Diabetes: Adding lifestyle changes to medication can deliver a knockout punch

Monique Tello, MD, MPH
Monique Tello, MD, MPH, Contributing Editor

Plenty of research supports the common-sense notion that a healthy lifestyle can prevent or treat many diseases. A diet high in fruits, veggies, whole grains, and plant protein and low in processed carbs, added sugars, saturated fats; regular physical activity; and emotional well-being are the potent treatments that can prevent the need for or even replace many prescription medications.

Yet lifestyle interventions are still not “mainstreamed” into primary care.

The power of lifestyle changes for diabetes

Here is yet another study supporting intensive lifestyle intervention, this time for diabetes. The study authors seem to downplay their findings, which, frankly, baffled me. I’m happy to enthusiastically report that this study strongly confirms what I’ve often observed over the past 15 years in medicine: the way we live and what we put in our mouths can be way more powerful than many of the pills we’re prescribed.

Basically, the study authors recruited 98 people with type 2 (adult-onset) diabetes who were all pretty similar. They had had diabetes for less than 10 years and their blood sugars were not completely out of control (HbA1c* less than 9%); they were not on insulin; they all had a body mass index between 25 and 40 (that is, they were overweight).

They divided people into two groups for a year. Both groups stayed on their regular medications. The standard care group (34 people) received basic counseling and education in type 2 diabetes, including lifestyle advice by a nurse at the start of the study and again every three months.

The other group (64 people) also received a pretty intensive lifestyle intervention:

  • five to six exercise sessions per week, consisting of 30 to 60 minutes of supervised aerobic activity, along with two to three sessions of weight training
  • an individualized nutrition plan with dietary counseling, including calorie restriction for the first four months
  • a smart watch/step counter and encouragement to be physically active in their leisure time (with a goal of at least 10,000 steps per day).

The lifestyle group did have slightly better overall blood sugar control after a year, but the real kicker was this: 73% of the lifestyle participants were able to decrease the dosage of their diabetes medications, compared to only 26% of the standard care group. And, over half of the lifestyle participants could safely discontinue their medications! As a matter of fact, 44% of the standard care group had to have their medications increased during the study, compared to only 11% in the lifestyle group.

*HbA1C is the abbreviation for hemoglobin A1c, the product formed by the attachment of glucose (blood sugar) to hemoglobin (a protein in red blood cells). A test for HbA1c is a useful measure of blood sugar control over time. An HbA1C level between 4% and 5.6% means that blood sugar has been in a good range over the past few months.

Other improvements in measure of health

In addition, the lifestyle group enjoyed significant improvements in pretty much all their measurements: weight (13.2 lbs. lost, compared to 4.4 lbs.), BMI (31 to 29, compared to 32.5 to 32), and abdominal fat (2 lbs. lost, as compared to 0.2 lbs.), with a gain in lean body mass (i.e. muscle). Over a third of the lifestyle group lost over 10% of their body weight, compared with 3% of the standard care group. And the lifestyle folks also experienced a significant improvement in their physical fitness, as measured by a fancy machine measuring oxygen uptake by the body during intense exercise.

The study authors seemed to emphasize that lifestyle improved blood sugar only modestly better than standard care at 12 months. What was incredibly striking, though, was the trend in the blood sugars over the entire year. At six months, the lifestyle group’s HbA1c levels decreased very significantly, from 6.6% to 6.2%, while the standard care group’s HbA1c increased from 6.7% to 6.9%. At 12 months, both groups drifted closer to where they had started, with the lifestyle group still a bit better than the standard care group at 6.3% as compared to 6.6%.

Why is this?

There are two possible reasons. One was that the lifestyle group had fully supervised exercise and dietary counseling sessions (including calorie restriction) for only the first four months, and after that, supervision was progressively decreased, and as a result people were less likely to stick with the program. In fact, the article shows that participation in the exercise and dietary counseling sessions dropped off over the year.

Another factor is that the participants’ diabetes medication was being adjusted throughout the study for health and safety reasons. If the HbA1c dropped below 6.5%, then their medication was decreased, and if it stayed that low or went lower, the medication was discontinued. Likewise, if the HbA1c went above 7.5%, then the medication was increased. The lifestyle group did have more episodes of low blood sugar than the standard care side, and while that can be dangerous, it also signals that the lifestyle participants needed less medication as time went on.

So, it’s reasonable to speculate that if the exercise and dietary session supervision was continuous throughout the study, and if the medications were not continually adjusted, then the results would have shown even greater improvements for the people in the lifestyle group.

