Diagnosis and Possible Reversal of Pre-Diabetes: - Natural ...

Addressing Accurate Diagnosis And The
Significance of Patient Compliance
Commentary by Tom Sult, MD
We are surrounded by pre-diabetes (PD), insulin resistance (IR) or
syndrome X—all names for the same thing. While we all may know
what to look for, it can still sometimes be difficult to see. Below are
some of the hallmark symptoms of PD.
• Central obesity. People with elevated insulin will store every extra
calorie they eat as central fat. On days they are trying to be “good”
by skipping meals or starving themselves (a bad idea) they will
burn muscle and not fat. The result is an overweight trunk with
thin legs and arms.
• Constant hunger. When a person with PD eats a high glycemic
index (GI) food, the blood glucose (BG) rises, followed by an
exaggerated insulin release, resulting in reactive hypoglycemia,
which in turn results in hunger. If he “fixes” hunger with another
high GI food, the cycle will start all over again.
• Blurred vision. BG is a major component of the osmotic pressure
in the blood. With swings in BG come swings in osmotic pressure,
causing a distortion of the lens and cornea of the eye, which
results in blurred vision.
• Fatigue. In PD, insulin receptors are insensitive to insulin. This
results in low muscle concentrations of available carbohydrate
and inefficient energy metabolism.
• Depression. The metabolic derangement resulting from PD has
many psychological effects. Depression may arise from the same
type of energy metabolism inefficiencies seen in fatigue.
• Brain fog. The brain is the most prolific consumer of glucose of
any organ. With problems in glucose metabolism and transport,
brain fog seems to arise.
Many clinical tests exist to diagnose PD, but some are more accurate
than others.
• Fasting blood glucose (FBG) . FBG is a late indicator of pre-diabetes.
The metabolic disorders known as PD may exist for 3 to 5 years
prior to diagnosis if done by FBG. A fasting blood sugar level
between 100 and 125 mg/dL is considered pre-diabetes. Optimal
blood sugars are significantly lower—some say as low as 70.
• Postprandial blood glucose (PBG) and glucose/insulin tolerance
testing (GITT). PBG is a better indicator of pre-diabetes because
it is more like a stress test of the glucose metabolism system. I
generally do a GITT with a fasting insulin and FBG, then a 75
gram glucola followed by a 2-hour postprandial insulin level
and BG. I look for fasting insulin less than 10 and FBG less than
95 (some say 85). The postprandial limits are insulin less than 3
times the fasting level and not greater than 30, the BG not greater
than 140 (although I think that is too high).
• Lipids. Lipid levels are another early indicator of PD. We know
that those with PD have elevated triglyceride and low HDL levels.
An ideal triglyceride to HDL ratio (THR) is less than 2. A THR
greater than 4 is worrisome and probably represents PD. A THR
of 6 or more is a significant risk factor for heart disease.
Maintaining a high index of suspicion for pre-diabetes is key to the
diagnosis. Following proper diagnosis, one of the key challenges with
treatment is patient compliance.
The treatment of PD is primarily a lifestyle issue. While there
are pharmacological treatments available, studies have shown them
inferior to lifestyle management. The primary problem with lifestyle
management is compliance. In my early practice I had a “my way or the
highway” type of approach to lifestyle. With age comes some humility,
accompanied by greater empathy for my patents.
Whether the treatment plan features a low glycemic index diet,
increased activity, or various nutrients such as fish oil or lipoic acid, the
nmj oCT09 CR
advice is sound. What fascinates me is how we often do not do what we
know is good for us. I am trained in functional medicine. This means I
assess the biochemical individuality of the patient, consider his current
lifestyle, and then determine whether the two are ideally compatible.
Once this is accomplished I set up a program with follow-up visits. It
is not uncommon for the subsequent visits to reveal a lack of followthrough
with the program. In days gone by I would have been quite
irritated by this. I now see it as the therapeutic moment.
The therapeutic moment is when you have an opportunity to
understand and intervene in noncompliance. Understanding why a
patient was not able to comply with a plan is far more important than
the noncompliance itself. Sometimes it is time, sometimes money, and
sometimes preference. Often it is a deeper issue, like food as comfort
and companion. Creating a therapeutic alliance with the patient and
exploring these issues is often magical, not just for the patient but for
the provider as well.
Tom Sult, MD, is a residency trained and board
certified family doctor. He is boarded in Holistic
medicine and on the faculty of the Institute for Functional
Medicine (IFM). Dr Sult’s practice is in Central
Minnesota were he has a consultative, tertiary care
clinic for Functional Medicine. He primarily sees
autism, Lyme disease, autoimmune disorders, environmental
illness and other chronic complex disease.
Dr Sult teaches GI and Toxicology for IFM. His primary interest is
addressing the underlying causes of illness and addressing the interplay
of genetic predisposition with lifestyle and environmental change.
©2009 Natural Medicine Journal 1(2), October 2009 | Page 4