Eating habits and diabetes: How we eat may be more important than what we eat
Lessons from a clinical trial of a naturopathic nutrition study
(supported by Diabetes Action!)
Studies have shown that people who use complementary and alternative medicine (CAM) also have increased control over health.
Self-management of diabetes isn’t easy, especially for people attempting to make lifestyle changes as part of a “big picture” effort to control their diabetes. Even with conventional treatment options, only 47% of people with diabetes achieve the recommended target for blood sugar levels (hemoglobin A1c <7%)1. It is well established that dietary control is the cornerstone of diabetes treatment, yet it is the most complex aspect of diabetes management and can be challenging for people to understand and follow despite following a healthy diet which is one critical dimension of diabetes care that can prevent future complications. Studies have shown that people who use complementary and alternative medicine (CAM) also have increased control over health 2 and an overall orientation toward a healthy lifestyle3. It is not known if these aspects of self-care emerge as a result of CAM usage or reflect a predisposition in some people to use CAM as part of an overall healthy lifestyle strategy. However, it has been suggested that for some people with chronic conditions like diabetes CAM is a “critical component of self-care management” for diabetes and chronic disease4.
Naturopathic medicine is a system of medicine frequently classified as “complementary and alternative medicine (CAM)” or integrative medicine. Recent surveys tell us that 73% of people with diabetes use some form of CAM, which is higher than estimates for other health conditions5, 6. In some states, naturopathic physicians (NDs) are primary care providers with a scope of practice* that includes nutritional supplementation, herbal medicine, nutrition, exercise, mind-body modalities, minor surgery and most prescription drugs, including all classes of hypoglycemic medications. Few studies have examined how naturopathic approaches impact health in people with diabetes7, 8. Until recently, no study has focused on the nutritional apsects of naturopathic recommendations.
(*To learn more about licensure and scope of practice of naturopathic providers in your state go to: www.naturopathic.org)
In our study, supported by Diabetes Action, we sought out to determine if several naturopathic approaches to diabetes nutrition improved blood sugar (See Table 1). People worked with a naturopathic physician for 12 weeks in a primary care clinic. Their visits included both one-on-one and group visits. We measured if the clinical approach increased patients’ understanding of nutrition, eating behaviors, and their overall confidence in managing the dietary aspects of their diabetes. Several questionnaires were administered to each participant, including the Seven Eating Styles instrument, measures of self-efficacy and diabetes management, food intake (3-day diet records), and laboratory measurements of blood sugar and heart disease risk (i.e., HbA1c and lipids). Details of the protocol and results have been published 16 .
Table 1: Core Components of Naturopathic Nutrition
20-40% CHO, 25-45% protein, 15-35% fat
This is a lower carbohydrate diet that is still diverse, well-balanced, and practically achievable
Low Glycemic Index
Select low GI carbohydrates by paying attention to fiber and whole foods
Low GI foods have a reduced post-prandial glycemic spike and subsequently keep insulin lower
Select foods that provide maximal micro-nutrient intake per calorie
Because diabetic diets are often low calorie, it is important to maximize nutrition, especially dietary antioxidant intake
Based on individual needs, select foods that have function beyond calorie or nutrients
For example, including oats in the diet will lower cholesterol and allow emphasis on food rather than medication
Understand Quality of Foods
Learn to select healthy fats. Make conscious choices about organic, wild, local foods
Some fats, like omega 3 fatty acids, have beneficial effects on glycemic control, whereas trans fatty acids and saturated fat increase CV risk
Understand personal eating behavior
Understand emotional and situational eating habits to avoid overeating
Several eating patterns have been linked to overeating; empowerment over negative habits creates change and lead to self-efficacy across diabetes self-care skills.
Cultivate healthful attitudes toward food
Understand food nourishes more than the physical body
For example, children who eat meals with family at the table have lower rates of obesity.
