Essential Points:

• Lifestyle Changes are Crucial: Managing diabetes effectively involves making lifestyle changes, including regular exercise (150 minutes per week) and a balanced diet. These steps help improve insulin sensitivity, manage weight, and reduce complications that can increase fall risk.

• Addressing Complications: Diabetes can lead to nerve damage (diabetic peripheral neuropathy), vision loss, and hearing/vestibular deficits, all of which increase the risk of falls. Managing these complications through proper medical care, exercise, and dietary adjustments is vital for fall prevention.

• Diet and Emotional Eating: A healthy diet is key in managing diabetes and fall risk. Emotional eating and stress can lead to poor dietary choices, contributing to insulin resistance. Tackling emotional eating through stress reduction and healthier food choices is essential for long-term health management.

In this article we close the loop on the Science of Falling Diabetes series and discuss managing the disease and associated complications to allow reduced risk of falling. If you haven’t read the prior articles in the series be sure to check out What is Diabetes? and Long-term Complications of Diabetes and Risk of Falling to have a deeper base of understanding while reading this last article in the series.

Managing diabetes and fall risk can be both simple yet complicated. In this article we will discuss :

1. General diabetes management through lifestyle change

2. Managing nerve damage that can lead to increased fall risk (Focusing on diabetic peripheral neuropathy [DPN])

3. Managing vision loss that can lead to increased fall risk

4. Managing hearing and vestibular deficits that can lead to increased fall risk

Hopefully after reading this article you’ll have a better understanding of how to manage diabetes as it relates to fall risk. Let’s get into it.

1. General Diabetes Management Through Lifestyle Change

A diagnosis of diabetes can be a heavy burden and mean a complete overhaul of your lifestyle in order to manage the disease.

Often diet and exercise routines need to be adjusted, checking of blood glucose is necessary, and medications may need to be taken. It’s a lot to think about, but this all needs to be done to slow, prevent, or even reverse the progression of the disease.

In this article, we will only be focusing on the diet and exercise aspects of lifestyle change as those are the pieces that we as individuals have the most control over. It is important to always follow the instructions of a medical provider for proper administration of medications and performance of blood glucose testing.

Exercise

Per the CDC, individuals should get at least 150 minutes of moderately intense exercise weekly to help with diabetes prevention and management. (1) Exercise improves the body’s ability to respond to insulin. (2, 3) In other words, exercise decreases insulin resistance and improves insulin sensitivity. Unfortunately, more than 75% of Americans don’t meet this exercise guideline. (4) Thus, 75% of Americans are missing out on a key aspect of preventing and controlling blood sugar..

Moderate intensity exercise, refers to physical activity that causes you to break a sweat and feel like you're putting in a good effort. You should be able to maintain a conversation to some extent during this level of intensity. The positive health benefits of exercise do not require any specific type of physical activity, as any exercise that raises the heart rate can be effective. Some examples of moderate intensity exercise include running, swimming, playing traditional sports, dancing, weightlifting, and even parkour.

For example, although I like to lift weights and run, it’s not uncommon for me to strap on my VR headset and play Beat Saber or Thrill of the Fight as my workout. It may seem out of the ordinary, but there are no rules on what can be called exercise as long as the body is moving and exerting itself beyond typical daily demands. Aiming for the 150 minute mark a week is a good starting goal, but it is ok for someone to do more if they find an enjoyable physical outlet.

In early disease stages such as prediabetes, exercise may even prevent and reverse the onset diabetic changes altogether when paired with a healthy diet. (2, 3) This reversal stems from both increased insulin sensitivity due to exercise, and the decreased insulin spikes associated with healthy diets. Additionally, exercise-induced insulin sensitivity seems to be even more effective when weight-loss is achieved. (5)

In general, any type of exercise can be used to increase insulin sensitivity and weight-loss, but a mix of cardiorespiratory training (e.g. running, rowing, swimming) and resistance training (e.g. lifting weights, calisthenics) should be performed for optimal health and physical performance.

Diet

A poor diet, more often than not, is the largest contributor to the onset of type 2 diabetes due to its role in creating insulin resistance and weight gain.

A poor diet can present in multiple ways, but for the purpose of this article we will define a poor diet as a chronic eating pattern that is excessive in calories, high in fat and sugars, while simultaneously being low in fiber and vital nutrients. Creating a healthy diet comes down to not only the foods someone eats daily, but also the emotional and psychological aspects that may lead to the consumption of these health-poor foods in the first place.

