NON-PHARMACOLOGICAL METHODS IN MANAGEMENT OF DIABETES 1

Non-pharmacological Methods in Management of Diabetes

Maryna Farynets, Michele Smith, Bridget Bobovnyik

Centofanti School of Nursing, Youngstown State University

3749 Nursing Research

Professor Heasley

19 June 2022
NON-PHARMACOLOGICAL METHODS IN MANAGEMENT OF DIABETES 2

Non-pharmacological Methods in the Treatment of Diabetes

Introduction

Diabetes Mellitus is one of the biggest medical problems in modern society. It has a significant

impact on morbidity, mortality, and medical expenses in every country, thus becoming a global problem.

Millions of adults in the United States and worldwide have this insidious disease and a surprising number

of them are not aware of options available for controlling blood glucose. Many of these people know only

pharmacological methods for controlling blood glucose and preventing complications. There are several

effective nonpharmacological measures that every person struggling with controlling blood glucose can

use. Those measures include changes to diet and exercise routines as well as lifestyle modifications.

Researchers work to evaluate the risk factors associated with Diabetes Mellitus and the role of the

modifiable factors in the management of the disease.

For this research, our group used MEDLINE and CINAHL databases. Search strategies utilized to

find articles about diet include (diabetes Mellitus) AND (blood glucose)) AND (glycemic index). To

narrow down the research, several filters were used for each topic. Our group looked for studies that are

not older than five years, peer-reviewed, and meta-analyses. With these filters, we yielded 79 results for

the glycemic-index topic. During the search for ketogenic diet articles, we used keywords (diabetes

mellites) AND (blood glucose)) AND (keto diet). With the same filters, we yielded two results for the

ketogenic diet topic. Furthermore, strategies utilized to find articles about exercise include (diabetes

mellitus) AND (exercise) AND (blood sugar)). Filters that were used helped us to find the studies that are

not older than five years and are meta-analyses. Two and a half thousand articles were yielded using these

strategies. Using keywords ((exercise*) AND (diabetes) AND (blood*)) with filters on five years and

Meta-analysis we yielded 23,540 results. Finally, search strategies utilized to find articles about lifestyle

modifications include: (diabet*) AND (lifestyle modification or lifestyle choice) AND (effect or
NON-PHARMACOLOGICAL METHODS IN MANAGEMENT OF DIABETES 3

correlation) with filters on five years, peer-reviewed, and all adults, yielded 415 results. Additionally,

using (habit) AND (lifestyle) AND (glycem* or diabet*) AND (effect or correlation) keywords and filters

on five years, peer-reviewed, and all adults, yielded 31,872 results.

Nutrition

The first treatment in controlling diabetes should be a change in diet. Nutrition is an easily

modifiable factor that depends on the choices a person makes. Every patient can determine the foods that

best control blood glucose levels. In combination with other modifiable factors, the diet has a meaningful

effect on the patient’s fasting glucose level and HbA1c. A combination of protein, fats, carbohydrates,

vitamins, and minerals in the diet determines food value and effectiveness in human health. The glycemic

index is a system assigned to carbohydrate-containing nutrients which measures how specific foods affect

blood glucose levels. Food can be divided into a high glycemic index and low glycemic index categories.

This division is based on recognizing that not every carbohydrate has the same composition and the same

effect on blood glucose. The glycemic index division was created to help patients with diabetes make

better food choices that do not disrupt their blood glucose levels (Zafar et al., 2019).

According to Zafar et al. (2019), a diet with a low glycemic index has a significant effect on

glycated hemoglobin and fasting glucose. Specifically, these effects include lower numbers for fasting

blood glucose levels and lower HbA1c numbers. Additionally, a low GI diet improves body weight,

cholesterol levels, and BMI, in people who are obese and overweight. This diet has advantages over other

diets for diabetic patients and people with impaired glucose tolerance. Zafar et al. (2019) analyzed 54

studies that demonstrate improvement not only in HbA1c but also in LDL and TC.

Many diets incorporate principles of GI index and their effect on blood glucose levels. One of the

newer nutrition approaches in the treatment and prevention of Diabetes Mellitus is the ketogenic diet. The

main goal of this diet is a weight decrease which improves insulin sensitivity. The ketogenic diet is a diet

that incorporates an incredibly low amount of carbohydrates (<55g/day). The main source of energy is
NON-PHARMACOLOGICAL METHODS IN MANAGEMENT OF DIABETES 4

proteins and lipids that help the body to reduce stored fat and reduce body weight. The blood ketone body

continues at 0.5-3.0 mmol/L with decreased glucose levels and normal pH, without the symptoms of

nutritional ketosis. Nutritional ketosis is unique in that it does not have adverse health consequences for

the patient compared with severe pathologic diabetic ketosis (Yuan et al., 2020, p.4).

