Diabetes: The Preventable Epidemic
A Concise Update of Important Issues Concerning Natural Health Ingredients
Reprinted with permission from THE STANDARD
Edited by Thomas G. Guilliams, Ph.D.
Without
exaggeration, diabetes is becoming a modern, albeit silent, epidemic.
Currently, over 10 million Americans are diagnosed with some form of
diabetes, while another 5 million are considered to be diabetic
without their knowledge. The
modern Western diet and lifestyle has done much to lead our
generation to the threshold of insulin resistance, and with it, the
collection of symptoms known as Syndrome X.
This issue of THE STANDARD (published by Ortho Molecular
Products.com) will review some of the basics of preventable diabetes
(type II) and the consequences of poor glycemic control leading to
insulin resistance. The major focus will be on the accumulated
research of various nutraceuticals as they have been used to treat or
prevent diabetes and its harmful complications.
Diabetes mellitus is a metabolic disorder characterized by
elevation of fasting blood sugar (glucose). While the cause of the
elevated blood glucose may be associated with either too little or
too much insulin, the complications of chronically high serum glucose
are devastating to the individual. Complications of uncontrolled
blood sugar include increased risk of heart disease, stroke, kidney
disease, blindness, and loss of nerve function. Regulating blood
sugar for diabetics is therefore crucial to both the immediate as
well as long-term care of diabetic patients.
Type I Diabetes
Often called insulin dependent diabetes mellitus (IDDM), this form
of diabetes is characterized by the destruction of the pancreatic
beta cells that manufacture insulin. Typically this form is diagnosed
while the patient is a child or adolescent and requires insulin for
the management of blood sugar. Many theories have attempted to
account for the damage of these important insulin producing cells
including autoimmune processes, chemical damages, viral infection,
and genetic disposition. Whatever the cause, the result is very low
or no insulin; a protein that is the primary mediator of glucose
transport into cells. This diminished insulin level leads to elevated
levels of glucose in the blood, which then results in numerous
complications. Of the more than 15 million Americans with diabetes,
only about 10% are considered to have type I diabetes.
Type II Diabetes
Almost 90% of diabetics are considered to have noninsulin
dependent diabetes mellitus (NIDDM) or type 2 diabetes. While also
characterized by high blood glucose levels, type II diabetics often
have high, rather than low, levels
of serum insulin. Type 2 diabetics are typically insulin resistant,
rather than insulin depleted. A current report in JAMA concludes that
nearly one-fifth, or 47 million Americans are at an increased risk of
type 2 diabetes, using the criteria of abdominal obesity, elevated
triglycerides, low HDL cholesterol, high blood pressure and high
normal blood sugar (1). In this report, these symptoms were called
"metabolic syndrome", but many people already know them
as "Syndrome X". This syndrome and the subsequent
diabetic condition that follows are preventable. Through an awareness
of the various risk factors, proper diet and exercise; type 2
diabetes could be altered from a national epidemic to a manageable
but minor disease. History tells us, unfortunately, that the Western
diet and lifestyle have a tenacious hold on the American culture and
this trend toward obesity, insulin resistance and diabetes is
unlikely to abate anytime soon.
Diabetic Complications
Hyperglycemia (high blood glucose) causes complications in
patients with diabetes, regardless of whether it is type 1 or 2.
While some complications can be of an acute nature (ketoacidosis due
to low insulin or hypoglycemic shock due to insulin overdose), most
complications are a result of years of unregulated and high serum
glucose. These complications include increased heart disease,
retinopathy, nephropathy ending in renal failure, neuropathy, foot
and leg ulcers, impotence, and the inhibition of many important
metabolic enzymes. Most of these complications are due to
hyperglycemic-induced increase reactive oxygen species (ROS) that
cause glucose-induced activation of protein kinase C, increased
formation of glucose-derived advanced glycation end products (AGEs)
and increased glucose flux through the aldose reductase pathway (2).
These vascular complications are cumulative, but preventable.
Maintaining proper blood glucose is vital to preventing these
complications. Additionally, there are a number of natural
ingredients that can prevent and even reverse the progress toward
these devastating complications.
Syndrome X and Insulin Resistance
Syndrome X is the name given to a collection of metabolic
conditions; highlighted by insulin resistance, but also includes
obesity (especially in the abdomen), high cholesterol, low HDL
cholesterol, high triglycerides and hypertension. These symptoms are
often termed prediabetic syndrome. Insulin resistance is one of the
key features and dangers of this syndrome. Insulin resistance is a
condition where the pancreas is able to manufacture more than enough
insulin, but cells have become resistant to insulin's effects.