Psychological Aspects of Diet

Poor eating habits can be habitual or stem from emotional and psychological drivers. To solve these issues effectively, psychological aspects of eating behaviors should be explored in conjunction with a diet change. By exploring the root cause of diet choices, you may be able to make an effective and long lasting health transformation.

One common cause of excessive eating is termed “emotional eating”. Emotional eating is when a person eats to calm and dampen negative feelings rather than to curb hunger. (6, 7) This type of eating has been linked to increased weight gain and risk of diabetes. (8) Chronic stress at work, pressure to excel in school, anxiety about bills, and loneliness in a post-pandemic world are just a few examples that can lead to emotional eating.

The majority of foods linked to emotional eating are rich in excessive amounts of fat and sugar. These types of foods are commonly referred to as “comfort foods” and can include candy, pizza, baked goods, and high sugar drinks to name just a few.

Comfort foods can set off a cascade of events that lead your body to release large amounts of a feel-good chemical called dopamine. At the same time, these often high fat and sugar laden foods tend to have excessive calories and spike insulin. (9) As you may remember from the prior articles in this series, chronic insulin spikes can lead to insulin resistance and eventually type 2 diabetes.

Dopamine is a neurotransmitter (a messenger molecule in the brain) that has many jobs in the body. One particular job is to act as a rewarding feel-good hormone. (10) That feeling of pleasure might sound good, but excessive dopamine can lead to a negative feedback loop and essentially reward the act of emotional eating. (11) Consequently, your brain becomes conditioned to seek out unhealthy foods when you are stressed to get your next hit of dopamine. Furthermore, unhealthy foods have been shown to negatively impact mental health over long periods of time. (12) This can further spur on emotional eating and lead to a rapid downward spiral both mentally and physically.

If that sounds like a drug addiction to you, that’s because a sugar addiction basically is. (13)

Luckily, there are ways to deal with negative eating habits stemming from emotional and psychological origins. Working to reduce stress, removing temptations from the immediate surroundings, and seeking out a professional mental health expert can help you deal with this half of the diet equation. (7)

Understanding Healthy Versus Unhealthy Foods

Once the mental aspects of diet are at least acknowledged, it is time to adjust the diet itself. Although to some people, the distinction between healthy and unhealthy foods seems clear, I want to define what these terms mean and give a few examples.

A healthy food is defined as:

“any natural food popularly believed to promote or sustain good health, as by containing vital nutrients…or having a low sodium or fat content.” (14) In regards to diabetes, this definition should also include foods that contain low sugar content

Unhealthy food is thus defined as:

An unnatural food, devoid of significant vital nutrients, containing high sodium, fat, and/or sugar content.

Our definition of unhealthy food lines up well with the Standard American Diet known as SAD. SAD is defined as a diet which contains, “excess sodium, saturated fat, refined grains, and calories from solid fats and added sugars" (15) It is unfortunately the predominant way of eating in America, and potentially why America has such high levels of obesity and diabetes.

Creating a Healthy Diet

Creating a healthy diet for diabetes is quite simple as long as we follow our north star, the definition of a healthy food.

Examples of healthy foods include fruits, vegetables, whole grains, lean proteins, and healthy fats. Fruits and vegetables are rich in vitamins, minerals, and fiber, which can help support healthy digestion and immune function. Whole grains are a good source of complex carbohydrates (slow digesting), which provide sustained energy throughout the day. Lean proteins, such as chicken, fish, and tofu, provide essential amino acids needed for muscle growth and repair. Healthy fats, such as those found in nuts, seeds, and avocado, are important for brain function and hormone production.

Additionally, I want to introduce the idea of glycemic load to further fine tune a healthy diet.

Glycemic load is a measure that takes into account both the quantity and quality of carbohydrates in a food and how it affects blood sugar levels. (16) The more refined and processed a food is, the higher it’s glycemic load tends to be. This is because it can be digested quickly and enter the bloodstream all at once. For individuals with diabetes, glycemic load is an important consideration when planning a diet, as high glycemic load foods can cause rapid spikes in blood sugar levels, which can lead to complications over time as discussed in Long-term Complications of Diabetes and Risk of Falling.

Choosing low glycemic load foods, such as whole grains, fruits, and vegetables, can help regulate blood sugar levels and reduce the risk of complications associated with diabetes. (16) Additionally, pairing high glycemic load foods with low glycemic load foods can help balance out the overall glycemic load of a meal.