During ketogenesis an insulin receptor is promoted; consequently, a ketogenic diet supports a

negative balance of energy, decreases instability, and a reduction of insulin secretions, which is initiated

by a decrease in carbohydrate intake. Fat oxidation provides energy in a ketogenic diet. Restriction of

carbohydrate intake decreases absorption of simple sugars, which promotes lowering blood glucose and

less fluctuation of glucose levels. A systematic review and meta-analysis by Yuan et al. (2020) of 13

studies show that patients who incorporated the Ketogenic diet into their daily routine had a reduction in

fasting glucose level by 1.29 mmol/L compared to the pre-diet level. It also had a therapeutic effect on the

improvement of HbA1c. A ketogenic diet also has an impact on lipid metabolism. After implementation

of this diet, patients had TG reduction by 0.72 mmol/L, TC decreased by 0.33mmol/l, and LDL decreased

by 0.05 mmol/L. Furthermore, HDL increased by 0.14 mmol/L (Yuan et al., 2020, p.6).

According to Yuan et al. (2020), a ketogenic diet also affects body weight. The results of the

meta-analysis show that the average weight reduction is 8.66 kg, body mass index decreased by 3.13

kg/m2, and weight circumferences lowered by 9.17 cm (p.4). Since obesity is strongly associated with

insulin resistance, the reduction of body weight improves insulin sensitivity and quality of life in obese

and overweight patients. Side effects of the ketogenic diet are only shortly described in a meta-analysis by

Yuan et al. (2020). It mentions weakness, nausea, vomiting, and headache are the most frequent side

effects after a two-week intervention. Constipation and orthostatic hypotension were the most common

side effects after 10 weeks of intervention. Additionally, patients reported a sense of hunger and diarrhea

among other common side effects. Despite these side effects, a ketogenic diet is another

nonpharmacological option that can be successfully used in the management of diabetes.

Exercise
In the article by Savikj and Zierath (2020), both authors explore the physiological effects of

aerobic training (running), resistance training (weightlifting), and combined training (both running and

weightlifting) on individuals who are diagnosed with type 2 diabetes. The physiological effects focused

on within the study were HbA1c levels, insulin sensitivity, and glycemic control. The results from the

study yielded combined training as the preferred method of training in individuals diagnosed with type 2

diabetes.

Aerobic training is the most prescribed method of exercise for individuals diagnosed with type 2

diabetes management. Moderate to high-intensity aerobic training lowers HbA1c levels after a two six-

month period, as compared to conventional treatment. Furthermore, a meta-analysis of nine random

control trials reported that aerobic training elicits a small but consistent decrease in HbA1c levels of

0.67% (~7.5 mmol/mol) in individuals diagnosed with type 2 diabetes. Moreover, aerobic training

increases insulin sensitivity by enhancing skeletal muscle glucose uptake. This effect is maintained for 48

hours. As stated in the article, “exercise-induced improvements in insulin action are likely to result from

skeletal muscle adaptations, such as increased glycogen stores and synthesis rates, supported by increases

in GLUT4 protein content and glycogen synthase activity” (Savikj and Zierath, 2020, p.1494). Thus,

aerobic training improves insulin sensitivity and glycemic control.

One single session of resistance training results in an acute improvement in glycemic control.

Within the nine random control trials, the results indicate that longer resistance training periods, such as a

period of five-six months, lowers HbA1c levels by 0.4-0.8% (4.1-8.7 mmol/mol). This is likely due to

skeletal muscle adaptations. Moreover, controlled trials during a four–six-week period of an extensive

whole-body training reveals that individuals who are diagnosed with type 2 diabetes have increased

insulin sensitivity, as well as increased glucose disposal, 48 hours after the session of resistance training.

As stated in the article by Savikj and Zierath (2020), “in addition to aerobic regimens, resistance training
NON-PHARMACOLOGICAL METHODS IN MANAGEMENT OF DIABETES 6

regimens are efficacious in improving glycemic control in individuals with type 2 diabetes” (p. 1494).

Thus, resistance training is just as effective as aerobic training.

Lastly, combination training—both aerobic and resistance training—was studied during a six-

month period. The results of this training method indicate an even further decrease in HbA1c levels by

0.9% (10.6 mmol/mol) as opposed to aerobic or resistance training alone. Moreover, the nine random

control trials of combination training displayed greater insulin-sensitivity effects in four out of the six

months, compared to both aerobic or resistance training alone. Furthermore, “these differences may partly

be accounted for by larger increases in skeletal muscle mass and subsequent expansion of glycogen

storage capacity” (Savikj and Zierath, 2020, p.1495). Regardless, training of any method improves

glycemic control and insulin sensitivity.

