Diabetes: Functional Medicine Approach Vs. Usual Care

A Functional Medicine (FM) approach to diabetes care focuses on identifying and treating the etiologies for "imbalances in the core physiological systems."(1) If underlying triggers and imbalances can be identified, the FM approach to addressing "root causes"(1) can be utilized through the use of specialized testing to treat and potentially reverse diabetes. If the FM approach is successful, the impact on diabetes disease burden as well as diabetes-associated health care costs could be significant. This project will assess the clinical as well as cost effectiveness of a FM approach to diabetes care compared to a usual care approach for patients with diabetes on insulin for 5 years or less.

This is a prospective, randomized, controlled, open-label clinical trial with a 1:1 randomization of patients with diabetes who have been on insulin less than 5 years to receive either Functional Medicine care in addition to usual care or to continue usual care delivered by an endocrinologist. The total number of patients planned for enrollment is 90, 45 in each arm. Patient recruitment will begin in the Cleveland Clinic main campus Endocrinology clinics and may later include Endocrinology practices at other Cleveland Clinic Health System sites.

Following voluntary informed consent, study subjects will complete a screening/baseline visit. After this visit, patients will be randomized to continuing usual care delivered by endocrinologists or to FM plus usual care. Once randomization occurs, the patient will continue to remain under the care of their endocrinologist and any other usual physicians. If randomized to the FM plus usual care group, subjects will receive additional care through a functional medicine physician.

A stratified randomization procedure will be used to allocate patients into the two groups according to the strata: Total Daily Insulin dose \< = 50 units vs. \> 50 units.

All subjects: In addition to usual care provided by the endocrinologist, study visits will occur at screening/baseline, 6 months, 12 months and 24 months. Lab data/Biometrics (if not recorded within 1 month time frame) will be obtained at this time. Quality of life instruments (Diabetes Distress Scale, SPADE, PHQ-9 and MSQ; Appendices D, E, F and G) will also be administered. At baseline, the 12 month visit, and the 24 month visit, a Body Fat Analysis by Bioelectrical impedance analysis (BIA) will be performed. There will also be 10 cc of blood collected for plasma and serum samples as well as 10 cc of urine and approximately 1 gram of stool for the bio repository if patient agrees to provide the samples.

Usual care subjects only: Subjects randomized to the usual care arm will receive a nutritional education session.

FM plus usual care subjects only: Subjects randomized to the FM plus usual care arm will be evaluated using the functional medicine approach to diabetes outlined in the Functional Medicine Diagnostic and Treatment Approach to Type 2 Diabetes Mellitus and Cardio-Metabolic Syndrome. Subjects randomized to the FM plus usual care arm will also receive nutrition therapy and dietary supplements. These will be prescribed and monitored at all Functional Medicine study visits. An estimated total of 50ml of blood will be collected from those subjects in this arm of the study at each designated visit. In addition, subjects may be asked to provide a urine and stool sample. Functional Medicine labs will be used in part to determine which supplements will be recommended.

Eligibility Criteria:
Inclusion Criteria:

* Seen in the Cleveland Clinic Main Campus Endocrinology Clinics
* Diagnosis of Type 2 Diabetes
* Insulin treatment for at least 12 months, but for less than 96 months
* Total Daily Insulin Dose \<= 150 units

Exclusion Criteria:

* Positive glutamate decarboxylase antibody
* C peptide \< 0.8 ng/ml
* Use of Insulin Pump for diabetes treatment
* HbA1c \> 12%
* History of Diabetic Ketoacidosis (DKA) defined by patient report or any emergency department visits or hospitalization for DKA
* Pregnancy
* Breastfeeding
* Known diagnosis of Cognitive Impairment or Dementia
* Estimated Glomerular Filtration Rate \< 45 ml/min/1.73m
* Congestive Heart Failure New York Heart Association (NYHA) Functional Class III or IV
* Active Malignancy
* Human Immunodeficiency Virus infection on treatment with medications
* Treatment with steroids (medication related diabetes)
* Treatment with antipsychotics (medication related diabetes)
* Abnormal baseline Complete Blood Count
* Liver Function tests \> 3 times upper limit of normal, Viral Hepatitis, or Elevated Liver Function tests of Unclear Etiology
* Currently participating in a supervised diet program through Department of Endocrinology
* Currently participating in any other research study, such as 15-1134: Prospective Validation of Predictive Tool study through Department of Endocrinology
* Treatment with Coumadin (warfarin)