This increases blood glucose as well as stimulates insulin-induced
metabolic functions (conversion of carbohydrates to fats leading to
obesity). The constant intake of refined carbohydrates, leading to
dramatic spikes in blood glucose followed by dramatic spikes in
insulin secretion, is the primary cause of insulin resistance and
then type 2 diabetes. It is for this reason that diet is possibly the
most important aspect to the treatment and prevention of type 2
diabetes and its precursor condition, Syndrome X.
Diet and Lifestyle are Vital
It is difficult to over emphasize the importance of diet as it
pertains to preventing and treating type 2 diabetes (many of the
principles discussed here are applicable to type 1 diabetes as well,
the role of therapeutic levels of insulin in these patients has
nuances that are not discussed here). Since diabetes is a metabolic
disorder, food can be considered either a poison or a therapy
depending on its content. Not only can food lead to obesity, food is
the primary foundation for blood sugar control, often called
glycemic control or balance. The steady balance or glycemic control
is the key to prevent and treat syndrome X and type 2 diabetes.
Avoiding foods that destabilize glycemic balance and eating foods
that promote glycemic balance is the key to a healthy diet for
everyone, but especially for those with insulin resistance.
Since this review is primarily focused on therapeutic natural
ingredients, so-called nutraceuticals, this will only provide basic
principles for the diet. More information should be gathered from a
resource designed specifically with that subject in mind, some of
which are provided in the general reference section at the end of
this review.
General Guidelines
- Understand that glycemic index and total carbohydrates may
differ dramatically
- Avoid most processed foods regardless of their protein/carb
ratio
- Avoid trans-fatty acids and increase omega-3 fatty acids and
GLA
- Increase dietary fiber
- Avoid or test for commonly allergenic foods (dairy, gluten
etc)
- Avoid refined sugar in all its forms
- Avoid alcohol
- Avoid artificial sweeteners like aspartame; try stevia or
xylitol instead
- Drink plenty of pure water
- Don't assume anything; read the label
Other lifestyle factors are also important for those with diabetes
or syndrome X. Among them, exercise and stress management are vital.
Physical activity and regular exercise may not only have direct
impacts on glucose use and insulin sensitivity, but also on many risk
factors such as obesity, triglycerides, and hypertension. In a recent
study, exercise had significant improvement on the vascular function
in type 2 diabetics (62). It should be noted that patients taking
pharmaceuticals to reduce blood sugar or insulin should be monitored
during exercise to prevent hypoglycemia. Typically, less hypoglycemic
medication is required during physical activity. If the patient is
not physically active, a slow progression into an exercise program
with consistent monitoring of blood sugar is prudent. In a study just
published in New England Journal of Medicine, effective lifestyle
changes were compared to a popular oral hypoglycemic in preventing
type 2 diabetes in patients with pre-diabetic hyperglycemia (69). In
this study, 3234 pre-diabetic patients were given
either metformin (Glucophage - 850 mg b.i.d.), put on a lifestyle
modification program (goals of 7% reduction in weight and 150 minutes
of physical activity per week), or placebo. Each group was instructed
with the same dietary guidelines. After almost 3 years, there were
31% fewer diabetics in the drug group versus placebo, but there were
58% fewer diabetics in the lifestyle group than placebo. Lifestyle
modification was significantly more effective than metformin in this
study, not to mention the other benefits gained by weight reduction
and increased physical activity.
Another key factor is stress management. Along with the pancreatic
production of insulin, the adrenal glands are important in the
regulation of blood sugar. The adrenal hormone cortisol is stimulated
whenever the body is under stress. Whether this stress
comes from mental or emotional stress, chronic inflammation, food
allergies, or low blood sugar; cortisol effectively raises blood
glucose levels by stimulating gluconeogenesis. This raised glucose
level can exceed desired levels when stress-induced cortisol levels
are extremely high (alarm reaction). Chronic glycemic imbalance or
other stress could then result in both reduced insulin sensitivity
and adrenal exhaustion. Studies have shown that glycemic control of
diabetics with higher measurable stress is worse than those with
lower measurable stress and, additionally, techniques to reduce
stress lead to better glycemic control among diabetic patients
(3,4,5). Reports have also directly linked the function of the
hypothalamic-pituitary-adrenal axis with the risk of type 2 diabetes
(11). An excellent way to determine adrenal stress is by measuring
salivary cortisol throughout a single day (See The Standard vol. 3
no.1 for a complete discussion of diagnosing and treating adrenal
stress).
