Lecture 1, May 26th - Dr

1INTEGRATED CLINICAL STUDIES – MAY 26TH, 2008 DR. MONA MORSTEIN – REVERSING DIABETES WITH NATUROPATHIC MEDICINE LECTURE 1 Dr. Mona Morstein: leading expert in naturopathic care of diabetes Will focus on what we can do in Ontario and Canada. Wide scope of practice in Arizona (where she practices) PAGE 1: Goal of treatment: to reduce blood sugar. She is moderator of Naturopathic Chat: 1250 NDs and students. groups.yahoo.com/groups/naturopathicchat Send ALL info: read instructions carefully. We can’t e-mail as students, but great to read. There is no ‘cure’ for diabetes. Can only reverse, control. Can get them to the point where they could go into other doc’s office and not be diagnosed, but if they leave the protocol, they will develop symptoms again. Case is one of Dr. M’s first patients. Hard to create a seizure, but he was overmedicated. Actos: poorly thought of now. Still completely out of control with DM, although he is on meds. Standard care: Diet, exercise, metformin (tells LV not to make glucose), Sulfonylurea (tells pancreas to make more insulin). Thiazolidinedione: increases insulin sensitivity. Poor care given by all standards. Not prescribed diet/exercise. Not even sent to dietician, or talked about weight loss. No concept that he could do other than take drugs. PAGE 2: Got off of oral hypoglycemics and hypertension meds. Has been off them for 5 years, and is normotensive. Lots we can do without meds! Basics of diabetes: Affects everyone: ‘non-discriminating’ CDC: if things don’t change, 1/3 people will develop DM (in US) (DM in this lecture is DM II, but even type I diabetes is increasing too) Pancreas: Simalyn: synthetic amylin. If you need insulin because your beta cells have been destroyed, need amylin too. Slows gastric emptying, slows insulin release. Tells brain we are satiated (insulin does this too). Interaction of hormones keeps blood sugar balanced. PAGE 3: Gestational diabetes: developed during pregnancy MODY: Mature onset of diabetes of youth: genetic defect in insulin secretion, defect in insulin receptor on cell wall. Chronic pancreatitis: m/c in alcoholics – damaged through chronic inflammation Treatment for kidney stones (shockwaves) can damage pancreas as well. Good studies showing that early intro of dairy/wheat in susceptible individuals who then get a virus are more susceptible to DM. If you introduce food later (after 6 months), you are giving them larger portions because they are bigger kids, lots of antigen in first exposure to dairy, wheat. Best to give small amounts to intro at 5-6 months of age. Also LADA: slow auto-immune process. Commonly diagnosed as type 2 diabetics, treated this way. Most MDs haven’t heard of this, NDs too. Increased incidence among adult patients. To diagnose LADA: there is GAD antibody test. Won’t be positive in type 2. All of Dr. M’s LADA patients are women. 40s, lean body frame. ICS MAY 26TH, 2008 – PAGE 1

Type 2: always associated with insulin resistance. Link established (WHO?) with cell levels of heavy metals. Not totally clear: are they less able to excrete it? Does exposure lead to development of DM? Watch the reference range that your lab considers “normal”: Dr. M’s lab says that upper limit of fasting insulin is 25. NDs like to see level below 12. Lab used their HEALTHY EMPLOYEES to set their reference ranges!! Not the medical literature! Check their values. IFG: impaired fasting glucose PAGE 4: If you can catch condition when it is insulin resistance, can do a lot to prevent development to diabetes. Dr. M tests with FOOD, not ‘glucola’. Uses meal from McDonald’s: Fat, CHO. 1.5 hours post-prandial used. May be coming down at 2 hours. Patient examples: #1: (FG and FI are US values). With excessive insulin (114), still couldn’t get their glucose levels into normal range (8 mmol/L) #2: Divide US numbers by 18 to get Canadian values. This patient has severe insulin resistance. Producing over 200 units of insulin after 1 meal. Normally, we produce 40 units for an entire day worth of food. SHBG: sex-hormone binding globulin. If it is low, it is an indication of insulin resistance. In pregnancy, can predict risk of developing diabetes in pregnancy. These other markers are associated with later development of DM. Thrifty Gene: Esp. seen in Native Americans, other cultures where feast and famine is traditional pattern of food intake. Now gives these populations the tendancy to gain weight when there is food around all the time. In 1900s, it took 3000 calories a day to be a housewife. We are doing much less work now. We are not getting exercise by doing our daily activities. Diets have changed: it was okay to get saturated fats, as long as they were balanced with essential fatty acids. Wild game has more fatty acids, our beef has less EFA since they are now being fed corn. Obesity due to lack of exercising. Nutrient deficiency due to poor diet. Not eating enough fruit, vegetables. Japanese have had 70% carbohydrate diet, but it was fine until North American food imported with more saturated fat. Carbs not the problem for them. NA Caucasians: nutritionally poor carbs have been the problem. PAGE 5: Thrush or other fungal infections (toenail) may be first presentation Skin tags: at least insulin resistance. Look at diet, do post-prandial food test. There are other reasons for skin tags, but if they have them with abdominal obesity… look into it further. A1C: good measure of their history of blood control over the past 3 months. Fatty liver? Can progress to cell death. Check to see if there is liver damage so that we can support liver. Other markers for systems affected by DM. When insulin is injected, we develop insulin antibodies. Therefore, measuring insulin antibodies is not the most accurate measure. Can ONLY use C-peptide to assess patients taking insulin. **C-peptide is much better measure to determine if a person needs to be on insulin. 1,5AG: Shown in recent studies to be more accurate than A1C in assessing post-prandial glucose management. PAGE 6: If you are Type 1, test for other autoimmune (Celiac’s, Hashimotos) at least once a year. But if their genetic testing shows that they don’t have celiac, don’t need to continue testing.

