type of restriction is usually short lived.  Many regain the weight and are back where they started again and again.  Studies have found that it is actually the type of fat, protein and carbohydrates as well as the ratio of each during meals and timing of meals that matters.  The most simple way to think about this is to focus on eating whole unprocessed foods.  Foods that are naturally found in nature such as fresh fish, meats, eggs, full fat dairy, vegetables and fruits.  Filling up on these at all of your meals will make you much less hungry and decrease cravings for sugary,high carbohydrate foods like breads, pastas and cakes.  Adding foods like nuts to eat as snacks and to use as flavor enhancers along with spices will also help you feel fuller and more satisfied.  

A great book to get you started is called Always Hungry? by Dr. David Ludwig.  Dr. Ludwig discusses how eating more good fats in a specific ratio to healthy proteins and carbohydrates can help sustain a healthy weight and lower insulin resistance.  This helps to reverse diseases like pre diabetes and obesity.  Dr. David Ludwig has written this book based on his clinical experience and research.  He is a practicing endocrinologist and leading Harvard Medical School expert and "obesity warrior"   Dr. Ludwig is said to have "rewritten the rules on weight loss, diet and health."  Always Hungry? includes a three-phase program that ignores calories and targets fat cells directly. The recipes and meal plan include satisfying and healthy high-fat foods (like nuts and nut butters, full-fat dairy, avocados, and dark chocolate), savory proteins, and natural carbohydrates. This is dieting without deprivation.   This is a great way to finally lose weight and help reverse prediabetes.  

Diet Tips:  
Skip artificial sweeteners.  Fake sugar can cause your blood sugar to rise just like real sugar.  In fact, anIsraeli study showed that ingesting artificial sweeteners might lead to obesity and related ailments such as diabetes.  The sweeteners appear to change the population of intestinal bacteria that direct metabolism, the conversion of food to energy or stored fuel.  Artificial sweeteners may favor the growth of bacteria that make more calories available to us, calories that can turn into belly fat and that dreaded muffin top! 

Don't eat directly before a workout.  If you ate within four hours of a workout you should skip that pre workout snack.  As I will discuss in the next section on exercise, when you workout your muscles use glucose from your bloodstream as fuel.  When you use up available blood sugar your body will burn fat for energy.  If you eat too much before you exercise your body will not need to burn as much subcutaneous fat.  Your body will instead use the glucose from the snack as energy and leave the belly fat behind.  

Sprinkle cinnamon on your food.  There is evidence to suggest thatcinnamon or cinnamaldehyde, increases fat burning potential and helps to normalize circulating levels of leptin/ghrelin ratio.  Leptin and ghrelin  help control appetite and energy.  This study also showed cinnamon reduced inflammation in mice fed a high fat diet, which augurs well for its anti-obesity role. 

Exercise
Go exercise!  This is easier said than done.  For most people it is hard enough just to get off the couch.  Figuring out what type of exercise works best for them is even more difficult.   There are several different types of exercise from walking, running, cycling or weight training just to name a few.  Recently, studies have shown that high-intensity interval training (HIIT) also called high-intensity interval exercise (HIIE), helps to lower blood glucose levels and improves insulin sensitivity.  

This type of training involved repeated bouts of high intensity effort followed by varied recovery times.  According to the American College of Sports Medicine (ACSM.org), the intense work periods may range from 5 seconds to 8 minutes long, and are performed at 80% to 95% of a person’s estimated maximal heart rate, the maximum number of times your heart will beat in a minute without overexerting yourself. The recovery periods may last equally as long as the work periods and are usually performed at 40% to 50% of a person’s estimated maximal heart rate. The workout continues with the alternating work and relief periods totaling 20 to 60 minutes.  HIIT training can easily be modified for people of all fitness levels and special conditions, such as those overweight or diabetic.

HIIT has been lab tested as a major component of fat loss around the belly.  As discussed in the previous post Part I Reversing Diabetes, belly fat or visceral fat can lead to diseases such as heart disease,cancer and diabetes.  According toa study from the University of New South Wales in Australia, women who did three HIIT workouts per week lost significantly more subcutaneous fat (the fat that you can see and pinch) then women who did only steady-state cardio. They also managed to improve insulin resistance.  
   
When developing a HIIT program, consider the duration, intensity, and frequency of the work intervals and the length of the recovery intervals. Intensity during the high intensity work interval should range ≥ 80% of your estimated maximal heart rate. As a good subjective indicator, the work interval should feel like you are exercising “hard” to “very hard”. Using the talk test as your guide, it would be like carrying on a conversation, with difficulty. The intensity of the recovery interval should be 40-50% of your estimate maximal heart rate. This would be a physical activity that felt very comfortable, in order to help you recover and prepare for your next work interval.  For more information on high-intensity interval training take a look here: ACSM.org.  

According to a study from November 2015 in the Obesity Review Journal; HIIT appears effective at improving metabolic health, particularly in those at risk of type 2 Diabetes.  High intensity interval training (HIIT) improves liver and adipose tissue insulin sensitivity.  HIIT lowers glucose levels by improving adipose and liver insulin sensitivity independently of changes in adiposity, adipose tissue inflammation or liver lipid content.   

Further evidence for high-intensity interval exercise effects on blood sugar control come from a study published in Metabolism from 2016.  This study showed that HIIT or HIIE is effective at lowering evening/fasting glycemic.  Exercise performed in the fasted state reduces postprandial glycemic (after eating a meal) increments to a greater extent than post-breakfast exercise does.  Basically, performing HIIT under fasted conditions may be very beneficial as it lowered most aspects of glycemia.  

