Essentials of Complementary and Alternative Medicine (June 1999)

Nutritional Biotherapy for Diabetes
Dietary modification is the cornerstone of complementary medical management of diabetes, particularly for noninsulin-dependent or Type II diabetes. Since 1986, the 
American Diabetes Association has held the position that “medical nutrition therapy is integral to total diabetes care and management” (
224
). The ideal diet for 
diabetics is one high in carbohydrate-rich foods that have a low glycemic index, combined with high-fiber content (30 to 40 g/day) (
225
, 
226
). Diabetics can greatly 
reduce their dependency on insulin and improve glucose control by adopting a high-fiber, high-complex-carbohydrate, low-fat diet (
227
, 
228
 and 
229
). Saturated fats 
appear detrimental to the course of diabetes (
230
), whereas both omega-3 polyunsaturates (e.g., fish oils) and monounsaturated fatty acids (from olive oil), combined 
with vitamin E, may be beneficial to diabetics (
231
, 
232
 and 
233
). Other nutritional agents that may improve glucose control, insulin sensitivity, and other aspects of 
diabetes include the following supplements:
Chromium (
234
, 
235
 and 
236
)
Zinc (
237
, 
238
, 
239
 and 
240
)
Magnesium (
241
, 
242
, 
243
, 
244
, 
245
 and 
246
)
Potassium (
247
, 
248
 and 
249
)
Vitamin C (
250
)
Vitamin B6 (pyridoxine) (
251
, 
252
, 
253
, 
254
 and 
255
)
Alpha-lipoic acid (
256
, 
257
, 
258
, 
259
, 
260
, 
261
, 
262
 and 
263
)
In addition to the diet and supplement program, management should include regular exercise and (if the patient is obese) short periods of fasting to reduce tissue 
resistance to insulin (
264
).
TRAINING AND QUALITY ASSURANCE IN NUTRITIONAL BIOTHERAPY
Medical training has not kept pace with the rapidly evolving field of nutrition. In general, physicians are inadequately trained in how to use nutrition to prevent and 
treat illness. In an annual survey by the Association of American Medical Colleges, more than half of medical school graduates consistently reported that their training 
in nutrition was deficient. Authors of the National Nutrition Monitoring and Related Research Act, passed by Congress in 1990, concluded that the level of physicians' 
nutrition education could not realistically meet national goals for health promotion and disease prevention.
With few exceptions, United States medical schools expose their students to only the most elementary aspects of nutrition, usually through a biochemistry course. 
Fewer than 35% of allopathic schools offer a separate nutrition course; schools that do offer this course frequently fail to bridge these teachings into clinical training. 
At best, medical students learn about vitamin deficiencies that are relatively rare in an affluent society, rather than about the hazards of excess, about important 
drug-nutrient interactions, or about the nutritional imbalances that may accompany surgery, radiotherapy, and other conventional treatments. In one survey, three of 
four first-year medical students believed a knowledge of nutrition was important to their career; however, only one in ten felt that way once they reached their third 

year (
265
).
In a consensus statement prepared following a 1997 conference sponsored by the American Medical Student Association (AMSA), medical students declared that 
they lacked sufficient education in three areas: nutrition, research issues, and societal issues in medicine. In response to the call for improved nutrition education, the 
Washington, D.C.-based Physicians' Committee for Responsible Medicine (PCRM) produced Key Nutrition Issues for Medical Students (Physicians' Committee for 
Responsible Medicine, [202] 686–2210), which is designed to supplement medical education. This book provides a curriculum guide to key issues related to nutrition 
biotherapy for cancer, diabetes, heart disease, hypertension, renal disease, osteoporosis, and arthritis. The curriculum also provides study questions for a 
self-directed learning experience.
