Epidemic levels...Overwhelming health care costs...Blindness, heart and nerve disease, and kidney failure." Such alarming sound bites filled the media about a month or two ago when the Centers for Disease Control and Prevention (CDC), Atlanta, released statistics on the increasing incidence of diabetes. For marketers looking for new demographic niches, this unhappily promises to be a large one.

Diabetes mellitus is a chronic disease that results from impairment in the body's production and/or use of the hormone insulin. Insulin is produced by the pancreas and helps transport glucose (sugar) into the cells of most organs where it is used for energy. Insulin also lends a hand in protein synthesis and fat storage. When diabetes is not under control, glucose and fat remain in the bloodstream, contributing to both organ and blood vessel damage over time.1, 2

Diabetes effects more than 16 million Americans, approximately one-third of which are undiagnosed.4 It is also on the rise. "From 1990 to 1998, the frequency of diabetes, especially Type 2 diabetes in adults, increased by about 33%. This increase was mainly due to new cases, and was closely associated with increasing weight and physical inactivity in this country," notes Frank Vinicor, Ph.D., director of the Division of Diabetes Translation, CDC. (See diabetes types, page 30.)

There is also growing awareness, particularly in the natural products industry, of a metabolic disorder called Syndrome X that is genetic in nature and starts with insulin resistance.

Terry Kristen Strom, co-author of SYNDROME X Overcoming the Silent Killer That Can Give You A Heart Attack and director of marketing for Shaman Pharmaceuticals, provides a description of the condition as follows. Insulin functions to escort glucose into cells. With insulin resistance, insulin does not work as well as it should. People with Syndrome X pump out higher levels of insulin. (As the body's insulin resistance increases, the pancreas produces additional insulin to maintain normal glucose levels.) Essentially, that insulin takes glucose and rams it [into] the cell by the sheer force of extra insulin in the bloodstream. The high insulin level may lead to potential complications, including polycystic ovarian syndrome, hypertension, dyslipemia, arteriosclerosis, Type 2 diabetes, heart disease, and possibly certain forms of cancer. This syndrome also is blamed, in part, on an American lifestyle of low physical activity and high fat and calorie diets.⁵

Management Through Diet

Diabetes treatment tends to focus on normalizing blood glucose levels. Type 1 diabetes treatment typically includes dietary management, exercise, insulin injections or the use of an insulin pump, and regular blood glucose monitoring. Type 2 diabetes treatment is similar, but also includes weight loss if needed and possibly oral medication and/or insulin.³ The obesity in Type 2 diabetes tends to be self-perpetuating in that high insulin levels, or hyperinsulinemia, interferes with lipolysis (the breakdown of fat) and thus weight loss.⁵

Numerous theories exist on the proper macronutrient composition of a diabetic's diet. Dr. Gerald Reaven, endocrinologist, professor of medicine at Stanford University, and co-author of SYNDROME X, believes an optimal diet is composed of 45% of calories from carbohydrates, 40% fat, and 15% protein. Conversely, experts at the Pritikin Longevity Center in Santa Monica, Calif., promote a diet high in complex carbohydrates and very low in fat (less than 10% of total caloric intake).

Many individuals rely on the American Diabetic Association's Exchange System. (See photo and caption.) Some diabetics use a food's glycemic index to help guide diet.⁷ This is a measure of how rapidly a food will raise blood sugar. Foods that are digested rapidly (simple carbohydrates) produce a greater increase in blood sugar and have a higher glycemic index than more slowly digested foods (e.g., complex carbohydrates). The index's usefulness is controversial since it's impacted by many factors.⁴

Alternative Treatments

Several dietary supplements and functional foods are marketed to diabetics. As is often the case, the supporting science for the specific ingredients both varies in strength and continues to emerge. Here are a few.

• Bran and dietary fiber. Bran is simply dietary fiber from the course outer hull of the grain of wheat. Past studies of individuals who consume a high fiber diet (50 g or more per day) indicate that these individuals have a decreased risk for many diseases, including diabetes.⁸
• Fenugreek seeds. This product consists of the dried ripe seeds of a European herb.⁹ Studies indicate that fenugreek has a favorable effect on postprandial glucose levels¹¹, fasting blood sugar, and lipid profiles.¹² It is a fibrous herb and therefore decreases the rate of digestion and subsequently slows down the typical rise in blood sugar that accompanies a meal while helping to increase satiety.
• Ginseng. This botanical is shown to have a pharmacological effect on diabetes, although the mechanism for this has yet to be elucidated.^{9, 13} Many commercial products vary widely in their ginseng content and quality. Ginseng appears relatively safe, but side effects that have been reported include insomnia, diarrhea, and skin eruptions.⁹
• Antioxidants. Lipid oxidation increases in diabetics and is thought to be partially responsible for kidney damage. A number of published clinical studies find vitamin E supplementation to be of potential benefit, but other antioxidants such as a-lipoic acid also show promise.¹⁰ A search of the National Institutes of Health research database (www.ncbi.nlm.nih.gov/entrez/query.fcgi) provides a wealth of recent clinical studies investigating the role of micronutrient and alternative medicines that reduce the risk of diabetes or complications that arise once the condition has occurred. Chromium, magnesium, biotin, coenzyme Q10 and conjugated linoleic acid are some of the more high profile ingredients under investigation. Even moderate alcohol intake, particularly in women, has been supported by epidemiological evidence.