...participants made notable changes in behavior and eating more healthfully
After the 12-week study, blood sugar control (measured by HbA1c) improved significantly from 8.2±0.23% at baseline to 7.7±0.28% at week 12 (p=0.02). Although systolic and diastolic blood pressures decreased (-4±-12.5mm Hg and -4.5±-9.1 mm Hg, respectively), and BMI decreased slightly (33.6±3.8 to 32.8±3.3 kg/m2), these changes were not statistically significant. Similarly, total cholesterol remained unchanged (174.6±14.6 mg/dl at week 0 and 175.1±10.1 mg/dl at week 12).
Perhaps most importantly, participants made notable changes in behavior and eating more healthfully. Changes measured by the Problem Areas in Diabetes composite score improved from a mean 38% out to 19% (p=0.05; lower scores signifying fewer problems). Adherence to self-management recommendations improved as well. Daily blood sugar monitoring increased from a mean 47% of the time to 86% (p=0.05). During this intensive dietary program, participants were asked to monitor their blood sugar multiple times per day in order to learn to identify relationships between food choices and blood sugar; participants checked blood sugars multiple times as directed 5.3 days per week (increased from 2.3 days per week at the beginning of the study) (p=0.04). “[Following] the dietary guidelines provided by the doctor” increased from 1.4 to 3.0 (p=0.02) on the 5 point scale!
The acceptability of the nutritional approach was good. Agreement with the statement “I would encourage others to follow this diet” had a mean response of 3.9 (with 4 indicating “strongly agree”). Participation was rated easy on average; 3.6 on a 0 to 4-point scale ranging from very difficult to very easy. There were no adverse events or side effects during the study.
Eating behavior as measured with the Seven Eating Styles instrument (see Complementary Corner next month) revealed some key findings about how people with diabetes may benefit by shifting their approach to the emotional and social elements of nutrition and eating. The Total Integrated Eating Score, which reflects a balanced, holistic view of eating behavior, improved significantly during the study (p=0.03). Newly discovered by this research, a high score in the Emotional Eating domain (indicating more of an issue) correlated most strongly with higher baseline A1c values (p = 0.04). Improvements in a summary score of the Seven Eating Style, the Integrated Eating score, also correlated with improvements in Hba1c (p=0.046). HbA1c improvement was not correlated with any other dietary factors, including the percentage of calories coming from carbohydrates or total caloric intake. Among the individual Seven Eating Style elements, participants made significant changes in Emotional Eating (p=0.004), Sensory/Spiritual Nourishment (p=0.005), Attention to Atmosphere (p0.002), and in their Total Integrated Eating Score (p=0.006). Changes did not occur in the domains of Food Fretting, Task Snacking, or Social Eating. The Fast Food/Fresh Food element, which captures the overall quality of dietary intake, trended toward improvement (p=0.12).
Our study demonstrated that HbA1c improved by an average of 0.5% following a naturopathic nutrition approach. The impact of educational and behavioral programs for type 2 diabetes, on average, result in a 0.43% reduction in HbA1c, which is consistent with our results. 17 Our previous research of whole-system naturopathic treatment for type 2 diabetes demonstrated a 0.65% reduction in HbA1c (p = 0.05), however this reduction occurred over a longer period of care.7 This difference also suggests a possible contribution by other aspects of naturopathic care, in addition to nutrition, including dietary supplementation, stress reduction counseling, or other elements of whole-system naturopathy that were not evaluated by our study.
Perhaps counseling approaches that include more emotional and social elements of eating and nutrition may be more effective than focusing on calories and carbs? Stay tuned…
Our results suggest that eating behaviors correlate with increased glycemic control. Improvements in emotional eating, bringing attention to the spiritual dimensions of food and the dining atmosphere, and focusing on fresh whole foods versus fast convenience foods correlated with an overall decreased HbA1c, rather than macronutrient content of the diet alone. Perhaps counseling approaches that include more emotional and social elements of eating and nutrition may be more effective than focusing on calories and carbs? Stay tuned…
In health, Ryan Bradley, ND, MPH and Erica Oberg, ND, MPH
Ryan Bradley, ND, MPH is a naturopathic doctor, clinical researcher and epidemiologist in San Diego, CA. In addition to his research, he is a practicing clinician specializing in natural and integrative approaches to treating type 2 diabetes, chronic kidney disease and heart disease at Pacific Pearl La Jolla.