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Dr. M.: makes patient have dilated eye exam within 3 months. Can get proliferative retinopathy: overgrowth of BV in retinal wall. If they have this, and you lower their blood sugar quickly over short term, will make it WORSE. Increases IGF-1 (growth hormone). Decreased insulin = more growth hormone, more angiogenesis, worsening of proliferative retinopathy. Dr. M has supplement regimen that she gives to PR patients to protect their eyes, and lowers their blood sugar more slowly. Most damage to eyes, kidneys, nerves, endothelial lining (BV): these cells can’t keep glucose out. DM takes 18 years off your life, last 12 years are in sickness PAGE 7: 5% is normal. Target is set at 6-6.5% because using conventional meds, can’t get it lower without hypoglycaemic events. PAGE 8: We are the whole health care team. Guidelines are from CDA: say that we don’t need supplements, even though studies show that DM patients are deficient. Have high carb, low fat diet. CVD: High insulin leads to plaques in vessels. Haven’t seen changes in guidelines Cadbury Schweppes + ADA: says that it isn’t true that high sugar causes diabetes WHO disagrees: threatened by sugar industry. People eating diets with same number of calories: people eating more sugar gain more weight. PAGE 9: Dr. Liu: everyone agrees except for ADA ADA: guidelines for diet are not health promoting (eat less pasta so you can have chocolate for desert) PAGE 10: TZDs are frowned upon in US. Flowchart: on e-college. CDA guidelines: insulin or drugs. Only options. PAGE 11: Giving insulin can protect pancreas when A1C high. PAGE 12: 50% risk of gaining weight because of injection of insulin PAGE 13: Accord study: disregard: patients had history of CVD Were eating a high-carb diet (60-65%) Used TZDs Advance study: Did NOT use TZDs: independent studies show that it increases CVD and CHF. Conventional outcomes: OHA: Oral hypoglycaemic agents On 2 meds, and ½ are still uncontrolled. Almost all of them uncontrolled after 4 years. PAGE 14: ADA / CDA goals: lower A1C, Cholesterol and BP. Using conventional guidelines, 60% don’t get A1C under 7.0. ONLY 7% ACHIEVE ALL 3 GOALS! To reduce BP need 2-4 meds. PAGE 15: Less control now that more drugs being used! (NHANES report) ICS MAY 26TH, 2008 – PAGE 3

ND treatment Don’t get hypoglycemia when A1C is lowered to 5. PAGE 16: Start with diet diary for a week. Explain that this is not a tool of judgement! It is a tool of education. Glucograph: where they record their blood sugars. Work with patient: Docere! Address ideas of success and failure, anxiety and self-blame, judgement. Don’t want falsification. Unbiased grading of glucometers www.childrenwithdiabetes.com/d_0i_000.htm PAGE 17: What turns into blood sugar? Carbs, protein. Not fat. Glycerol backbone can become glucose if you aren’t eating other carbs. Don’t need to count in glucose levels. Shouldn’t use low carb diet for more than a year. High protein diets stimulate more weight loss, studies showing success with low carb diets PAGE 18: Dr. M. recommends Dr. Bernstein’s Diabetes solution. He has had DM for 60 years. The best book on diabetes, even if she doesn’t agree with everything he says nutritionally. Not the same Dr. Bernstein of weight-loss centres. His blood sugar went down from diet. Dr. B: Carbs = 30g / day The Dawn phenomenon: blood sugars are highest when you wake up. He prescribes less CHO at this time. Highest time of cortisol output: LV is breaking down glycogen GH secreted at 2am also increases blood sugar. Middle of the night: abdominal fat dumped into liver. Liver doesn’t monitor blood sugar, just monitors insulin. Low blood insulin, dumps glucose. When insulin resistant, can’t sense it, so it dumps glucose (result of abdominal fat?) This phenomenon settles down by lunch: increase carbs. Dr. M is anti-grazing: she is not concerned with hypoglycemia with her therapies. PAGE 19: Study: overweight guys eating low carb diet, ate eggs, saw decrease in inflammatory markers. This was regular eggs, not omega-3 ones. Eggs have lecithin that lowers cholesterol Dr. M not too concerned with how they cook them: okay to break yolks, not just sunny-side up. Egg white is protein, but nutrients, anti-oxidants are in the yolk. TC is least accurate index of CV health More carbs in a bowl of oatmeal than what she wants them to eat all day. “Grass finished” cattle: have grass from start to finish. Otherwise, they have been fed corn for their last 3 months. Beans, peas and lentils: most diabetics can’t eat these until they are well-controlled. Re: fish: tells patients not to eat big fish. SMASH fish better: sardines, mackerel, anchovies, wild salmon, herring. Oily and small fish. Avoid farmed salmon Cottage cheese is very high in carbs. Too much lactose. Unsweetened almond or soy milk. In hard cheeses: more fat and protein, less fat. Yogurt: pretty high in carbs. Can only eat plain yogurt. Veggies: Chard helps lower blood sugar? Can’t eat high carb veggies. Bernstein: no fruits, Dr. M. says only berries: low carb and with anti-oxidants. Not as breakfast, but for lunch. One study showed that rye raised BS less than wheat. This diet takes out crunchy things! Crackers help satisfy this. Grain fibre helps keep bowel movements regular.

