Non-pharmacological Treatment Options in the Management of Diabetes Mellitus

“GL depends on the amount of carbohydrate present in a particular food item for digestion and absorption, and is calculated by measuring the carbohydrate content of the item, multiplied by its GI and divided by 100.(9,10) GL is a concept”

“In recent years, gut microbiome has been proposed to influence a multitude of physiological and pathological processes in human beings.(74) Marked changes in the gut microbiome after bariatric procedures have been shown to improve metabolic parameters and bodyweight in multiple studies.”

“People with T2DM receiving microbiota from normal individuals showed improvement in glycaemic control, emphasising the role of gut microbiota in metabolic control.(80) Germ-free mice receiving gut microbiota from post-bariatric surgery cases showed a reduction in body fat composition and lower respiratory quotient.”

“Ghrelin (a gut hormone that stimulates hunger) level was found to be low after bariatric surgery, which suppress hunger signals in these participants.(73) These alterations in hormonal mechanisms positively affect the energy balance, insulin sensitivity, β-cell function and glycaemic parameters to contribute to improv…”

“33 EUROPEAN ENDOCRINOLOGY This dietary pattern adapted in the olive-growing areas of the Mediterranean region (especially Greece and Italy) in the late 1950s and early 1960s, collectively known as MD, is used to describe the traditionally followed dietary pattern of people living in countries bordering the Mediterrane…”

“It improves the adverse lipid profile by reducing total cholesterol and low-density lipoprotein (LDL) cholesterol and increasing high-density lipoprotein (HDL) cholesterol.(33) These, in turn, reduce the risk of various cardiovascular events inherent to patients with T2DM.”

“All individuals should avoid prolonged sitting/sedentary activity by breaking every 30 minutes by briefly standing, walking or performing other activities.(42,43) Frequency, duration, intensity and type of exercise programme, age of the patient and adherence to the exercise programme are the major factors influencing…”

“3%), similar to that of laparoscopic cholecystectomy.(53,54) Factors which influence the risk of complications include experience and volume of surgeries in the centre, complexity of the procedure, age and BMI of Figure 3: Sleeve gastrectomy”

“However, recent studies have clearly demonstrated that different models of high-quality diets were associated with significant reductions in all-cause mortality, cardiovascular disease, cancer and T2DM by 22%, 22%, 15% and 22%, respectively.(8)”

“In the PREDIMED-Reus nutrition intervention trial among non-diabetic participants with high cardiovascular risk, MD was found to reduce the incidence of T2DM by 52%.(27) In patients with T2DM, MD is found to be beneficial in achieving glycaemic control, reducing insulin resistance and cardiovascular risk factors (BMI,…”

“Diets with low GL have also shown benefits in managing T2DM and reducing complications in several studies.(12,13,16,17)”

“The relative risk of development of T2DM in men who exercise once-weekly only was higher than those who do exercise five or more times per week in the physicians’ health study.(45)”

“In patients with T2DM, MD is found to be beneficial in achieving glycaemic control, reducing insulin resistance and cardiovascular risk factors (BMI, blood pressure, cholesterol, inflammatory markers and adhesion molecules) and improving liver function and sexual function.(28,29) Probable mechanisms of the beneficial…”

“Germ-free mice receiving gut microbiota from post-bariatric surgery cases showed a reduction in body fat composition and lower respiratory quotient.(81) Alterations in the intestinal and plasma bile acids is another postulated mechanism in the improvement of T2DM, bodyweight and other metabolic parameters after bariat…”

“Marked improvements in metabolic parameters such as a reduction in LDL cholesterol and triglycerides, and increase in HDL cholesterol were seen in patients.(98) Remission of abnormal kidney function in 86%, prediabetes in 76%, elevated blood pressure in 74% and dyslipidaemia in 66% of young adults with significant imp…”

“Careful patient selection and education, well defined standard preoperative protocols, properly educated medical teams, use of laparoscopic surgery, clearly defined discharge criteria and modern perioperative care are the major components of ERAS.51 Although this approach has shown benefits in terms of reduced hospita…”

“36 EUROPEAN ENDOCRINOLOGY pain, abdominal distension, bloating, hiccup, nausea, vomiting, breathlessness and tachycardia.(61)”

“MNT not only aims to control blood glucose, but also to improve other co-morbidities such as hypertension, dyslipidaemia and obesity.(19) Diets with low GI reduce postprandial blood glucose excursions that improve”

“The intestinal microbiome seen in obese individuals are replaced by organisms seen in lean individuals after bariatric surgery.(78) Germ-free mice receiving these ‘lean microbiota’ population showed significant weight loss and reduction in body fat.”