In the article by Wake (2020), the author explores the role of physical activity in the management

of type 2 diabetes and pre-diabetic individuals. Furthermore, Wake (2020) discusses the effects of aerobic

training, resistance training, and combination training. The results of the article demonstrate that

combination training is the most effective method of exercise in the management of individuals diagnosed

with type 2 diabetes and pre-diabetic individuals.

Physical activity may be used as a non-pharmacological method in the maintenance and

prevention of type 2 diabetes by improving glycemic control. According to Wake (2020), a randomized

trial reported that exercising 30 minutes after eating a meal provides better improvements in glycemic

control for individuals diagnosed with type 2 diabetes mellitus. Furthermore, a single session of exercise

has beneficial effects in type 2 diabetic individuals. Such effects include blood pressure control,

carbohydrate oxidation, improvement in glycemic index, and fat oxidation. Moreover, individuals who

exercised consistently for a 12-week period had significant improvements in oxygen uptake and

metabolic control. Physical activity has significant effects on insulin sensitivity. According to Wake

(2020), “whenever muscle cells contract during exercise, the muscle cells are able to take up glucose and

use it for energy, whether insulin is available or not” (p. 2913).

According to Wake (2020), individuals who perform aerobic training have improved not only,

glycemic control, insulin sensitivity, insulin action HbA1c levels, and reduced insulin resistance, but also

body composition, quality of life, and physical capacity. Additionally, aerobic exercises have a positive

effect on nerve function, functional capacity, cardiorespiratory fitness, insulin levels, lipid profile, blood

pressure, and cardiovascular risk. Individuals who perform resistance training have also improved HbA1c

levels, glycemic control, insulin sensitivity, insulin responsiveness, insulin action, and physical functions.

Moreover, resistance exercises decreased insulin resistance, abdominal fat, BMI, insulin levels,

triacylglycerol levels, lipid profile, body fat, blood pressure, and cardiovascular risk. Lastly, according to

Wake (2020), individuals who perform combined training have improved not only HbA1c levels,

glycemic control, insulin sensitivity, functional capacity, strength, and vascular function, but also

improved body composition, reduced blood lipids, and blood pressure. The results of Wake's (2020) study

concluded that all three methods of exercise have a significant role in combating diabetes.

Lifestyle Modification

Simply knowing that one’s diet and exercise routines can be modified to help maintain healthy

blood glucose levels is not enough. Despite advancements in technology that simplify glucose

monitoring, making glucose monitoring easier for the individual, there still is a lack of consistency in

self-monitoring in young adults. Being able to identify the various components that contribute to

successful glucose monitoring can improve one’s results in one’s glycemic index. Especially in young

adults, components such as personal habits, daily routines, stress levels, and impulse control have been

shown to have an effect, directly or indirectly, on the level of success in controlling glycemic levels an

individual has.

Routines that are regular and consistent within a time period help to provide structure in one’s

own life and have been shown to have a direct relationship with self-control. Routines are also reflective

of one’s habits, and habits can be shaped by a trigger, in one form or another. Hanna, et al. (2020) found
NON-PHARMACOLOGICAL METHODS IN MANAGEMENT OF DIABETES 8

that a trigger in the form of a text message reminder for those in their study improved glycemic control

for those who followed through at least half of the time (p.2). Those who were not as successful in

controlling their glucose levels were those who had experienced a change in some way to their daily

routine, such as a change in one’s work schedule. However, some disruptions could also be linked with

the level of stress one is experiencing at the time, as well. This is just one example of how an individual

trigger can affect one’s daily routine. Though, individuals who exercise regularly have better control over

checking one’s blood sugar levels. As a result, these individuals are the most successful in controlling

blood glucose levels.

Key lifestyle behaviors that have been identified include eating a high-quality diet, engaging in

physical activity, non-smoking, and moderation in alcohol intake. Management of diabetes usually

focuses solely on the person who has been diagnosed with diabetes. However, diabetes is a very

multifaceted disease that can affect every aspect of an individual's life. Amirehsani, et al. (2019) wrote

“To improve health, diabetes self-management requires persons with diabetes (PWD) to have the

knowledge, skills, health literacy, and self-efficacy, as well as to be empowered to set goals, actualize

behavior-specific action plans and problem solve if obstacles occur” (p.88). Knowledge, encouragement,

reinforcement, and educational support about diabetes mellitus are all crucial. However, “despite the

proven benefits of diabetes self-management education and support (DSME/S), less than 10% of privately

insured or Medicare patients attend such programs within the first year of a diabetes diagnosis”

(Amirehsani et al., 2019, p.88).