As ominous as the increase in diabetes is, hope lies in ongoing research that will provide a better understanding of how diets will assist in its management and prevention. NS

References

1. The American Diabetes Association www.diabetes.org
2. Centers for Disease Control and Prevention, Division of Diabetes Translation www.cdc.gov/diabetes
3. The University of Texas Southwestern Medical Center at Dallas www3.utsouthwestern.edu:8765
4. Mokdad A.H., 2000. Diabetes trends in the U.S. 1990-1998. Diabetes Care 23(9), 1278-83.
5. Michoff, L.E. and J.A. Grandin. 1996. Syndrome X Recognition and management of this metabolic disorder in primary care. Nurse Practitioner 21(6):74-86.
6. Nuttall, F.Q. and R.M. Chasuk. 1998. Nutrition and the Management of Type 2 Diabetes. The Journal of Family Practice 47(5) Suppl:S45-S53.
7. The Threat of Insulin Resistance to Your Heart and how to Prevent It. 2000. Environmental Nutrition 23(8)1-4.
8. U.S. Food and Drug Administration http://vm.cfsan.fda.gov/~dms/supplmnt.html
9. Tyler, V.E. 1993. The Honest Herbal. Pharmaceutical Products Press, New York.
10. Melhem, M.F. et al. 2001. J. Am Soc Nephrol 1:124-133.
11. Madar, Z. et al. 1988. Glucose-lowering effect of fenugreek in non-insulin dependent diabetics. Eur J Clin Nutr 42:51-54.
12. Sharma, R.D. et al. 1990. Effect of Fenugreek Seeds on Blood Glucose and Serum Lipids in Type 1 Diabetes. Eur J Clin Nutr 44:301-306.
13. Vuksan, V., et al. 2000. Similar Postprandial Glycemic Reductions with Escalation of Dose and Administration Time of American Ginseng in Type 2 Diabetes. Diabetes Care 23(9) 1221-6; 2000.

Ingredient selection and macronutrient makeup are critical in diabetic products. For example, Shaman Pharmaceuticals' Syn X contains the carbohydrate, fat and protein ratios recommended by Stanford University's Reaven. The product "has been shown to help people with Syndrome X maintain healthy insulin and blood glucose levels, healthy triglycerides and LDL cholesterol levels, " says Shaman's Strom. It is currently undergoing clinical testing at Stanford.

The American Diabetic Association's Exchange System categorizes foods into one of six exchanges: milk, vegetable, fruit, bread, meat, and fat. The portions of food in each group contain about the same number of calories and grams of carbohydrate, fat, and protein.6 Mixed foods (e.g., lasagna) may contain one or more exchanges from several different exchange groups. Each particular individual's food plan will specify how many exchanges they can eat from each group per day.

SIDEBAR: The Diabetic Market

Type 1: Insulin is no longer produced, daily insulin injections are required. Type 1 is autoimmune in nature (the body's immune system destroys the pancreas' insulin-producing beta cells) or idiopathic (no known cause). It is most commonly diagnosed in children and young adults and accounts for 5% to 10% of all cases.

Type 2: A metabolic disorder that develops when the body's production of insulin cannot compensate for its insulin resistance (impairment in the body's ability to use the insulin that is produced). It accounts for 90% to 95% of cases.

Gestational: Effects some 2% to 5% of all pregnant mothers and typically disappears after pregnancy.

Other: Diabetes that results from specific genetic syndromes, surgery, drugs, malnutrition, infections, and other illnesses. These account for 1% to 2% of cases.

On the Web: DIABETES

• www.diabetes.org and www.eatright.com - American Diabetes Association
• www.aadenet.org - American Association of Diabetes Educators
• www.syndromexweb.com - Shaman Pharmaceutical's site on Syndrome X
• See the site on diabetes - Colorado State University, Syndrome X information
• www.glycemicindex.com - The Glycemic Index
• www.niddk.nih.gov - National Institute of Diabetes & Digestive & Kidney Diseases
• www.glycemic.com - The Glycemic Research Institute, a nonprofit organization