“If the fasting plasma glucose is <100 mg/dL or HbA1c <6% for at least 1 year without any active pharmacological therapy, complete remission is obtained, and if these parameters are sustained for at least 5 years, prolonged remission is achieved.(85) Similarly, if fasting plasma glucose is between 100–125 mg/d or HbA1c…”

“All individuals should avoid prolonged sitting/sedentary activity by breaking every 30 minutes by briefly standing, walking or performing other activities.(42,43) Frequency, duration, intensity and type of exercise programme, age of the patient and adherence to the exercise programme are the major factors influencing…”

“Diets with low GL have also shown benefits in managing T2DM and reducing complications in several studies.(12,13,16,17)”

“Although this approach has shown benefits in terms of reduced hospital stay, reduction of morbidity has not been observed in a recent meta-analysis.(52)”

“Sleep deprivation results in weight gain and obesity by multiple mechanisms such as hyperactivity of the orexin system, overeating and reduced energy expenditure.(110)”

“A calorie-restricted diet by itself helps T2DM cases to improve insulin sensitivity, β-cell function and the glycaemic parameters.(70) Long-term calorie restriction is mandatory in patients who have undergone bariatric surgery to obtain maximum health benefits including the maintenance of diabetes remission.”

“Exercise also improves hepatic insulin sensitivity, reduces insulin resistance and improves glucose disposal in peripheral tissues.(37,38)”

“38 EUROPEAN ENDOCRINOLOGY results in the worsening of glycaemic control.(112) OSA also increases cardiovascular morbidity.”

“Remission of abnormal kidney function in 86%, prediabetes in 76%, elevated blood pressure in 74% and dyslipidaemia in 66% of young adults with significant improvement of weight-related quality of life were reported following 3 years of bariatric surgery in adolescents recently.(99)”

“Hyperoxaluria with nephrolithiasis is another important delayed complication of malabsorptive bariatric procedures.(65)”

“Post-bariatric surgery patients should adhere to specific dietary recommendations such as taking food in small fractions, eating slowly, chewing well and drinking fluids only after an hour of a meal to prevent many of these complications.(60) Failure to adhere to dietary recommendations after surgery results in pouch…”

“Secondary prevention measures aim to achieve tight glycaemic control by dietary modification and, thereby, reducing diabetic complications in patients with T2DM.18 Tertiary prevention measures are to manage diabetes-related complications such as cardiovascular or renal disease in those with T2DM.”

“The MD is found to be protective not only in healthy individuals but also in women with a history of gestational diabetes and those with cardiovascular disease.(25,26) In the PREDIMED-Reus nutrition intervention trial among non-diabetic participants with high cardiovascular risk, MD was found to reduce the incidence o…”

“The beneficial effect also shows a clear linear relationship with the total energy expenditure during exercise.(44) The relative risk of development of T2DM in men who exercise once-weekly only was higher than those who do exercise five or more times per week in the physicians’ health study.”

“Secondary prevention measures aim to achieve tight glycaemic control by dietary modification and, thereby, reducing diabetic complications in patients with T2DM.18 Tertiary prevention measures are to manage diabetes-related complications such as cardiovascular or renal disease in those with T2DM.”

“Obesity surgery mortality risk score helps to predict surgical mortality risk after bariatric surgery.(56) The variables considered are BMI >50, male sex, hypertension, risk factors for pulmonary thromboembolism and age >45 years.”