Success is not only found in the modification in the lifestyle of the individual but can also be

determined by that individual’s family or external support system. Findings suggest that family members

can either be a positive influence on healthy choices or become an obstacle and even sabotage healthy

changes. Changes in one’s lifestyle can be a bit intimidating; however, putting an action plan into play for

oneself or family is a way to track success over time. Individuals diagnosed with diabetes became

healthier and were more successful in controlling one’s blood sugar levels when the lifestyle and food
NON-PHARMACOLOGICAL METHODS IN MANAGEMENT OF DIABETES 9

choice changes were supported and adopted by the entire family. Additionally, other family members

were able to lower their individual risk for diabetes in the future.

Making healthier food choices can prove beneficial for reasons already discussed, as foods with a

higher glycemic index can be detrimental to maintaining a healthy glucose level. Eliminating smoking

from one’s habits is a modification that any individual should make for several reasons. Cardiovascular

disease and microvascular damage are much higher and are more prevalent in individuals with diabetes.

Being able to recognize and deal with one’s emotions can help as well. The more effective one’s

emotional coping strategy; the more control one has over his or her blood sugar levels. Because cigarette

smoking and/or drinking alcohol may be one’s current coping mechanism, maintaining a daily journal can

help one to stay accountable for his or her actions, thereby further assisting one to make these lifestyle

modifications.

The quicker and more consistent modifications are made and incorporated into one’s lifestyle, the

more likely those changes will become part of one’s daily routine. Success is determined by several

factors, but changes in one’s outlook and lifestyle can be considered another non-pharmacological option

that can be used in the successful management of diabetes.

Conclusion

In conclusion, diabetes is one of the major healthcare problems that have a significant effect on

the lives of millions of people around the world. Even with the advancement of technologies and the

development of new medications, there is no cure available. Management of diabetes generates billions of

dollars in expenses for pharmacological treatments but there are several ways in which it can be

controlled with fewer medications. Nutrition is one of the easiest ways to control blood glucose. Patients

with diabetes should choose low glycemic foods to manage their blood glucose. Additionally, a ketogenic

diet is acceptable for diabetes management. Maintaining blood sugar can be controlled through healthy

lifestyle choices, routines, effective coping strategies, and support. Combination training is the most
NON-PHARMACOLOGICAL METHODS IN MANAGEMENT OF DIABETES 10

beneficial method of exercise in individuals who are diagnosed with type 2 diabetes or those who are pre-

diabetic. However, aerobic and resistance training are also beneficial to the health of individuals who

have unmanaged glucose levels and HbA1c levels.

References

Amirehsani KA; Hú J; Wallace DC; Silva ZA; Dick S; (2019, February). Hispanic families' action plans

for a healthier lifestyle for diabetes management. The Diabetes educator. Retrieved May 19, 2022,

from https://pubmed.ncbi.nlm.nih.gov/30466357/

Hanna KM; Kupzyk KA; Hansen JR; Jones-Ryan ML; Drincic AT; (n.d.). Association of Habits,

triggers, glycemic control, routines, stress, and impulse control among emerging adults with type

1 diabetes. Diabetic medicine: a journal of the British Diabetic Association. Retrieved May 19,

2022, from https://pubmed.ncbi.nlm.nih.gov/32745273

Saviki, M., & Zierath, J.R. (2020). Train like and athlete: applying exercise interventions to manage type

2 diabetes. Diabetologia, 63(8), 1491-1499. Retrieved May 16, 2022, from https://doi-

org.eps.cc.ysu.edu/10.1007/s00125-020-05166-9

Wake, A. D. (2020). Antidiabetic effects of physical activity: how it helps to control type 2 diabetes.

Diabetes, metabolic syndrome, and obesity: targets and therapy, 13, 2909-2923. Retrieved May

16, 2022, from https://doi-org.eps.cc.ysu.edu/10.2147/DMSO.S262289

Yuan X; Wang J; Yang S; Gao M; Cao L; Li X; Hong D; Tian S; Sun C; (n.d.). Effect of the ketogenic

diet on glycemic control, insulin resistance, and lipid metabolism in patients with T2DM: A

systematic review and meta-analysis. Nutrition & diabetes. Retrieved May 30, 2022, from

https://pubmed.ncbi.nlm.nih.gov/33257645

Zafar MI; Mills KE; Zheng J; Regmi A; Hu SQ; Gou L; Chen LL; (n.d.). Low-glycemic index diets as an

intervention for diabetes: A systematic review and meta-analysis. The American journal of

clinical nutrition. Retrieved May 30, 2022, from https://pubmed.ncbi.nlm.nih.gov/31374573