In terms of outcomes-based curricular competencies, some medicals schools have begun to incorporate the Physicians' Curriculum in Clinical Nutrition (American 
Academy of Family Physicians, [800] 274–2237), published by the Society of Teachers of Family Medicine. Like the PCRM guidebook, this curriculum considers key 
issues in the prevention and treatment of a wide variety of diseases. Section I of the curriculum also explores many issues related to basic care, such as nutritional 
screening and assessment, nutritional counseling, geriatric care, women's health, obesity, eating disorders, and nutrition support skills. Section II presents issues 
related to educational program development, patient-care methods (nutrition screening, co-counseling, precepting, chart review), and implementation of a nutrition 
rotation and nutritional course.
The American Society for Clinical Nutrition (ASCN) recently proposed having at least one physician nutrition specialist (PNS) at every major medical center. To hold 
this position, the individual would have completed a fellowship in clinical nutrition after residency. The primary function of the PNS would be to provide leadership to 
the nutrition services team at the hospital and to assist with complex nutritional cases throughout the region. All associated schools of medicine would use the PNS as 
a role model for physicians in training and for developing and coordinating their nutrition education programs. AMSA recently teamed up with the ASCN to sponsor an 
internship program that places medical students across the United States to work with authorities in clinical nutrition for 2-month intervals.
The ultimate goal should be to teach all medical students about the interconnectedness between nutrition and health. Dr. Steven Zeissel, nutrition department chair at 
the University of North Carolina School of Public Health and Medicine, has developed a series of computer-assisted nutrition teaching programs funded, in part, by 
the National Institutes of Health. This electronic textbook, an interactive CD-ROM system, enables students to interact with a patient on screen along with a guiding 
physician or role model. With this case-oriented format, students learn practical applications of nutritional biochemistry and appropriate decision making for 
nutrition-related health problems. Immediate feedback is given to indicate whether the student's chosen nutritional strategy is appropriate. (Note: This program is 
currently available to medical schools only; see 
www.med.unc.edu/nutr/nim
.)
As of December 1998, the computerized nutrition teaching programs were distributed to 100 medical schools nationwide. Approximately 50 of these schools are using 
the first 10 modules, which are intended for first- and second-year students. The five modules in the disease series cover issues relevant to the nutritional 
management of cancer, obesity and cardiovascular disease, diabetes and weight management, anemia, and metabolic stress. The remaining five modules concern 
the life cycle (maternal and infant health, and nutrition for the second half of life) and special topics (supplements, fortified foods, and sports nutrition).
For physicians who would like to increase their understanding of nutritional medicine issues, postgraduate programs in nutrition are available at many American 
universities (particularly those which include a school of public health), and excellent programs are increasingly available at medical schools and osteopathic schools 
as well. The University of Texas Health Science Center at San Antonio has integrated nutrition into all 4 years of training. Most osteopathic medical schools place 
nutrition in their mission statement. Naturopathic colleges, such as John Bastyr University in Seattle and the National College of Naturopathic Medicine in Portland, 
also offer comprehensive nutrition programs.
QUALITY ASSURANCE AND PROFESSIONAL COMPETENCY
Currently, quality assurance in the administration of nutritional biotherapy remains a vague, loosely defined concept. This is primarily because there is little or no 
agreement within the conventional and CAM communities as to the level of nutritional knowledge physicians should have in their clinical practice. For example, the 
Residency Review Committee for Family Practice has required education in nutrition since 1982. However, a consensus is still lacking as to the core competencies 
required by a practicing family physician. Many physicians may understand the fundamentals of nutritional biotherapy yet may be ill-equipped to evaluate, manage, 
and intervene in the nutritional aspects of medical problems. Similarly, they may lack competence to counsel patients on dietary management and prevention of 
disease.
At the least, physicians should ask patients what they eat and whether they are taking supplemental micronutrients during history-taking. Physicians also should have 
a substantial grounding in the nutritional literature as it pertains to the management of the major chronic diseases: cancer, heart disease, obesity, diabetes, 
hypertension, arthritis, osteoporosis, and renal disease. Such knowledge will, in turn, enable them to better integrate information from the medical history (including 
dietary history), physical examination, and laboratory data used to assess the patient's nutritional status. Dietary and supplementation needs can then be evaluated 
from a more thoroughly informed nutritional perspective.