- Saaddine JB, Cadwell B, Gregg EW, et al. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002. Ann Intern Med. Apr 4 2006;144(7):465-474.
- Sasagawa M, Martzen MR, Kelleher WJ, Wenner CA. Positive correlation between the use of complementary and alternative medicine and internal health locus of control. Explore (NY). Jan-Feb 2008;4(1):38-41.
- Nahin RL, Dahlhamer JM, Taylor BL, et al. Health behaviors and risk factors in those who use complementary and alternative medicine. BMC Public Health. 2007;7:217.
- Thorne S, Paterson B, Russell C, Schultz A. Complementary/alternative medicine in chronic illness as informed self-care decision making. Int J Nurs Stud. Sep 2002;39(7):671-683.
- Garrow D, Egede L. National patterns and correlates of complementary and alternative medicine use in adults with diabetes. J Altern Complement Med. Nov 2006;12(9):895-902.
- Yeh GY, Eisenberg DM, Davis RB, Phillips RS. Use of complementary and alternative medicine among persons with diabetes mellitus: results of a national survey. Am J Public Health. Oct 2002;92(10):1648-1652.
- Bradley R, Kozura E, Buckle H, Kaltunas J, Tais S, Standish LJ. Description of clinical risk factor changes during naturopathic care for type 2 diabetes. J Altern Complement Med. Jun 2009;15(6):633-638.
- Bradley R, Oberg EB. Naturopathic medicine and type 2 diabetes: a retrospective analysis from an academic clinic. Altern Med Rev. Mar 2006;11(1):30-39.
- Serra-Majem L, Roman B, Estruch R. Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Rev. Feb 2006;64(2 Pt 2):S27-47.
- Nuttall FQ, Gannon MC. The metabolic response to a high-protein, low-carbohydrate diet in men with type 2 diabetes mellitus. Metabolism. Feb 2006;55(2):243-251.
- Hartweg J, Farmer AJ, Perera R, Holman RR, Neil HA. Meta-analysis of the effects of n-3 polyunsaturated fatty acids on lipoproteins and other emerging lipid cardiovascular risk markers in patients with type 2 diabetes. Diabetologia. Aug 2007;50(8):1593-1602.
- Riccardi G, Capaldo B, Vaccaro O. Functional foods in the management of obesity and type 2 diabetes. Curr Opin Clin Nutr Metab Care. Nov 2005;8(6):630-635.
- Bantle JP, Wylie-Rosett J, Albright AL, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. Jan 2008;31 Suppl 1:S61-78.
- Manco M, Mingrone G. Effects of weight loss and calorie restriction on carbohydrate metabolism. Curr Opin Clin Nutr Metab Care. Jul 2005;8(4):431-439.
- Weiss EP, Holloszy JO. Improvements in body composition, glucose tolerance, and insulin action induced by increasing energy expenditure or decreasing energy intake. J Nutr. Apr 2007;137(4):1087-1090.
- Oberg EB, Bradley RB, Allen J, McCrory MA. Evaluation of a naturopathic nutrition program for type 2 diabetes. Complement Ther Clin Pract. March 2011;doi:10.1016/j.ctcp.2011.02.00.
- Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Diabetes Educ. May-Jun 2003;29(3):488-501.
- King DK, Glasgow RE, Toobert DJ, et al. Self-efficacy, problem solving, and social-environmental support are associated with diabetes self-management behaviors. Diabetes Care. Apr;33(4):751-753.
- Yannakoulia M. Eating behavior among type 2 diabetic patients: a poorly recognized aspect in a poorly controlled disease. Rev Diabet Stud. Spring 2006;3(1):11-16.