You can check out a list of foods and their glycemic loads here.

Overall, individuals with diabetes should work with a healthcare professional or registered dietitian to develop a personalized meal plan that takes into account their unique nutritional needs and glycemic load considerations. By making thoughtful choices about the foods they eat, individuals with diabetes can help manage their blood sugar levels and improve their overall health and well-being.

Bonus: Can Fasting Help Diabetes?

Fasting is a practice that has been used for centuries for its potential health benefits, but only in the last few decades has fasting been more heavily explored and vetted for the scientific truth in these claims. In recent years, research has shown that fasting can be particularly beneficial for individuals with diabetes. (17, 18) One way in which fasting may help diabetes is by improving insulin sensitivity. During fasting, the body produces less insulin, which can help to improve the body's insulin sensitivity. This can help regulate blood sugar levels more effectively, which is particularly important for individuals with diabetes.

Another way in which fasting may help diabetes is by promoting weight loss. (17, 18) Obesity is a significant risk factor for developing type 2 diabetes, and losing weight can improve insulin sensitivity and reduce the risk of developing diabetes. Fasting can be an effective way to promote weight loss, as it can lead to a reduction in calorie intake. Additionally, fasting can promote the production of ketones, which are molecules that the body produces when it burns fat for energy. Ketones can help reduce appetite and promote weight loss, making fasting a useful tool for individuals with diabetes who are looking to manage their weight.

Interestingly enough, a case report published in 2018 looked into fasting’s effects on three individuals diagnosed with type 2 diabetes from 10-25 years. (17) All three participants had a complete discontinuation of insulin during the study between 5-18 days after starting the medically supervised fast. Additionally, all patients showed improvements in several other clinically significant health outcomes, such as HbA1C, body mass index, and waist circumference. These positive results suggest that therapeutic fasting can be an effective treatment option for individuals with diabetes looking to improve their health and reduce their reliance on insulin.

It is important to note that fasting should NOT be done in those with type 1 and 2 diabetes unless medically supervised due to potential complications.

2. Managing Nerve Damage (Diabetic Peripheral Neuropathy Focus)

As discussed in Long-term Complications of Diabetes and Risk of Falling, diabetic peripheral neuropathy (DPN) is a common complication of diabetes, affecting up to 50% of individuals with the disease. (19) It is a progressive type of nerve damage that occurs as a result of high blood sugar levels, leading to numbness, tingling, and pain in the extremities, weakness, and balance deficits. DPN is a significant cause of morbidity and disability in patients with diabetes, affecting their quality of life.

There are various management strategies for DPN that include pharmacological and non-pharmacological interventions.

One of the primary pharmacological interventions for DPN is the use of medications that target neuropathic pain, such as gabapentin and pregabalin. (20) These drugs work by reducing the overactivity of the nerves and lessening the transmission of pain signals. However, these medications have some side effects such as drowsiness, dizziness, weight gain and may not be effective for all patients. As a result, there has been growing interest in non-pharmacological interventions.

Non-pharmacological interventions such as physical therapy, acupuncture, and biofeedback can help manage DPN symptoms by improving strength, balance, easing pain down to manageable levels, and potentially improving nerve function. (22, 23)

Moreover, lifestyle changes, such as maintaining a healthy diet, regular exercise, and managing blood sugar levels, can help prevent and manage DPN. Tight glycemic control has been shown to reduce the risk of developing DPN, while exercise can improve nerve function and reduce pain. (23, 24)

Additionally, it is essential to maintain your foot hygiene, wear comfortable shoes, and avoid walking barefoot to prevent foot injuries that can worsen DPN. A daily foot check, by using a mirror to see all aspects of the foot, is mandatory to avoid wounds and added complications.

Currently, there are no evidence-based methods to reverse DPN, making prevention the most effective medicine in this case.

3. Managing Diabetic Vision Loss

Diabetic-related vision loss, which comes in many forms, can lead to blindness if not managed properly as discussed in Long-term Complications of Diabetes and Risk of Falling. Vision is one of the Three Bodily Balance Systems, and when damaged can lead to an increase risk of falling and injury. The key to managing diabetic retinopathy, and other diabetic-related eye disease, is controlling your blood sugar levels. (25) Maintaining a healthy diet and exercise routine can help keep your blood sugar levels within a normal range. Additionally, taking medication as prescribed by your doctor can help manage diabetes and prevent vision loss. It's important to have regular checkups with an eye specialist to monitor any changes in your vision and adjust the treatment plan as needed.

