Required Reading

Review by Jacob Schor, ND, FABNO

Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type 1 and Type 2 Diabetes by Dr. Mona Morstein, ND, DHANP

Chelsea Green Publishing, White River Junction, Vermont.

c. 2017; 560 pp.; $29.95.

There are a few things we know right off the bat. First, diabetes is common. Two, the standard treatments offered to patients with diabetes are mediocre at best for controlling the disease; and third, a naturopathic approach, in particular a whole foods, low-carbohydrate diet as championed by Mona Morstein, works far well.

The Centers for Disease Control reported in July 2017, “More than 100 million U.S. adults are now living with diabetes or pre-diabetes… as of 2015, 30.3 million Americans – 9.4 percent of the U.S. population –have diabetes. Another 84.1 million have pre-diabetes, a condition that if not treated often leads to type 2 diabetes within five years.” Diabetes was the seventh leading cause of death in the US in 2015.¹

A 2017 estimate suggests that incidence of diabetes will increase 54% between 2015 and 2030 so that there will be nearly 55 million Americans with diabetes, and annual deaths from diabetes will top 385,000.

Thus, almost one in ten people have diabetes plus about one in four people are headed toward diabetes. Whether you plan on seeing diabetics in your practice or not, you won’t have a choice. You’re going to. I limit my practice to oncology patients only, yet, probably 10 – 15% of my patients are diabetic, about the same as this national average. It doesn’t matter if you want to specialize in treating allergies or SIBO, you are still going to see diabetic patients. You don’t get to choose.

The standard medical approach advocated by the American Diabetic Association (ADA) to treat insulin-dependent diabetes is to have the patient follow a slightly altered version of the standard American diet, and then take enough insulin to match their carbohydrate intake. Basically, the ADA-suggested diet is a low-fat, high-carb diet. The problem with this is that getting that insulin dose to match exactly is hard, and the higher the carbohydrate intake, the harder it gets to pull off. Too much insulin and the patient is hypoglycemic, too little and they are hyperglycemic. Most of their days and nights are spent riding a rollercoaster between these two extremes.

Over the years, Dr. Morstein has developed a strategy of low-carbohydrate diets for treating these patients. The lower the carbohydrate intake, the lower the insulin requirement. Patients can control their blood sugar easier, and they feel better.

This approach is modeled off the work of Richard Bernstein, MD, who pioneered this concept of low-carb diets for treating diabetes.² Bernstein has over the years shared a number of comments disparaging the American Diabetic Association’s stance on a range of diabetic-related topics. I mention this because while many of us feel that Bernstein is onto something valuable, we must concede that his ideas are far from mainstream.

His 1997 book, Dr. Bernstein’s Diabetes Solution, recommends “… limiting daily carb intake to about 30 grams, the amount in a sweet potato or about four or five cups of cooked broccoli.”Bernstein believes the fewer carbs eaten, the easier it is to stabilize

blood sugar with insulin.”³

To sum up Dr. Morstein’s approach, think of it as a healthier version of Bernstein. Bernstein is fixated on carbohydrate intake alone. Morstein attempts to add healthy food choices on top of that. Her practice has focused on treating diabetes for a quarter of a century. She is the expert on treating diabetes in the naturopathic profession.

Dr. Morstein practices in Tempe, Arizona. She was the professor of nutrition at Southwest College of Naturopathic Medicine from 2002 to 2013. She’s been teaching diabetes-focused continuing education seminars for doctors for the past fifteen years. She is the founder of the Low Carb Diabetes Association (LCDA): https://lowcarbdiabetes.org/.

Dr. Morstein breaks down naturopathic diabetes treatment into what she calls “The Eight Essentials” and then divides her book to cover each of them in turn:

1. Diet

2. Exercise

3. Sleep

4. Stress Management

5. Healing the Gut and Microbiome

6. Environmental Detoxification

7. Supplementation

8. Medications

Of course, this is the same focus most naturopathic physicians might use in treating any chronic disease.

This is the information you need to know if you ever plan to see a diabetic patient in your practice. As previously mentioned you’re going to see diabetics, whether you want to or not.

Reading this book feels like you are sitting in one of Dr. Morstein’s seminars, except that here she has enough time to cover each topic in as much detail as she wants, and no one is expecting you to have a photographic memory. I would say it’s the next best thing, but perhaps it is better. There is ample time and space to say everything and insert charts to store the detailed information you may not need now but might need to look up someday. There are over 500 pages in the book; if you read 50 pages a day, think of this as a two-week seminar. The advantage of reading the book is that you can take your time. Dr. Morstein is a fast talker and even faster thinker; keeping up with her train of thought is an exhausting task

As I sit to write this review a new article published in the May 2018 issue of the journal Pediatrics catches my eye. The authors conducted an online survey of type 1 diabetics who followed a very low-carb diet. Almost half (43%) of the 326 respondents in the study were parents of children with T1DM. Participants had a mean daily carb intake of only 36 grams and a mean hemoglobin A1c level of 5.67%. If you do not understand the significance of that last line, you really do need to read this book. The study authors use the word ‘exceptional’ in their conclusion to describe how well controlled these participants’ diabetes was.⁴ Not only does this low-carb diet strategy work, it works really well.