The Natural Approach
The first goal in therapy is to reach and maintain an optimal
fasting blood glucose level. This can be done in a way that benefits
other metabolic outcomes such as improving lipid profiles and
reducing blood pressure. The second goal in therapy is to prevent and
treat the chronic consequences and complications associated with
years of poor blood sugar control.
Supplemental Fiber
Dietary fiber is an important aspect of blood sugar control. The
addition of water-soluble fibers such as gums, pectins, and mucilage
are capable of reducing the speed at micronutrients and
nutraceuticals that should be considered in the treatment of diabetic
and syndrome X patients.
Chromium
Chromium is a key constituent in the molecule known as glucose
tolerance factor (GTF). This complex facilitates the uptake of
glucose into cells in conjunction with insulin, somewhat like a
cofactor to insulin. A recent study compared the supplemental intake
of 200 mcg of Cr/day, 1000 mcg/day Cr or placebo on the glucose and
insulin variables of 180 men and women with type 2 diabetes. While
they noted some improvement in the 200 mcg/day group, the group
taking 1000 mcg/day had statistical improvements in HbA1c
(glycosylated hemoglobin), fasting glucose, insulin and cholesterol
levels when compared to placebo (12). Additionally, research has
concluded that non-insulin dependent diabetic patients have a
compromised chromium status, when compared to healthy controls. The
researchers speculate that this is one of the factors leading to
insulin resistance in these patients (13).
Vanadium
For some time, vanadium has demonstrated an insulinlike property
in isolated cells and tissues and has been considered to have
therapeutic potential for diabetic patients. What has been described
as an insulin-mimetic activity by most researchers may actually be an
insulin-enhancing function (14). Regardless of the mechanism, vanadium
has been used clinically to help manage serum glucose levels. A small
study showed that 100 mg/day of vanadyl sulfate (VS) for three weeks
was able to significantly improve hepatic and peripheral insulin
sensitivity in insulin-resistant NIDDM patients. These effects were
even sustained for as much as 2 weeks after discontinuation of
vanadyl sulfate (15). This same dose did not alter insulin
sensitivity in non-diabetic individuals, suggesting a corrective role
for vanadium (16). The safety and efficacy of 100 mg/day of VS has
been tested and shown to be quite good (17), and other studies have
been successful and safe at even higher doses (18). It should be
noted that chronic use of vanadium at these high doses has not been
validated; and a lower dose may be helpful when used in combination
with other natural remedies.
Biotin
The importance of this vital micronutrient produced by healthy gut
microbes has often been overlooked in the management of diabetics.
Biotin has a number of relevant activities including stimulation of
glucose-induced insulin secretion, enhancing insulin sensitivity, and
the acceleration of glycolysis in the liver and pancreas by its
enhancement of the enzyme, glucokinase (24). Biotin supplementation
has been shown in both insulin-dependent and non-insulin dependent
diabetic animal models to improve glucose and insulin tolerances
(20,21). In humans, improvements in which carbohydrates are absorbed
and increase tissue sensitivity to insulin. This has been of benefit
for both type 1 and type 2 diabetics (6,7). The use of psyllium husk
powder (5 grams twice daily 20-30 min. before meals) has been shown
to reduce fasting and postprandial blood glucose levels as well as
improve lipid profiles in type 2 diabetics, when compared to placebo
in double-blinded studies (8). Other studies had similar results when
giving type 2 diabetics 5 grams of psyllium before each of three
meals daily (9). Long-term favorable effects on glycemic control and
lipid concentrations are also associated with 15g/day of supplemental
guar gum (10). Adding supplemental fiber to the diet, in the form of
a psyllium or similar product can be an excellent way to keep and
maintain glycemic control. Increase in soluble dietary fiber will
promote healthy bowel transit times and benefit the gut microflora as
well.