“Diets with low GL have also shown benefits in managing T2DM and reducing complications in several studies.(12,13,16,17)”

“The MD is found to be protective not only in healthy individuals but also in women with a history of gestational diabetes and those with cardiovascular disease.(25,26) In the PREDIMED-Reus nutrition intervention trial among non-diabetic participants with high cardiovascular risk, MD was found to reduce the incidence o…”

“The insulin doses can be calculated as per the carbohydrate counting principles adopted for patients to optimise diabetes control.(30) Carbohydrate counting is a method of calculating the grams of carbohydrate consumed in a meal expressed as grams or as servings.”

“But with continued exercise, muscle glycogen breakdown decrease and fall in blood glucose results in the suppression of insulin secretion and an increase in glucagon secretion, which stimulate hepatic glycogenolysis.(34) With prolonged exercise, muscle glycogen stores get depleted and free fatty acids, derived from th…”

“This is collectively termed as the FITT principle: Frequency (the number of times exercise is done), Intensity (the amount of effort for the exercise), Time (the duration of exercise) and Type (aerobic or resistance).(47)”

“Physical activity improves insulin sensitivity, bodyweight, cardiovascular risk factors, physical fitness, lipid level, blood pressure and overall wellbeing, and reduces the risk of cardiovascular morbidity and mortality.(32)”

“Exercise also improves hepatic insulin sensitivity, reduces insulin resistance and improves glucose disposal in peripheral tissues.(37,38)”

“Obesity affects a proportion of patients with T1DM that increases their insulin requirements and adversely affect their metabolic control.(5) Therefore, lifestyle modifications are important even in cases with T1DM.”

“The risk of development of iron deficiency is 13–52% within 2–5 years after bariatric surgery, which can be significantly reduced by iron supplementation.(62) The chance of the development of calcium deficiency is about 10% and vitamin D deficiency is up to 51%, which can lead to secondary hyperparathyroidism.”

“9% respectively, were observed in a recent meta-analysis examining five RCTs and 10 observational studies involving 446 patients treated by this technique.(105)”

“35 EUROPEAN ENDOCRINOLOGY the patient, male sex, limited physical activity and associated problems such as hypertension, obstructive sleep apnoea (OSA) and risk factors for pulmonary thromboembolism.(55) Obesity surgery mortality risk score helps to predict surgical mortality risk after bariatric surgery.”

“The MD consists of a high amount of olive oil, vegetables, legumes, whole grains, fruits and nuts, a moderate amount of poultry and fish, a low amount of whole fat dairy products and red meat, and low to moderate amounts of wine.(23,24) The MD is found to be protective not only in healthy individuals but also in women…”

“6).(103) Serious complications were reported in 1.”

“37 EUROPEAN ENDOCRINOLOGY A sustained remission of diabetes is seen in 30–63% of T2DM patients following bariatric surgery on an average follow-up period of 1–5 years.(88) Although 30–50% of patients achieved initial remission relapse after a median follow-up duration of 8.”

“Although results of the Look AHEAD trial did not demonstrate clear cardiovascular mortality benefits of intense lifestyle interventions including dietary restrictions aiming at weight loss, intense lifestyle interventions were associated with better glycaemic control in the participants.(7) The Look AHEAD trial partic…”

“Significantly better HbA1c reduction has been reported with this strategy in a recent metaanalysis.(31) Therefore, in an ideal situation, carbohydrate counting should be recommended to all patients with T1DM.”

“Physical activity for patients with type 1 diabetes mellitus Exercise training in the form of resistance, endurance and combined training consisting of both, has been shown to improve glycaemic control and diabetes outcomes in patients with T1DM in a recent systematic review and meta-analysis.(46) However, we need to…”

“This abdominal and visceral adiposity in turn modulates several hormonal and chemical mediators in the body that result in ‘diabesity’, the term coined to interlink diabetes in relation to obesity.(3) The ‘metabolically obese’ phenotype having normal bodyweight and normal or low body mass index (BMI), but increased ab…”

“Increased secretion of glucagon-like peptide-1, glucose-dependent insulinotropic peptide, peptide-YY and oxyntomodulin that alter energy balance and glucose metabolism have been reported.(48,71,72) Ghrelin (a gut hormone that stimulates hunger) level was found to be low after bariatric surgery, which suppress hunger s…”

“Better understanding of the pathophysiology of diabesity resulted in the development of several novel therapeutic strategies over recent years for the management of this alarming global epidemic.(4)”

“Secondary prevention measures aim to achieve tight glycaemic control by dietary modification and, thereby, reducing diabetic complications in patients with T2DM.18 Tertiary prevention measures are to manage diabetes-related complications such as cardiovascular or renal disease in those with T2DM.”

