<h2>Practice points</h2><ul><li>A low glycaemic and high fibre diet provides primary prevention of both diabetes and associated cardiovascular disease3</li><li>Daily exercise (both resistance and aerobic) contributes to reducing glycosylated haemoglobin (HbA1c)5</li><li>Chromium (Cr), magnesium (Mg) and zinc (Zn) have a role in insulin and blood glucose metabolism; and people with diabetes may have associated low serum levels of these minerals6,7,8,9</li><li>Chromium (Cr) picolinate can lower blood glucose, insulin, cholesterol and triglyceride levels as well as reduce requirements for hypoglycaemic medication10</li><li>Magnesium may be effective in reducing plasma fasting glucose levels and raising HDL cholesterol levels11</li><li>Fish oil has no clear effect on glycaemic control, but it is helpful for lowering triglycerides and very low-density lipoprotein (VLDL) cholesterol in T2DM4 at a dose of 2-3 g per day3</li><li>Antioxidant support such as vitamin C works to improve endothelium-dependent vasodilation in T2DM9</li></ul><h2>Description</h2><ul><li>An estimated one in eleven adults have diabetes1 and based on current trends, one in every three children born today are likely to develop diabetes2</li><li>There are three main types of diabetes:</li><li><ul><li>Type 1 (T1DM) in 5-10% of cases, caused by a deficiency in insulin production usually following destruction of pancreatic islet cells2</li><li>Type 2 (T2DM) in 90-95% of cases, usually due to insulin resistance and inadequate compensatory insulin secretion from the pancreas2</li><li>Gestational diabetes (GD) in 4% of all pregnancies, as a variant of T2DM.2 Blood glucose usually returns to normal after the baby is born but women have a 30-50% chance of developing diabetes within 20 years.3 The children are at higher risk of developing diabetes2</li></ul></li><li>Prediabetes or metabolic syndrome is a state in which the body is resistant to the action of insulin, and blood glucose levels are raised but not to levels seen with diabetes diagnosis. The risk of developing diabetes is increased, especially when combined with abdominal obesity, body mass index (BMI) over 30 kg/m2, elevated triglycerides, low high-density lipoprotein (HDL), high cholesterol and hypertension3</li><li>People with diabetes have an increased risk of atherosclerosis, hyperlipidaemia, hypertension, myocardial infarction, stroke, aortic aneurysms, and peripheral vascular disease4,2</li></ul><h2>Metformin - nutrient depletion</h2>For diabetic patients taking metformin be aware that the drug causes moderate depletion in both folic acid and vitamin B12.16 Assess deficiency and consider supplementation as appropriate.

<h2>Management principles</h2><ul><li>Establish glycaemic control to minimise diabetes complications</li><li>Support cardiovascular health by normalising cholesterol, triglycerides and blood pressure</li><li>Motivate the patient to make dietary and lifestyle changes</li><li>Reduce systemic inflammation and oxidative stress</li><li>Refer to GP, endocrinologist, dietician, podiatrist, ophthalmologist, naturopath and fitness coach where necessary</li></ul>

Management

<h2>Primary recommendations</h2><h2>CHROMIUM (Cr)</h2>Mechanism of actionPeople with acne seem to have lower serum and skin zinc levels5<ul><li>Cr is an essential nutrient involved in normal carbohydrate and lipid metabolism</li><li>It increases insulin binding to cells, the number of insulin receptors and activates insulin receptor kinase leading to increased insulin sensitivity13</li><li>Low Cr levels are associated with impaired glucose, insulin and lipid metabolism6</li></ul>Dosage informationDosage range: 50-200 mcg/day Cr picolinate.9Higher doses might be more effective as well in reducing triglyceride and total serum cholesterol levels in some people.9Adverse effectsCr is generally well-tolerated. Advise people with renal problems to avoid Cr supplements. There is some concern that excessive Cr might damage the kidneys and potentially worsen renal disease.12Key interactions<a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">Refer to Complementary medicine interactions guide</a><h2>MAGNESIUM (Mg)</h2>Mechanism of actionMg is involved in glucose metabolism and is an insulin sensitiser12A deficiency of Mg aggravates insulin resistance and contributes to increased risk of cardiovascular disease12Dosage information300 mg/day of Mg (which can be combined with Zn 30 mg, vitamin C 250 mg and vitamin E 150 mg).14 Results can be improved by using a highly absorbable form such as citrate or aspartate.Adverse effectsMg can cause diarrhoea and gastric upset. If this is the case, then divided doses are recommended.Key interactions<a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">Refer to Complementary medicine interactions guide</a><h2>ZINC</h2>Mechanism of action<ul><li>Zn is involved in insulin signal transduction, glucose metabolism and cellular antioxidant defence8</li></ul>Dosage information30 mg elemental zinc daily.3Adverse effects<ul><li>Taken on an empty stomach Zn may cause nausea. Always advise to have supplement with a meal.15</li><li>Toxicity signs include nausea, vomiting, diarrhoea, fever and lethargy after ingestion.15</li><li>High doses of Zn (100-150 mg/day) may interfere with copper metabolism and cause hypercupraemia, red blood cell microcytosis and neutropenia.</li></ul>Key interactions<a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">Refer to Complementary medicine interactions guide</a>