Essential Fatty Acids
The role of essential fatty acids is critical in the overall
health of diabetics as it is with all individuals. For a complete
review of essential fatty acids and their role in diabetic therapies
see The Standard Vol. 3 no. 2. In summary, the decreased conversion
of the essential omega- 6 fatty acid linoleic acid into
gamma-linolenic acid (GLA) in diabetic patients leads to the
therapeutic benefit of ingesting GLA-rich oils such as borage and
evening primrose. The greatest benefits of GLA supplementation are
increasing nerve conduction and the improvement of skin related
disorders. Additionally, omega-3 fatty acids from flax seed oil or
fish oil supplementation should be considered as well. The benefit of
these oils in diabetic patients is primarily in their relationship to
the cardiovascular system, an area which diabetics are vulnerable due
to increased lipid peroxidation, atherosclerosis, cholesterol and
other lipid disorders. The long chain EPA and DHA found in fish oils
are also necessary for the retina in particular, a tissue that is
often damaged after years of poor blood sugar management (diabetic
retinopathy - see The Standard Vol. 2 no. 1 for more information
about treating diabetic retinopathy). The reduction of oxidized and
trans-fatty acids and the increase of high quality essential fatty
acids should be a goal for everyone, but especially for those who
have, or are susceptible, to type 2 diabetes.
Micronutrients and Nutraceuticals
While the role of diet and lifestyle is fundamental to improving
outcomes for diabetic patients, supplemental nutrients and natural
therapeutic ingredients can also play a vital role in patient care.
Tissue levels of B-vitamins are significantly depleted in animal
models of diabetes (19) as has also been reported in humans with
diabetes. A high quality multivitamin-mineral product should be the
basis of supplemental therapy, one with adequate levels of B
vitamins, vitamin C and magnesium. Below are additional oral glucose
tolerance tests as well as diabetic related neuropathy symptoms are
associated with increased biotin intake (22, 23).
Alpha Lipoic Acid
Also known as thioctic acid, alpha lipoic acid is a natural and
versatile antioxidant with numerous therapeutic uses. As an
antioxidant it is able to "recharge" vitamin C, vitamin E
and glutathione because of its three-fold water-soluble, fat-soluble
and sulfhydryl properties. In the case of impaired glucose metabolism
and the complications associated with diabetes, the actions of lipoic
acid are quite helpful. Not only does lipoic acid modulate glucose
and insulin sensitivities but acts as to prevent and treat many of
the oxidative damages that occur with hyperglycemia. One recent study
compared insulin sensitivity in type 2 diabetics after one month of
placebo, 600 mg/day, 1200 mg/day, or 1800 mg/day oral lipoic acid
(25). They found that the treatment, regardless of dose, was equally
able to improve insulin sensitivity by 27% over placebo. This data
confirmed research they had done previously by intravenous
administration (26,27).
As an antioxidant, lipoic acid is capable of decreasing oxidative
stress, the main stimulus for diabetic complications. A
cross-sectional study was performed to assess the oxidative load (by
looking at lipid peroxide levels) in diabetic patients some of which
were taking 600 mg lipoic acid per day for 3 months (28). The lipoic
acid group had 36% lower levels of lipid peroxides and a 38%
improvement in the ratio between oxidative stress and oxidative
defense (measuring lipid peroxides vs. alphatocopherol/ cholesterol
levels). These data confirm the antioxidant role of lipoic acid in
these patients with poor glycemic control, a group prone to oxidative
stress and damage.
Perhaps the longest use of lipoic acid in diabetes is in the
treatment of diabetic neuropathy. Lipoic acid has been used in
Germany for over 30 years for the treatment of diabetic-induced
neuropathy (29,30). Its mechanism of action seems to be related to
its antioxidant activity leading to improved microcirculation and a
positive influence on impaired neurovascular reflex arc in patients
with diabetic neuropathy (34,35). While most of these studies were
performed using intravenous delivery, recent studies confirm that
similar results can be obtained by oral administration of 800 mg/day
(31) or in other studies 600 mg t.i.d. (32). However, one study
showed only marginal favorable effects when using 600 mg t.i.d. in a
multicenter controlled trial (33). Clearly more data must be gathered
in the use of lipoic acid in long-term studies, but it is clear from
the available literature that the use of lipoic acid is a vital and
safe component to nutraceutical therapy in diabetic patients, as well
as those with metabolic insulin disorders like syndrome X. The use of
high oral doses of lipoic acid should be accompanied with biotin to
prevent competitive inhibition of biotin-dependent enzymatic
processes (36).