I have been having something of a debate with Dr. Morstein about the title of the book, Master Your Diabetes: A comprehensive, integrative approach to both type 1 and type 2 diabetes. The argument comes down to whether the adjectives ‘comprehensive’ and ‘integrative’ are coordinate or cumulative adjectives. If they were coordinate adjectives, both modifying the noun ‘approach’ then their order wouldn’t matter and separating them with a comma would be appropriate.⁵ This is the position that Dr. Morstein and apparently her editors take. As I read it, the order of the adjectives does make a difference; saying an ‘integrative, comprehensive approach’ doesn’t sound right. My position is that ‘comprehensive’ modifies ‘integrative approach’ and thus the comma is uncalled for. Why do I say this?

Dr. Morstein is a naturopath through and through. She has no ability to see the world through anything else but a naturopathic paradigm. She could not write a book that wasn’t about integrative medicine. Well, she could have used the phrase ‘naturopathic approach’ instead of ‘integrative approach’ but without any change in meaning or intention. She could have written a short-focused book, say on type 1 insulin dependent diabetes or on diet alone, but instead she wrote a ‘comprehensive’ book, one that covers all types of diabetes, even including the odd duck disease LADA (latent autoimmune diabetes of adults), and a wider range of treatment options. This book is comprehensive, the A to Z, ‘the everything you are ever going to need to know’ treatise. She’s going to argue with me about this; we’ve been colleagues and friends since we were both students at National College of Naturopathic Medicine, once upon a time.

I do have two complaints about the book, though, I am not going to put any of the blame on Dr. Morstein. Instead, I am going to blame the publisher, Chelsea Green, a small employee-owned publishing house in rural Vermont. They began publishing books almost 40 years ago with titles focused on sustainable living. In recent years have they have expanded their niche to books on alternative health.

My first problem is that the book is in sore need of a copy editor to proofread the text more thoroughly and correct spelling and grammatical errors. Few people would consider me a neurotic reader, but I found myself reading with a red pen in hand, unable to pass by the numerous errors without circling them.

The second problem and perhaps the most troubling was the references, or more exactly the lack of citations. There are twenty-plus pages of bibliography at the end of the book but there is no way to link statements in the text with a particular citation in that bibliography. The accepted custom in writing books these days in which statements regarding medicine are made is to cite either published scientific research in support of each statement not considered to be common knowledge or at a minimum to source a particular idea.

Let me provide an example or two of this lack in the book: “… Dr. Liu analyzed the American diet over a span of decades and found high fructose corn syrup and decreased fiber intake to be leading factors in the development of diabetes.” (page 46)

“Dr. Liu who?” reads my note in the column. This is the only mention of Dr. Liu in the book. The reader has no idea of who he is, when he performed this analysis or when it was published. Liu is a common enough name among scientific researchers that searching the literature via PubMed yields nearly 50,000 citations. Even limiting the search to articles related to diabetes yields nearly 13,000.

In science, knowledge tends to shift over time as new research is published. Take the statement, “Statin drugs given to prediabetic patients caused a 9 percent increased risk of developing diabetes.” (page 130)

I confess to a habit, or some might say addiction, to wanting access to the source of information, to reading abstracts and full texts. This 9% number likely came from a 2010 meta-analysis published in Lancet by Sattar et al. The authors “… identified 13 statin trials with 91,140 participants, of whom 4,278 ….developed diabetes during a mean of 4 years. Statin therapy was associated with a 9% increased risk for incident diabetes (odds ratio [OR] 1.09; 95% CI 1.02-1.17)….” They point out that for every 255 patients treated with statins for four years, there will be one extra case of diabetes and conclude that “… the risk is low both in absolute terms and when compared with the reduction in coronary events.”⁶

We should make note before committing this 9% to memory that a newer study adds complexity to this idea that statins increase risk of diabetes. Published in May 2018, a year after Dr. Morstein’s book was, a meta-analysis by Cui et al suggests that certain statin drugs depending on dose may improve blood sugar control in diabetics. Specific dose ranges of pitavastatin, atorvastatin, rosuvastatin and pravastatin appear to lower A1c levels, possibly improving diabetes.⁷

Scientific knowledge is not static, and we acknowledge this inconstancy by citing references.

Another paragraph starts with the phrase, “In several studies….” without going on to cite them somewhere. Or at least not in the world I live in, a place where truth is still valued.

As I wrote, the modern custom is to reference any ‘fact’ stated in the text. This is true in all medical writing, but it becomes vastly more important in ‘alternative medical literature’ as the opinions are more likely to be questioned and thus our responsibility to leave a clear trail of evidence becomes more important. As mentioned, this would appear to have been negligence on the part of Chelsea Green, the publisher, and we can hope that these errors are corrected in a second edition. While I encourage you to read this book now, I will stall passing on a copy to my friend Jane the endocrinologist over at the VA hospital even if there is a lot she could learn by reading it.

Those complaints aside, you should still purchase and read Dr. Morstein’s book. Even if you don’t want to read it, the detailed discussions of each insulin type are valuable enough to justify purchase of the book and space on your shelf.