Successful management of diabetic-related vision loss involves taking care of your overall health, which is vital for preventing the progression of diabetic-related eye disease. (25) Maintaining a healthy weight and refraining from smoking are crucial in this regard, as they can aggravate the condition. Equally important is managing your blood pressure and cholesterol levels, as both play a significant role in preventing vision loss. Regular exercise and a nutritious diet can help regulate these levels, thus minimizing the risk of further complications.

Finally, it's essential to follow your doctor's recommendations regarding treatment options for diabetic-related eye disease. (26) This may include laser treatment or injections to prevent further damage to the retina. In severe cases, surgery may be necessary. It's crucial to communicate with your doctor about any concerns you have regarding your treatment plan, as early detection and treatment can prevent vision loss and improve your quality of life.

4. Managing Diabetic-Related Vestibular and Hearing Damage

One of the lesser-known complications of diabetes is hearing and vestibular impairments.

The first step in managing diabetes-related hearing and vestibular impairments is to control blood sugar levels. (27) High blood sugar levels can cause damage to the blood vessels and nerves that supply the inner ear, leading to hearing loss and balance problems. By keeping blood sugar levels within a healthy range, the risk of developing these complications can be reduced preemptively.

After a diagnosis of diabetes, regular hearing and balance screens should be undergone frequently. These tests can detect any changes in hearing or balance function and allow for early intervention. People with diabetes should have these tests annually or as recommended by their healthcare provider.

For people who have developed hearing loss or balance problems due to diabetes, there are various management options available. (27, 28) Hearing aids can help to amplify sounds and improve speech understanding. In cases where hearing loss is severe, cochlear implants may be an option. For balance problems, vestibular rehabilitation therapy can help to improve balance function and reduce the risk of falls.

Finally, it is important to remember that diabetes-related hearing and vestibular impairments can have a significant impact on your quality of life. It is important to seek support from family, friends, and healthcare professionals to manage the physical and emotional challenges that may arise.

Wrap-up

In this article we discussed the main ways to deal with complications from diabetes that may lead to increased fall risk. We focused on ways to improve diabetic complications in the areas of lifestyle, nerve injury, visual deficits, and vestibular/hearing impairments. One important aspect that showed up in all these areas is to improve blood sugar levels through an appropriate diet and exercise regimen. Healthy eating and exercise can prevent progression of diabetic complications or stop them from occurring all together. Finally, it is important to regularly see your doctor for checkups and use medications as prescribed for treatment of any complications that do arise.

References

1. Get active! Centers for Disease Control and Prevention. November 3, 2022. Accessed May 9, 2023. https://www.cdc.gov/diabetes/managing/active.html#:~:text=The%20goal%20is%20to%20get,%2C%20shoulders%2C%20and%20arms).

2. Goodyear LJ, Kahn BB. Exercise, glucose transport, and insulin sensitivity. Annual Review of Medicine. 1998;49(1):235-261. doi:10.1146/annurev.med.49.1.235

3. Knowler WC, Barret-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine. 2002;346(6):393-403. doi:10.1056/nejmoa012512

4. DNPAO data, trends and maps: Explore by topic. Centers for Disease Control and Prevention. 2020. Accessed May 9, 2023. https://nccd.cdc.gov/dnpao_dtm/rdPage.aspx?rdReport=DNPAO_DTM.ExploreByTopic&islClass=PA&islTopic=PA1&go=GO%29.

5. Keshel TE. Exercise training and insulin resistance: A current review. J Obes Weight Loss Ther. 2015;s5. doi:10.4172/2165-7904.s5-003

6. Gavin ML, ed. Emotional Eating. Kids Health. April 2022. Accessed May 9, 2023. https://kidshealth.org/en/teens/emotional-eating.html.

7. Mayo Clinic Staff. Weight loss: Gain control of emotional eating. Mayo Clinic. December 2, 2022. Accessed May 9, 2023. https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/weight-loss/art-20047342.

8. Tsenkova V, Boylan JM, Ryff C. Stress eating and health. findings from MIDUS, a National Study of US Adults. Appetite. 2013;69:151-155. doi:10.1016/j.appet.2013.05.020

9. Avena NM, Rada P, Hoebel BG. Sugar and fat bingeing have notable differences in addictive-like behavior. The Journal of Nutrition. 2009;139(3):623-628. doi:10.3945/jn.108.097584

10. Dopamine: What it is, Function & Symptoms. Cleveland Clinic. March 3, 2022. Accessed May 9, 2023. https://my.clevelandclinic.org/health/articles/22581-dopamine.