If complicated nutritional interventions are needed beyond the initial level of care, or if the physician cannot follow up with patients who are at nutritional risk, he or 
she should refer them to subspecialists in clinical nutrition. These specialists include registered dietitians or licensed dietitians (RDs and LDs, respectively). The RD is 
registered to administer medical nutrition care with the Commission on Dietetic Registration, the accrediting body of the American Dietetic Association. Medical 
nutrition care includes the following three components:
1. Interpreting and recommending nutrient needs relative to medical prescribed diets, including, but not limited to, specialized oral feedings and artificial nutrition 
(enteral and parenteral formulas).
2. Food, nutrient, and prescription drug interactions.
3. Developing and managing food service operations whose primary function is nutrition care and provision of medical prescribed diets.
The LD is licensed to practice dietetics but cannot make medical differential diagnoses of the health status of an individual.
There is a tendency for physicians to immediately refer patients to clinical nutrition specialists for any nutrition-related complaint or concern. This situation is 
unfortunate given the many complementary applications of nutritional biotherapy that can accompany conventional medical care. Patients in need of nutritional care 
should be able to rely on their physicians for the delivery of nutritional screening and a comprehensive assessment (both nutritional status and nutrient intake) as well 
as counseling on core dietary needs (perhaps using BINT as a reference point). Interactions with the physician should include informed communications, appropriate 
referral methods, and, whenever possible, advice on testing procedures aimed at elucidating the patient's biochemical individuality.
Mastery of nutritional biotherapy represents an essential but widely undervalued area of proficiency for physicians and, until core competencies in nutritional 
biotherapy are established, reliability of such skills will likely be questionable. Ideally, physicians actively studying nutritional biotherapy may benefit by observing 
dietitians in action, and vice versa. In the context of a multifaceted integrative medical team, this should be done in the presence of another clinical nutrition specialist 
and a psychologist (or behavioral scientist), in order for the practitioner to take cues and offer feedback on improving the clinical delivery of nutritional biotherapy.
REIMBURSEMENT STATUS
Nutritional agents and other dietary supplements do not call for the same level of rigorous testing as investigational drugs, according to the 1994 Dietary Supplement, 
Health and Education Act. This may help explain why prescriptions for nutritional supplements and other nonpatentable agents are not covered by insurance unless 
there is evidence of illness induced by a nutritional deficiency. The lack of coverage seems surprising given that dietary modifications or nutritional supplementation 
can lower overall health care costs.
It is also generally not efficient for medical doctors to spend the needed time for patient education on nutritional issues. Lack of reimbursement, along with time 
constraints imposed by the managed care economy, are among the primary reasons that physicians today do not typically offer nutritional guidance.
The cost of dietary supplements, including nutrients, botanicals, and phytochemicals, is generally much lower than pharmaceutical drugs. Most of these natural 
substances are available over the counter; many are now sold in pharmacies and health food stores. This trend has worked to the advantage of naturopathic 
physicians. In Connecticut and Washington, naturopathic physicians enjoy 100% coverage mandated by state law. Therefore, in those states, nutritional supplements 

are fully covered for prescriptions written by naturopathic physicians, some of whom work side by side with allopathic practitioners. Although many insurance 
companies have begun to cover naturopathic medicine per se in recent years, allopathic physicians still cannot obtain coverage for their patients' dietary supplements 
unless there is evidence of a nutritional deficiency to warrant supplementation from the perspective (albeit outmoded) of the insurance company.