And that jibes with previous studies looking at lifestyle intervention for the prevention and treatment of heart disease. There’s so much accumulated evidence supporting lifestyle intervention as a very effective treatment, that major insurance carriers will now cover such programs.

I do hope that patients will realize that lifestyle changes are as good as, and sometimes better than, prescription medications. Primary care doctors need to help them do just that.

Resources

Lifestyle medicine potential for reversing a world of chronic disease epidemics: from cell to community. International Journal of Clinical Practice, October 2014.

Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association. Circulation, August 2012.

Head-to-head comparison of intensive lifestyle intervention (U-TURN) versus conventional multifactorial care in patients with type 2 diabetes: protocol and rationale for an assessor-blinded, parallel group and randomised trial. BMJ, December 2015.

Effect of an Intensive Lifestyle Intervention on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial. JAMA, August 2017.

Effects of Lifestyle Modification Programs on Cardiac Risk Factors. PLoS One, December 2014.

Comments:

  1. Ray

    Great article Monique! I remember reading about this when it was released and thought exactly the same. Why was there not being more made of the reduction in medication that resulted in just a small drop in HbA1c? It’s a pretty important contributing factor!
    In our clinics we base exercise around walking each day and focus on just fresh unprocessed foods and achieve great results even in those with long term insulin use.

  2. Alexia Clark

    Agree with this zero sugar, zero grains approach entirely.

    there is other ways to keep sugar level low. my father is eating leaves of mamejo plant(found in India). it is recommended by his friend and surprisingly it helps him to keep his sugar level low. infect he eats sweet once in a week but no spikes in sugar level. normally his sugar level is from 100 to 140.

  3. hassan emad

    Agree with this zero sugar, zero grains approach entirely. The much touted carb loading diet has not proven as beneficial as once believed partially because scientific research about lectin and leptin had not been done yet

  4. Thomas Turk

    Disinfo.. One month of zero grains and zero sugar reverses diabetes2. One reported reversal in 2 weeks. All grains are high in lectin plant phenols, chemicals that desensitize cell membranes to insulin, causing insulin over production. Grains are also high in leptin plant hormones that interrupt signaling between the liver and pancreas, causing insulin disruptions. These 2 cause obesity and diabetes2.
     
    Wheat and most other grains raise blood sugar.  A slice of organic whole wheat bread raises blood sugar more than a candy bar.

    • ai

      Agree with this zero sugar, zero grains approach entirely. The much touted carb loading diet has not proven as beneficial as once believed partially because scientific research about lectin and leptin had not been done yet. A high carb diet from whole grains is more beneficial than one of simple carbs for a healthy, fully active person. For a sedentary person tending towards metabolic syndrome, it is not beneficial and seems to have proven itself to be detrimental.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      I agree (and mountains of research does too) that refined carbohydrates cause and worsen diabetes. Added sugars and processed flours can be downright dangerous for many people. I imagine that an entirely carbohydrate-free diet (meaning eliminating whole grains as well as refined grains) could be even more successful in treating diabetes than just eliminating processed carbs, but, may be difficult for some folks to maintain over the long haul. A basic whole-foods plant-based diet can be successfully used to prevent and treat diabetes (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466941/) and may be more palatable to folks.

  5. Dr Walter Schwager

    “five to six exercise sessions per week, consisting of 30 to 60 minutes of supervised aerobic activity, along with two to three sessions of weight training; an individualized nutrition plan with dietary counseling, including calorie restriction for the first four months.”

    These specific interventions are quite disruptive as they are difficult to integrate in a standard life style, and will result in low compliance. Walking, jogging, household activities and such are more likely to be maintained. Diets also need to be fine tuned: low carbs, low sugar, high fibre and such. Avoidance of pop drinks but also fruit juices.

    • Thomas Turk

      including calorie restriction for the first four months.”.. Why calorie restrictions? it’s the carbs that fatten.. digested carbs 1st top up muscle and liver glycogen, the rest is rapidly converted to body fat in the mitochondria via the Krebs Cycle. Digested fats slowly convert to usable energy in the liver.

    • Monique Tello, MD, MPH
      Monique Tello, MD, MPH

      I agree, and your sound suggestions are similar to what was conducted. Many people don’t do anything active at all, and so a lifestyle intervention that includes supervised activity at the beginning can help people to get comfortable with, as well as get in the habit of, being active. I totally agree that physical activity should ideally be worked into a regular day as much as possible. I also agree that the type of foods consumed is far more important than the overall Kcal#, and in this case, the dietary intervention included a personalized nutritional plan. This likely included instruction on avoiding refined grains and other processed carbohydrates, as would be standard.

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