“Although bariatric procedures are usually done in patients with T2DM, obese patients with T1DM also have shown some beneficial effects with a significant reduction of insulin requirements and modest improvement in diabetes control.(6)”

“People who sleep less than 6 hours per night are at risk of developing diabetes, and it is advised to have 7 hours of uninterrupted sleep per night.(108)”

“Gastro-gastric fistulas, an abnormal communication between the gastric pouch and the excluded stomach, is a rare complication after bariatric surgery that results in inadequate weight loss or weight gain, marginal ulceration, recurrent gastrointestinal haemorrhage and abdominal pain.(63) Some surgeons perform prophyla…”

“Different studies showed that OSA is associated with increased insulin resistance and the development of T2DM, even independent of obesity.(111,112) The reported overall prevalence of OSA in T2DM varies from 58–86%, although it is largely an unrecognised problem.”

“EndoBarrier Gastrointestinal Liner (GI Dynamics®, Boston, US), duodenal-jejunal bypass sleeve, is a mechanical device that is placed in the proximal small intestine to prevent the contact of food with pancreatic and biliary secretions until it reaches the initial part of the jejunum.(104) A 60 cm sleeve, made of polym…”

“Surgery was associated with a significant reduction in bodyweight, insulin requirements, improvement of obesity comorbidities and some diabetes complications.(102) However, there was only a marginal effect on glycaemic control in treated patients on longterm follow-up.”

“Factors identified to influence remission were: preoperative glycaemic control, history of insulin use, duration of diabetes, patient compliance, weight loss, the type of diabetes (T2DM or late onset autoimmune diabetes, or T1DM) and greater baseline visceral fat area.(86,87)”

“The MD consists of a high amount of olive oil, vegetables, legumes, whole grains, fruits and nuts, a moderate amount of poultry and fish, a low amount of whole fat dairy products and red meat, and low to moderate amounts of wine.(23,24) The MD is found to be protective not only in healthy individuals but also in women…”

“However, the presence of neuroglycopaenic features is often associated with PBH, which helps suspicion of this condition in patients.(66) Carbohydrate-restricted diet, increased consumption of dietary fibres and avoidance of alcohol helps to reduce the incidence of PBH.”

“Drugs such as acarbose, diazoxide, octreotide and verapamil are useful in treating PBH.(67,68) Restoring gastric restriction with an adjustable band, placing the gastrostomy tube and subtotal or total pancreatectomy are proposed as surgical treatment options for severe intractable PBH.”

“Increased secretion of glucagon-like peptide-1, glucose-dependent insulinotropic peptide, peptide-YY and oxyntomodulin that alter energy balance and glucose metabolism have been reported.(48,71,72) Ghrelin (a gut hormone that stimulates hunger) level was found to be low after bariatric surgery, which suppress hunger s…”

“Another common complication is small bowel obstruction within the first month of surgery that presents with severe abdominal pain, nausea, vomiting, obstipation and tachycardia resulting from kinking at the jejunojejunostomy site, anastomotic site stenosis, external compression, or adhesions or herniation through the…”

“21) in the surgical groups compared to non-surgical groups.(100) Another recent study reporting 12-year follow-up data showed that the age- and sex-adjusted mortality was significantly lower in the RYGB group compared with the non-surgery group (odds ratio [OR] = 0.”

“Anastomotic leak is another leading cause of mortality and usually presents with severe tachycardia, respiratory failure, left shoulder pain and left pleural effusion in the early post-operative period that should be differentiated from acute pulmonary embolism.(57)”

“, 2013) but may also improve insulin resistance and hereby potentially reduce the risk of depression(Raveendran, 2018).”