Whole Health emphasizes mindful awareness and Veteran self-care along with conventional and integrative approaches to health and well-being. The Circle of Health highlights eight areas of self-care: Surroundings; Personal Development; Food and Drink; Recharge; Family Friends; and Co-Workers, Spirit and Soul, and Power of the Mind; and Moving the Body. The narrative below shows what a Whole Health clinical visit could look like and how to apply the latest research on complementary and integrative health to endocrine health.
A Whole Health approach to endocrine health encourages exercise (at least 150 minutes a week) and specific diets (low glycemic index, Mediterranean, and vegetarian), as well as complementary practices such as biofeedback and meditation. This overview focuses primarily on insulin resistance and type 2 diabetes; other endocrine tools focus more on thyroid, adrenals, and relevant dietary supplements.
Meet the Veteran
Richard is a 62-year-old Navy Veteran who is following up in your office for discussion of abnormal labs detected on his physical exam two months ago. He has not been to the doctor in several years and his fasting lab work demonstrated a blood glucose of 130, triglycerides of 260, high-density lipoprotein (HDL, “good” cholesterol) of 29, and an low-density lipoprotein (LDL, “bad” cholesterol) of 135. His hemoglobin A1c (HbA1c) was 6.7. Other medical problems include obesity, with a body mass index (BMI) of 34, and borderline hypertension. He has a history of alcohol use, but he quit drinking alcohol 5 years ago and does not smoke. He is married and has three adult children. He is an avid outdoorsman. He and his wife have been under significant financial stress over the past two years due to his unemployment, though he is about to start a new job at a local manufacturing plant. Richard’s mother had diabetes and died of diabetic complications, and he wants to do whatever he can to avoid a similar course. He understands he has diabetes and presents now for follow-up. While he is willing to do all he can to treat early diabetes, he prefers to avoid medications if possible.
Personal Health Inventory
On his Personal Health Plan (PHI), Richard rates himself as a 3 out of 5 for his overall physical well-being and a 4 for overall mental and emotional well-being. When asked what matters most to him and why he wants to be healthy, Richard responds:
“I enjoy spending time with my wife Susan and I want us to be able to enjoy retirement together in a few years. I would like to be around for my kids’ families. If I had the time, energy or finances, I’d be able to hunt, fish, and travel with my wife.”
For the eight areas of self-care, Richard rates himself on where he is, and where he would like to be. He decides to first focus on the areas of Moving the Body and Food and Drink by scheduling more time to exercise and finding strategies for healthy eating.
For more information, refer to Richard’s PHI.
Type 2 diabetes mellitus (T2DM) is a metabolic disorder characterized by insulin resistance and eventual insulin deficiency leading to high blood glucose. Extensive research is currently underway to better understand the causes of insulin resistance in the body and the many pathways to it, including how obesity, toxins, infections, and emotional stress all contribute to chronic inflammation and the development of T2DM. Several large clinical trials have shown that control of hyperglycemia alone reduces the microvascular (small-blood vessel) complications of diabetes, but it does not reduce the macrovascular (large vessel) complications such as cardiovascular disease, or decrease mortality. This suggests, then, that only treating blood glucose in diabetics is not enough, and that other goals need more attention, including reducing inflammation and improving lifestyle choices. Patients need to know that diabetes is a preventable and reversible disease in most cases. This is the goal of the Whole Health approach to diabetes care.
Lab values offer important information about a patient’s diabetes control, but treating glucose levels and hemoglobin A1c values should not be the only goal. Lifestyle, control of inflammation, and emphasis on other vascular risk factors are of fundamental importance in the Whole Health approach.
Supporting patients in the tasks of managing their diabetes calls for more than education, in which patients only gain knowledge. Patients need to have the skills and confidence to effectively manage the condition on their own, since they live with it daily. Self-management occurs within the framework of daily life patterns. It involves making effective health decisions day by day.
Many clinicians feel it is difficult to counsel patients on self-management strategies. While this longitudinal process may be challenging in some ways, it can also lead to some of the most rewarding experiences in the patient-clinician relationship. One systematic review on this topic showed that self-management interventions have positive effects on diabetes-specific quality of life. In addition, interdisciplinary self-management interventions can lead to clinically relevant improvements in behaviors and some clinical parameters.There does not appear to be a significant difference between individual or group self-management interventions.
More-recent literature suggests there are many effective ways to engage with self-care activities. For example, a systematic review of 26 articles and 2,645 total participants with T2DM found that smartphone-based self-management led to better self-efficacy, better health-related quality of life, and lower hemoglobin A1c.While there are some reviews pointing to the successes of self-care for type 2 diabetes, there is still a significant body of literature pointing to the uncertainty of the benefit of these practices. One review suggested that people with T2DM are more likely to adhere to taking medications versus diet, exercise, blood sugar self-monitoring, or foot care. Personalizing care may be a key component to more successful engagement with healthy self-care activities. This is supported by a review of people with disabilities who also have been diagnosed with T2DM.
Food and Drink
Nutrition is a fundamental part of diabetes prevention and treatment. Current American Diabetes Association (ADA) guidelines do not endorse a specific dietary plan but rather identify carbohydrate counting as a key aspect of glycemic control. Patients on insulin must match carbohydrate content with doses of insulin and insulin secretagogues. To reduce cardiovascular disease (CVD) risk factors, patients with diabetes are advised to eliminate trans-fat intake and limit saturated fat to less than 7% of total calories. Weight loss also is recommended for overweight and obese patients.Many patients with diabetes turn to integrative medicine as they seek additional dietary guidance and want to know how specific diet plans and food choices will affect glycemic control and comorbid health conditions (Table 1).
The 2011 ADA guidelines acknowledge that incorporating glycemic index (GI) into a patient’s diet may provide additional benefit for glycemic control over consideration of total carbohydrate count alone. Table 1 lists some GIs for common foods. Authors of a Cochrane review of 11 small studies found a 0.5% reduction in HbA1c (95% CI -0.9 to -0.1, p=0.02) in patients with T2DM who followed a low-GI diet. This diet also led to a significant reduction in hypoglycemic events as compared with a high GI diet or other diets.Glycemic Index” Whole Health tool.This finding was confirmed in an independent meta-analysis of the same studies. One of the included studies also demonstrated a statistically significant increase in HDL. For more information, refer to the “
Table 1. Average Glycemic Index Content of Foods (Note: some variation based on preparation)