Postprandial hyperglycemia (after eating a meal) is considered to be more strongly associated with insulin resistance at the level of muscles, whereas fasting glycemic reflects hepatic insulin resistance.  Therefore, some types of exercise may improve muscular insulin sensitivity but have little effects on hepatic insulin sensitivity.  Two exercise strategies to consider are high-intensity and fasted-state exercise.   We will mostly focus on HIIE.  

High-intensity interval training involves alternating between repetitions of high intensity exercise bits; ≥70% of maximum or peak oxygen consumption, or 80%–100% of maximal heart rate and lower-intensity recovery periods.  Brief bouts of high-intensity exercise allow for the breakdown of glycogen (glucose stored as energy in muscles) and increased uptake of glucose into muscles thus helping to lower overall blood glucose (blood sugar) levels and burn fat.  

Exercise Tips:
An easy do-it-yourself way to begin HIIT is by performing a combination of exercises including sprints and plyometrics such as burpees, squat jumps and jumping rope.  You must push yourself as hard as you can, recover and catch your breath, then push yourself as hard as you can again.  This is performed for multiple intervals.  For example go all out for 30-90 seconds then recover and catch your breath for about the same amount of time.  Repeat this sequence for approximately 20 minutes.  

A great way to decrease body fat around your belly is lifting weights while bracing your core.  Research published in the journal American College of Sports Medicine: Health and fitness showed compound exercises can elevate fat burn for up to 72 hours post workout and have a great effect on subcutaneous fat loss by increasing fat fighting hormones.  



Stay tuned to Part III-Prediabetes a Reversible Disease Coming Soon!

Those with prediabetes have blood glucose (blood sugar) levels that are higher than normal but not yet high enough to be diagnosed as diabetes.  Doctors will sometimes refer to prediabetes as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG), depending on what test was used when detected.  Many americans that have prediabetes will convert to diabetes within 10 years.  There are an estimated 37,000,000 Americans that have prediabetes of which the majority have no idea that they do.  

Prediabetes is often without clear symptoms.  Some people who have pre-diabetes may experience some of the symptoms of diabetes.  These include frequent urination, fatigue, increased thirst and blurred vision.  People who are overweight (BMI of 25 or above) or have a family history of diabetes are definitely in a higher risk category as well as those of African American and Native American descent.  People with these risk factors or symptoms should definitely ask their doctor to have a blood test called hemoglobin A1c (HbA1C),glycosylated hemoglobin or glycated hemoglobin test.

The HbA1C test shows how well your diabetes is being controlled.  It provides an average of your blood sugar control over a 2-3 month period.  The HbA1C test measures what percentage of your hemoglobin or protein in red blood cells that carries oxygen, is coated with sugar (glycated).  The higher your A1C level, the more uncontrolled your blood sugar is and the higher your risk of diabetes and complications from diabetes.   If your HbA1c is between 5.7%-6.4% you are pre diabetic.  If it is 6.5% or above you are considered diabetic.  Ideally you want yours to be below 5.4%.  Also, you should take into account fasting blood glucose which should be less than 100mg/dl.  Those with pre-diabetes are 100mg/dl-125mg/dl and diabetes 126mg/dl or higher on two separate tests.  

So, you were diagnosed as pre diabetic, now what?  Well, there are several ways in which you can reverse this condition before it progresses.  But, before making any health or lifestyle changes definitely check with your physician first.  A good idea would be to see a doctor that practices functional or integrative medicine.  These physicians can be found all throughout the country.  Integrative or functional medicine is a healing-oriented medicine that takes into account the whole person including all aspects of lifestyle i.e. diet, exercise, family history, stress levels and environment.  It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and complementary.  
You can find local integrative doctors near you here: ACAM.org.  

 Losing about 7% of your body weight or 15 pounds if you weigh 200 pounds, is an easy place to start for those overweight.  However, things are not always so easy.  A recent study from Korea concluded that visceral fat mass, or fat around the organs, acquired using dual-energy X-ray absorptiometry (DXA), has stronger associations with diabetes and pre-diabetes than other measurements.  Therefore, fat around the organs or visceral fat, is a better predictor of pre diabetes than adipose fat or fat under the skin which is the fat we can see when looking at a person (or ourselves in the mirror).  

 Visceral fat is basically excess intra-abdominal tissue accumulation.  It is fat that is actually covering the organs including the liver, pancreas and kidneys.  A sign of excess visceral fat storage is if you have a belly that sicks out and a large waist.  This is most noticeable in overweight and obese people but anyone can have visceral fat and not know it.  Visceral fat cells do more than just make your pants tight, they also cause changes in the way your body functions by producing hormones and inflammatory factors leading to heart disease, inflammation, cancer, dementia, strokes, depression and diabetes.  
Carrying a high amount of visceral fat is known to be associated with insulin resistance, which can lead to glucose intolerance and type 2 diabetes. Researchers have found that visceral secretes a protein called retinol-binding protein 4 (RBP4) which has been shown to increase resistance to insulin.  Storing excess fat around the organs increases production of pro-inflammatory chemicals called cytokines, which leads to inflammation.  It also interferes with hormones that help regulate appetite, weight, mood and brain function.

A relatively good indicator of visceral fat is to take a measurement of your waist. Harvard University notes around 10% of our total fat is likely to be stored as visceral fat, therefore if you are carrying higher amounts of body fat than is recommended, it is therefore more likely that you are also storing more visceral fat than is healthy.  The most certain way to tell if you are carrying excess visceral fat is with an MRI.  MRI's are expensive and do not tell you if you have diabetes so this should be discussed with your physician.  

In order to reverse pre diabetes, you must focus on decreasing body fat and improving your insulin sensitivity.  In part II, I will discuss ways to do this using four categories for lifestyle change;  diet, exercise, vitamins and supplements and stress reduction.  Keep an eye out for this life changing blog post coming soon!