11. Singh M. Mood, food, and obesity. Frontiers in Psychology. 2014;5:925. doi:10.3389/fpsyg.2014.00925

12. Selhub E. Nutritional psychiatry: Your brain on food. Harvard Health. September 18, 2022. Accessed May 9, 2023. https://www.health.harvard.edu/blog/nutritional-psychiatry-your-brain-on-food-201511168626.

13. Avena NM, Rada P, Hoebel BG. Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake. Neuroscience & Biobehavioral Reviews. 2008;32(1):20-39. doi:10.1016/j.neubiorev.2007.04.019

14. Health Food Definition & meaning. Dictionary.com. Accessed May 9, 2023. https://www.dictionary.com/browse/health-food.

15. USDA Staff. Dietary Guidelines for Americans, 2020-2025.

16. Glycemic index and Glycemic Load. Linus Pauling Institute. January 3, 2023. Accessed May 9, 2023. https://lpi.oregonstate.edu/mic/food-beverages/glycemic-index-glycemic-load#:~:text=The%20glycemic%20index%20(GI)%20compares,glucose%20concentrations%20and%20insulin%20responses.).

17. Furmli S, Elmasry R, Ramos M, Fung J. Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. BMJ Case Reports. Published online October 9, 2018. doi:10.1136/bcr-2017-221854

18. Grajower MM, Horne BD. Clinical management of intermittent fasting in patients with diabetes mellitus. Nutrients. 2019;11(4):873. doi:10.3390/nu11040873

19. Hicks CW, Selvin E. Epidemiology of peripheral neuropathy and lower extremity disease in diabetes. Current Diabetes Reports. 2019;19(10). doi:10.1007/s11892-019-1212-8

20. Snyder MJ, Gibbs LM, Lindsay TJ. Treating painful diabetic peripheral neuropathy: An update. American Family Physician. August 1, 2016. Accessed May 9, 2023. https://www.aafp.org/pubs/afp/issues/2016/0801/p227.html.

21. Jahantigh Akbari N, Hosseinifar M, Naimi SS, Mikaili S, Rahbar S. The efficacy of physiotherapy interventions in mitigating the symptoms and complications of diabetic peripheral neuropathy: A systematic review. Journal of Diabetes & Metabolic Disorders. 2020;19(2):1995-2004. doi:10.1007/s40200-020-00652-8

22. Yu B, Li M, Huang H, et al. Acupuncture treatment of diabetic peripheral neuropathy: An overview of Systematic Reviews. Journal of Clinical Pharmacy and Therapeutics. 2021;46(3):585-598. doi:10.1111/jcpt.13351

23. Jahantigh Akbari N, Hosseinifar M, Naimi SS, Mikaili S, Rahbar S. The efficacy of physiotherapy interventions in mitigating the symptoms and complications of diabetic peripheral neuropathy: A systematic review. Journal of Diabetes & Metabolic Disorders. 2020;19(2):1995-2004. doi:10.1007/s40200-020-00652-8

24. Ang L, Jaiswal M, Martin C, Pop-Busui R. Glucose control and diabetic neuropathy: Lessons from recent large clinical trials. Current Diabetes Reports. 2014;14(9). doi:10.1007/s11892-014-0528-7

25. Bryl A, Mrugacz M, Falkowski M, Zorena K. The effect of diet and lifestyle on the course of diabetic retinopathy—a review of the literature. Nutrients. 2022;14(6):1252. doi:10.3390/nu14061252

26. NIH Staff. Diabetic retinopathy. National Eye Institute. July 8, 2022. Accessed May 9, 2023. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/diabetic-retinopathy.

27. D’Silva LJ, Lin J, Staecker H, Whitney SL, Kluding PM. Impact of diabetic complications on balance and falls: Contribution of the vestibular system. Physical Therapy. 2016;96(3):400-409. doi:10.2522/ptj.20140604

28. Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: An updated clinical practice guideline from the Academy of Neurologic Physical Therapy of the american physical therapy association. Journal of Neurologic Physical Therapy. 2021;46(2):118-177. doi:10.1097/npt.0000000000000382

Thank you for reading this 3-part series on diabetes and fall risk! Leave a comment below on your thoughts, experiences, or additional questions in regards to diabetes impact on balance.

Happy falling!