Impact on Conventional Medicine and Medical Costs
Complementary applications of nutritional biotherapy may translate into considerable reductions in treatment costs as well as reductions in overall disease burden and 
suffering. On the most basic level, there is the problem of malnutrition among hospitalized patients, a problem that often goes unrecognized. Other than patients with 
AIDS, patients with advanced cancer have the highest prevalence of malnutrition of any hospitalized group, and nearly half these patients die from 
malnutrition-related complications (
266
, 
267
). The prevalence of protein-calorie malnutrition in hospitalized cancer patients is approximately 30 to 50% (
268
, 
269
). A 
1998 study of hospitalized patients attending the surgical and internal medicine units of a major hospital in Buenos Aires found that many patients suffered from either 
low body mass index (BMI), excessive weight loss during hospitalization, or being overweight (
270
). Prompt nutrition assessment and appropriate nutrition 
intervention are needed to improve clinical outcomes and help lower the cost of health care, and further study is needed on the cost-effectiveness of comprehensive 
nutritional biotherapy programs.
The disease burden may also be attenuated by combining nutrition with standard medical care in a complementary fashion. For example, in a randomized, 
double-blind prospective trial of 43 recipients of bone marrow transplants at Brigham and Women's Hospital in Boston, glutamine supplementation significantly 
reduced the length of hospital stay (by 7 days) and thus the overall cost of postoperative care. For the glutamine-supplemented group, hospital charges were $21,095 
less on a per-patient basis compared with charges for patients who received standard therapy. Rates of both positive microbial cultures and clinical infection were 
also significantly lower among the glutamine recipients. Room and board charges were over $10,000 less per patient for the glutamine-supplemented group (p = 0.02) 
due to reduced hospital stay (
27
). Another randomized clinical trial yielded similar outcomes (
272
). Patients receiving glutamine perioperatively also show more 
sustained vigor postoperatively compared with nonsupplemented patients (
273
).
Additionally, appropriate nutritional guidance may lead to broad-based improvements in the control of many chronic diseases. In a cross-sectional study in California, 
27,766 Seventh-day Adventists answered questions on diet, exercise, medications, use of health services, and prevalence of disease (
274
). About half the group 
(55%) were vegetarians. Nonvegetarian males and females had statistically higher rates of coronary heart disease, stroke, hypertension, diabetes, diverticulosis, 
rheumatoid arthritis, and rheumatism compared with their vegetarian counterparts. Nonvegetarians also had higher rates of drug and chemical allergies. Compared 
with vegetarian women, nonvegetarian women reported significantly more overnight hospitalizations and surgeries in the previous year (p < 0.001), and 
nonvegetarian men reported more overnight hospitalizations and x-rays (p < 0.01). In addition, medication use was higher (115% versus 70%) in nonvegetarian 
women and was more than double in nonvegetarian men. These findings, along with other studies briefly mentioned in this chapter, suggest that a vegetarian diet and 
lifestyle modification may result in major decreases in the prevalence of chronic diseases, resulting in a reduced reliance on medications and health services.
A major limitation of the cross-sectional design of large observational studies, however, is its inability to detect the temporal direction of cause and effect. For 
example, if an individual adopted a more nonvegetarian diet when he or she became ill, this could influence the findings like that reported in this study. However, the 
Seventh-day Adventist population advocates vegetarianism as the optimal diet, based on their philosophy of health. When illness occurs, it is more likely that the 
affected individuals would alter their diet in accord with this philosophy (toward vegetarianism) and so may actually underestimate the true protective effect of 
vegetarianism against chronic disease.
The same study did not detect higher rates of cancer for nonvegetarian Seventh-day Adventists. However, a cancer-preventive effect of vegetarian diets has been 
demonstrated in previous studies of this population (
275
, 
276
 and 
277
). One study showed an orderly dose-response relationship between fatal prostate cancer and 
increasing intakes of animal products (milk, cheese, eggs, and meat) among Seventh-day Adventists (
278
). Results from another study of this population suggested 
that adopting a vegetarian diet early in life was of decisive importance with regard to eventual disease-related mortality; making dietary changes later in life had a 
smaller effect on the risk of eventually dying from chronic disease (
279
).
Overall, these and other studies suggest a lower morbidity burden in people who follow a vegetarian diet. Advocating a vegetarian diet may be an effective way to 
reduce health care costs, primarily through reductions in the number of hospitalizations, frequency of sick leave, and expenditures for medication and health services. 