Primary

<h2>Diet and lifestyle recommendations</h2><ul><li>Eat low Glycaemic Index foods (low-GI)3 including fresh fruits, vegetables, beans, nuts, seeds and wholegrains. These contain soluble fibre that reduces the GI of foods by slowing gastric emptying.</li><li>Avoid high Glycaemic Index foods (high-GI) such as white bread, white rice, potatoes and refined sugar products. These are associated with higher risk of obesity, T2DM and cardiovascular disease.</li><li>Glycaemic Load (GL) is also important as for instance whole fruit contains sucrose but because it also contains fibre it has a lower glycaemic load. Fruit juice, where the fibre has been removed, is high-GI.</li><li>Increase dietary fibre to 20-50 g of fibre a day as fibre seems to decrease blood glucose levels.12 Flaxseed meal (e.g. 1 tbl = 1.9 g of dietary fibre), psyllium husks, oats, chia seeds and soy beans are all sources of soluble fibre. Increase vegetable proteins such as chickpeas, lentils, kidney beans, soy beans, nuts and seeds as these improve diabetic control and reduce inflammatory markers.5</li><li>Increase vegetable consumption as vegetables are rich in antioxidants. Aim to eat a rainbow of coloured vegetables each day, especially orange and carotenoid-rich vegetables (pumpkin, sweet potato and carrots) as well as green, leafy vegetables.</li><li>Coffee consumption appears to be protective against diabetes and is associated with improved lipid levels, however caffeine seems to increase post-meal hyperglycaemia. Recommend decaffeinated coffee (steam filtered, not chemically processed).5</li><li>Quit smoking as smoking increases the risk of diabetes by 44%.5</li><li>Enjoy daily exercise as both resistance and aerobic training are helpful. Mindfulness-based Tai-Chi may also be helpful.5</li><li>Get sufficient sleep as this improves glycaemic control and improves insulin sensitivity.2</li></ul>

Diet & lifestyle

<h2>References</h2>1. Diabetes Australia. Diabetes Globally. https://www.diabetesaustralia.com.au/diabetes-globally Accessed 3 December 2018.
 2. Jaffe R. Food and Nutrients in Primary Practice. Diabetes. In Kohlstadt, I (Ed). Food and Nutrients in Disease Management. Boca Raton. CRC Press. 2009, 281-299.
 3. Phelps K et al. General Practice The Integrative Approach. Australia, Churchill Livingstone, Elsevier, 294-306.
 4. Hartweg J et al. Omega-3 polyunsaturated fatty acids (PUFA) for type 2 diabetes mellitus. Cochrane Library, 23 January 2008.
 5. Rakel D. Integrative Medicine. Third edition. Philadelphia. Elsevier. Saunders. 2012, 297-311.
 6. Natural Medicines. Chromium. Last reviewed 14th August 2018. https://naturalmedicines.therapeuticresearch.com/databases/food-herbs- supplements/professional. aspx?productid=932 Accessed 30 November 2018.
 7. Natural Medicines. Magnesium. Last reviewed 11/8/2018. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/ professional. aspx?productid=998 Accessed 27 November 2018.
 8. Lin C. Chromium, zinc and magnesium status in type 1 diabetes. Curr Opin Nutr Metab Care. 2015 Nov; 18(6):588-92.
 9. Kotsirilos V. A guide to evidence-based integrative and complementary medicine. 2011. Australia, Churchill Livingstone, Elsevier, 328-360.
 10. Suksomboon N et al. Systematic review and meta-analysis of the efficacy and safety of chromium supplementation in diabetes. J Clin Pharm Ther. 2014 Jun; 39(3):292-306.
 11. Song Y et al. Effects of oral magnesium supplementation on glycaemic control in Type 2 diabetes: a meta-analysis of randomised double-blind controlled trials. Diabet Med.2006 Oct;23(10):1050-6.
 12. Natural Medicines. Natural Medicines in the Clinical Management of Diabetes http://naturaldatabase.therapeuticresearch.com/ce/CECourse. aspx?cs=naturalstandard&amp;s=ND&amp;pm=5&amp;pc=18-110 Accessed 27 November 2018.
 13. Anderson R. Chromium in the prevention and control of diabetes. Diabetes Metab. 2000 Feb;26(1):22-7.
 14. Braun et al. Magnesium. Herbs &amp; Natural Supplements. An evidence-based guide. 4th edition. Vol 2. Australia, Elsevier, 677 - 692.
 15. Braun et al. Zinc. Herbs &amp; Natural Supplements. An evidence-based guide. 4th edition. Vol 2. Australia, Elsevier, 1197 - 1223.
 16. Natural medicines 2019. Nutrient depletion database. https://naturalmedicines.therapeuticresearch.com/ Accessed 3 December 2018.

Diabetes

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