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Sugars: Want to change their relationship to sugar altogether. Better to not just substitute one sweetener for another. Can use it ‘here and there’ but don’t want them to use it as replacement. People still gain weight with them. Sugared rats: couldn’t regulate their food intake!!! Chemical interference with ability to recognize food entering body: people gain more weight! She doesn’t care about sugar alcohol in gum, or a little diet pop. This compromise is fine. But not every day. Stevia and sugar alcohols seem to be better than other artificial sweeteners. Another good book: Complete book of food counts Good for patients to have Mealmixer.com: for food allergies Vegans/Vegetarians: often eat a lot of soy and carbs. May be very hard. Raw food diets: possible. Have to eat wide variety of beans, nuts, or switch diet… PAGE 20: Want to see patients EVERY WEEK to check levels. You are troubleshooting with them: helping with meds, signed up at gym? Helping get them into new lifestyle: need weekly support. More contact means better success. Phone follow-ups can help, but better to see them in person. Nutrients and diabetes: we may consider supplementing these. Diabetes Care: a more holistic journal for diabetics. Gastroparesis: vagus nerve is impacted: main cause is DM. Causes great quality of life problems. Very aggressive treatment of neuropathy. PAGE 21: Good quality multi: take max dose Zinc: makes, secretes, utilization of insulin Potassium: source that is not potatoes, bananas = AVOCADO: lots of potassium, good oils. Biotin: Dr. M didn’t see results with patients, although studies have shown it. Feeds into decarboxylase enzyme system. Dr. M gives ALA without supplementing biotin. Get it in diet and in multi Niacinamide: acute type 1 onset. Chromium: don’t overdo it (5000): Chromium polynicotinate, picolinate. PAGE 22: AOR did a lot of research on Benfotiamine. One of first company to starat producing it as supplement. Stops glucose from sticking to protein One problem with it: have to take it 4 times a day. Oils: Very good for diabetics: reducing inflammation… Start with fish oils. Zinc, magnesium, B vitamins needed to convert flax to EPA. Not enough conversion. PAGE 23: CLA: some human studies showing that there was weight loss with this supplement (see Dr. Phil’s notes: risks with CLA!) ALA: to all patients R form is only one active in body. NAC: cheap and simple to use. Doesn’t matter if it is with/away from food. Taurine: any eye pathology Alanine: to DMI that lose ability to make glucagon. Can’t tell LV to make blood sugar. Alanine led to big jump in glucagon secretion. PAGE 24: Apple cider vinegar with meals. Gymnema: helps to stop craving carbs. “Sugar destroyer”: Receptors don’t acknowledge sweet taste. Helps with diet compliance. Try it as tincture on tongue: will impair taste. ICS MAY 26TH, 2008 – PAGE 5

Alcohol stops gluconeogenesis: she says patients can definitely have wine with dinner. Dry wine, shots of alcohol (not sweetened). Alcohol tincture is fine. PAGE 25: Bitter melon is bitter. Better in extract form. Goat’s rue (no one does this) Bonito: Japanese fish. Can put flakes on salad. Diabetics: often put on ACE inhibitor to protect KI: bonito could be used instead. PAGE 27: Flavinox: very good herbal product from Allergy Research Group Patient 2: C-peptide is normal: this means that patient’s body is making insulin. Patient 4: www.rebuildermedical.com this is the one that Dr. M uses. $500 cost to patient. “Diabetic product”: Zinc, vanadil sulphate, chromium, alanine, glutamine. Gymnema.

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