There are many other nutraceuticals that have been used
successfully in the treatment of diabetic patients. Those that have a
positive effect on lipid or carbohydrate metabolism, increase general
metabolism or weight-loss, or inhibit the formation of sorbitol may
be beneficial for preventing or treating diabetes. These may include
carnitine, niacin, zinc, quercetin (or similar flavonoids) and
lipotropic agents like inositol and choline to name only a few. These
and others are likely to be the focus of attention in in vitro,
animal, and clinical research in the near future.
Herbs and Botanical Extracts
The use of various plants and their extracts for diabetes (sugar
in the urine) has been common since ancient times. Recently, we have
been able to scientifically investigate the use of several botanical
extracts for their hypoglycemic and insulin modifying effects. This
review will discuss those with the most research and potential for
therapeutic use as nutraceuticals in the U.S.
Gymnema sylvestre
Gymnema is a woody plant that grows in the central and southern
parts of India, where it has been used for almost two millennia for
the treatment of diabetes. Some preliminary research was conducted on
this plant over 70 years ago but most of what we know of its
hypoglycemic properties has been learned in the past 20 years. The
activity is thought to reside primarily in a group of compounds
called gymnemic acids, of which extracts are usually standardized. In
animal studies, gymnema leaf powder was able to control blood sugar
levels as well as other insulindependent metabolic pathways
(37,38).
One particular extract, known as GS4, has been used in clinical
trials with both insulin-dependent and non-insulin dependent diabetic
patients. In IDDM patients given 400 mg/day GS4, insulin requirements
were reduced as well as fasting blood glucose levels, perhaps by
increasing insulin usage or residual beta cell function (39). This
same gymnema extract was able to double the number of pancreatic beta
cells when given to diabetic rats (40). Likewise, this research group
also investigated the use of 400 mg/day GS4 in 22 Type 2 diabetic
patients who were taking conventional oral anti-hyperglycemic
medications. After 18- 20 months of Gymnema extract use, the patients
showed a significant reduction in blood glucose, glycosylated
hemoglobin and reduction in conventional drug use. Five of the 22
discontinued medication altogether and insulin levels in these
patients were increased after taking GS4 (41). Several mechanisms are
thought to account for the hypoglycemic activity of gymnema extracts.
As mentioned previously, gymnema extracts are associated with
increased pancreatic function and insulin release. While recent
studies have confirmed these results in animals (42), in vitro testsN
o . 1 seem to imply that these extracts may stimulate insulin
secretion by increasing beta cell membrane permeability (43). Other
research has also implicated gymnema in the suppression of blood
glucose by inhibiting glucose uptake in the intestine (44). The
current research and safety profile of gymnema extracts make it a
leading botanical in the treatment of type 2 diabetes, and
potentially, type I diabetes.
Bitter Melon
Bitter melon (Momordica charantia) is a tropical fruit that looks
like a cross between a gourd and a cucumber. The fruit is eaten as a
vegetable in many cultures, but has also been used for the treatment
of diabetes by these same cultures. A large body of research now
confirms the hypoglycemic effects of bitter melon in animal models,
while only a few clinical trials have been done with diabetic
patients. A trend in the animal research seems to imply the need for
some insulin production, as NIDDM animal models responded to bitter
melon treatment while IDDM models rarely did (45-49). This mechanism
seems to be confirmed by in vitro evidence that shows protection of
and increased numbers of pancreatic beta cells, and in some cases, an
insulin-releasing activity (50-52).
Bitter melon extracts were also able to reduce oxidative stress
and reverse the effects of chronic diabetes in an IDDM animal model
(53). Additionally, bitter melon extracts show triglyceride and
cholesterol lowering activity in diabetic animals (54), as well as
non-diabetic animals fed cholesterol-rich diets (55). In an
investigation of 4 traditional Indian anti-diabetic herbs (M.
charatia, Eugenia jambolana, Mucuna pruriens and Tinospora
cordifolia) in streptozotocin induced diabetic mice, bitter melon not
only reduced plasma glucose levels more than the other herbs, but
also significantly reduced renal hypertrophy compared to untreated
diabetic controls (56).