Ideally we should work toward shifting medical resources away from treating life-threatening illnesses to patient education and the management of chronic diseases.
PROSPECTS FOR THE FUTURE
The ancient notion that diet and nutrition have an important influence on health has evolved into the complex, multidisciplinary science of nutrition. Today, the notion 
that diet has an etiological role in cancer and other chronic diseases is well accepted. It is estimated that about half the diseases a primary care physician sees have 
a nutrition-related cause, and at least five of the top ten causes of death in the United States are linked to diet. Nutrition has been established as a major factor in the 
prevention and reversal of diabetes, hypertension, and heart disease. Substantial evidence also suggests that nutritional interventions can improve cancer survival 
and lessen the toxic effects of standard anticancer therapy, thus improving quality of life (
280
).
One of the areas in which nutritional bio-therapy could have a profound impact is medical care for the elderly, many of whom are already in crisis because of 
increased disease burden and limited resources for medical care coverage in this population. By the year 2020, 20% of the United States population will be aged 65 
years or older, and the greatest increase in numbers over the next two decades will be among those 85 years of age or older. This is expected to place an 
extraordinary burden on medical services. Nutritional biotherapy may effectively address disease-related processes associated with aging. For example, aging is 
associated with impaired immune responses and an increase in infection-related morbidity. Randomized placebo-controlled trials have demonstrated that modest 
supplementation with vitamins and minerals significantly improve immunity and decrease the risk of infection in old age (
281
, 
282
). Another example is that high 
potassium intake, either from diet or supplements, significantly lowered the risk of stroke. Men who took potassium supplements were 69% less likely to suffer a stroke 
compared with men who did not take supplements in the first 2 years of the study (
283
).
By fostering healthy aging, nutritional practitioners can improve the cost-effectiveness of health care delivery. Bland (1998) contends that nutritional pharmacology 
may biochemically modify some of the primary physical aspects of unhealthy aging; for example, chronic inflammation and oxidative stress, altered mitochondrial 
function, increased protein glycation (glycosylation), defects in methylation, poor detoxification capacity, and impaired immunocompetence (
284
). 
Nutritional–pharmacological strategies may also be applied effectively to mental health problems, ranging from learning disability and behavioral disorders in children 
to the cognitive and emotional disorders that afflict millions of adults and elderly persons (
285
). In addition, fitness training, stress management, cognitive 
restructuring, ergonomic adjustments, and counseling on a life-affirming lifestyle may reinforce the health-promoting benefits of a comprehensive nutritional program.
Another ongoing development is the explosion of new nutritional agents by the purveyors of nutritional pharmacology. Studies of tocotrienols, a form of vitamin E, 
indicate that these compounds may potentiate tamoxifen's therapeutic effects on breast cancer (
286
). Other forms of vitamin E, including gamma-tocopherol and 
tocopheryl succinate, may also hold similar promise for an improved therapeutic index in the complementary medical setting. Additionally, retinoids (vitamin A 
compounds) are now widely used in the treatment of cancers of the lung, breast, ovary, and bladder, as well as basal cell carcinoma, squamous cell carcinoma, 
melanoma, cutaneous T-cell lymphoma, and acute promyelocytic leukemia. Many of these agents are now considered part of standard cancer care, and yet they 
clearly fulfill a complementary role by serving as differentiators and immune modulators (
287
).
In the coming decades, the focus of nutritional biotherapy will move beyond primary prevention to encompass the adjuvant treatment and long-range management 
(including secondary and tertiary prevention) of chronic diseases. In this regard, nutritional modulation of standard treatments and of pathological mechanisms offer 
exciting possibilities for a more innovative and functional form of medicine. Considered on its own, nutritional biotherapy should never be labeled a cure for any of the 
major degenerative diseases. However, if properly implemented within the context of integrative medicine and complementary care strategies, nutritional biotherapy 
will become an increasingly valuable adjunct to primary medical treatment strategies.