Unfortunately, there are few published clinical trials using
bitter melon in humans. In one case, 86% of the NIDDM patients
experienced a hypoglycemic response to drinking an aqueous
homogenized suspension of the vegetable pulp (57). This was similar
to a report that 73% of type II diabetics responded to 2 oz of bitter
melon juice (58). In both studies, response was measured by reduction
in glucose tolerance after glucose challenge. These were not
controlled trials, nor did they use extracts, making it difficult to
assess what dose of the extract would best be used for diabetic
patients. Various powdered extracts are now available and dosing is
estimated at 750-1250 mg per day. More studies need to be conducted
to confirm the efficacy of these extracts in humans, although the
years of dietary use suggests that safety is unlikely to be an
issue.
Fenugreek
The seeds of this Mediterranean spice have long been used for
treating diabetes. It has been thought that the primary hypoglycemic
mechanism is related to the large amount of water-soluble fiber
content found in these seeds. Recently however, other hypoglycemic
compounds have been isolated from fenugreek seeds and are being
investigated for their role in treating diabetics (59-61). Most of
the human clinical trials have been done with between 5 to 100 grams
daily of fenugreek seed powder. This may be manageable for only a few
patients who are willing to ingest these large amounts of powdered
seed. Extracts may soon be used in clinical trials so that the
non-fibrous hypoglycemic portions can be tested for effectiveness,
dosing and safety.
Other Botanicals
It would be impossible to review all the other botanicals that
have published research indicating potential use with diabetics, let
alone cover all those for which traditional information is available.
That said there are a few which are worth mentioning here. One of
those is the herb Holy basil (Ocimum sanctum L.). In animal studies
and one human study, the leaves of holy basil had hypoglycemic
activity. Unlike some of the other herbs above, holy basil lowered
serum blood glucose in both normal and diabetic animals (63,64). A
single-blinded placebo-controlled crossover study did show positive
benefit in both fasting blood sugar and postprandial blood sugar in
NIDDM patients consuming holy basil leaves (65). This may be an herb
to watch as more research and extracts become available.
Another botanical worth considering is the multipurpose milk
thistle (Silybum marianum L.), or more specifically the
seed extract known as silymarin. Most often used for
its liver specific effects, silymarin has shown promise in protecting
chemically induced pancreatic damage (lipid peroxidation) in animal
models of diabetes (66,67). Silymarin (600 mg/day) was also given to
30 insulin-treated type II diabetics suffering from alcohol induced
lever cirrhosis. Both the treatment and the control group were
treated with their previous standard therapy (68). In the silymarin
group, their was a significant decrease in fasting blood glucose
levels, mean daily blood glucose levels, glycosylated hemoglobin
after only 4 months of treatment. At the same time there was a
reduction in fasting insulin levels and stabilization of insulin
need. While the data here is sparse, the overall safety and multiple
other benefits gained by using silymarin may make it a beneficial
addition to the natural treatment of diabetics. Research from the
University of Toronto has shown the potential use of American ginseng
(Panax quinquefolius L.) in glycemic control (70-72). The use of as
little as one gram of ginseng powder administered 40 minutes before a
meal/glucose challenge was able to lower prostprandial glycemia.
These effects were seen in normal as well as type 2 diabetic
patients. Taken 40 minutes before a meal, ginseng may be helpful in
the regulation of glycemic balance.
An extract of Lagerstroemia speciosa L., containing trace levels
of corosolic acid, is currently being studied for its ability to
lower blood glucose levels. A mechanism that allows glucose transport
into cells, apparently without insulin, is being postulated. This
mechanism seems to lower blood glucose regardless of diabetic status
(at least for rats), and is deemed phytoinsulin by one company
selling the extract. Other botanicals include Pterocarpus marsupium,
Atriplex halimu, and garlic (Allium sativum), to name only a few that
have published data. In the next 5-10 years, the growing desire to
use natural remedies combined with the epidemic growth of syndrome X
and diagnosed diabetes will cause the list of published botanical
research reports to expand, and give the clinician and patient many
more options.
Conclusion
Statistical research predicts that regardless of the type of
practice, at least one in five individuals entering clinics in the
United States has the metabolic precursors for insulin resistance and
type 2 diabetes. The treatment and prevention of these disorders is
both natural and eminently holistic. It was the intention of this
review to give the clinician information on the many natural options
available, and to act as a guideline for treatment and prevention. As
each patient presents a different and unique history, different
approaches may be applicable for their individual regimen. Balancing
lifestyle and diet changes, as well as introducing nutraceuticals for
prevention and treatment will be rewarded by slowing or even stopping
potentially devastating outcomes — a reward worth the
effort.
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