I'm David Hite, PhD, a member of the American Association of Diabetes
Educators. I provide Diabetes Education classes for a large non-profit
healthcare organization in Sacramento, California. I know that most of you
can't attend my diabetes class in person at the clinic, so I've created
this Diabetes Basics: Questions and Answers resource to help you
better understand Type-2 Diabetes, and learn how you can take control of
your diabetes or offer needed help to a friend or loved one who may be
struggling to avoid the medical complications that often come with this
disease. These Frequently Asked Questions are also useful to those of you
who have pre-diabetes and want to reverse those symptoms and avoid
progression to diabetes. Good health. Live well.
Questions and Answers about Diabetes Self-Care
Diabetes is a chronic
condition. It's not yet curable. But we do know some secrets to help you
stay healthy and reduce your risks of diabetic complications. Your doctor
is a very important part of staying healthy, so visit and have blood tests
2-3 times each year so you can spot potential problems early and make sure
you're still on track. But also understand that what you do for yourself
when you leave the doctor's office is just as important as anything your
doctor can do. The method I use is called the 5 Ms of Diabetes Self-Care.
It allows you to take personal control of your diabetes by following the
methods outlined below. It's not simple and there are no magic cures or
short cuts. Diabetes is a complex and frustrating medical condition.
There's a lot to learn, but the more you know, the easier it will be to
stay healthy. I hope this resource
helps answer some of your questions and sets you on the road to good
What are the steps
I need to know about to help control my blood sugars?
You can begin to take
control and live well with diabetes by following these 5 M's of diabetic
Monitor - Learn how to check blood
sugars and use those numbers to gauge your progress and know when to make
healthy changes to your plan.
Meals - Eat healthy nutritious meals.
Learn which foods help stabilize blood sugars and what foods to eat with
care. Learn the importance of portion control to avoid what I call Portion
Motion- Use physical activity and
exercise to lose weight; to increase your strength, stamina, and balance;
to help burn off excess sugars, and increase your energy levels.
Medication- Learn what each medicine
does and which ones may be most appropriate for you. Learn how and when to
take them so they are most effective and minimize the possibility of side
Motivation- Living with a chronic
condition is difficult. Many people feel overwhelmed and struggle to take
action. Every day you face challenges that can wear you down. Depression is
three times more common in people with diabetes than in the general
population. Learn strategies for making healthy lifestyle changes and where
to get support in maintaining them.
If I have so much
sugar in my blood why do I feel so tired and hungry all the time?
When you have
diabetes, sugars are trapped in the blood in high amounts. Your cells
aren't absorbing sugar properly, and that's why you may feel hungry and
lack energy much of the time. Your body cells are crying out for nourishment
despite having sugar all around them. It's easy for a person with diabetes
to overeat in response to these 'hunger feelings' and gain weight. This
weight gain, especially when the weight is held in the belly area, actually
predisposes a person to diabetes and makes it harder to control once you
have it because it increases insulin resistance. This inability to
use insulin properly causes the pancreas to work harder and tire sooner.
Lowering insulin resistance is one of the most important keys to successful
What are the
different kinds of diabetes?
There are two major
types; 1 and 2, and two less common types; type 1.5 (LADA), and gestational
diabetes. All types of diabetes result in the loss of blood sugar control
and involve the action of the hormone insulin, but each type has very
different root causes. Insulin is a hormone produced by cells on the
pancreas, an organ that sits just behind your stomach. Insulin works
like a chemical key to open pores in the cell wall. All of the cells in
your body have a wall that holds them together, but because cells are
alive, nutrients must be allowed to pass through this covering and move
into the cell. It's the job of insulin to open this cell 'door' so that the
nutrients in the food you eat can pass from the blood into the cell and be
burned for energy or used for growth and repair.
Insulin, the key to
the door, is normally released by the pancreas every time blood sugars
begin to rise. The more sugar in the blood, the more insulin has to be
produced so you can properly absorb those sugars. Diabetes occurs when a
person is no longer able to produce enough insulin or the insulin that is
produced is ineffective in delivering blood sugars into the cell.
Type-1: Formerly known as
insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes, results
from an autoimmune response by the body that destroys the insulin producing
beta cells in the pancreas leading to insulin deficiency. Occurs early in
life, generally before age 20, and has a rapid onset of symptoms. Blood
sugar is controlled by daily insulin injections.
Type-2: Formerly known as
noninsulin-dependent diabetes mellitus, or adult onset diabetes. Insulin
resistance and obesity are contributing factors. Generally slow onset.
Often initially controlled by diet and exercise.
Type-1.5 (LADA): Latent Autoimmune
Diabetes in Adults. Slow onset of symptoms with progressive loss of insulin
producing beta cells. Insulin resistance is often absent. Sometimes called
"double Diabetes" when it shares traits of both type-1 (loss of
insulin production) and type-2 (insulin resistance).
Gestational: Elevated blood sugars
and diabetic symptoms during pregnancy. Often disappear after delivery.
Usually controlled with insulin injections.
I know a young
child that was diagnosed with diabetes. Is this type-1 diabetes?
Yes, most likely.
Type-1 diabetes is sometimes called juvenile diabetes because it usually
affects children and young people, under the age of 20. It occurs when the
pancreas stops making insulin altogether (they are missing the
'key'). This is the result of an autoimmune reaction within the body. The
persons very own protective immune system mistakenly targets
insulin-producing cells on the pancreas and kills them. Normally your
immune system is programmed to attack only foreign cells like bacteria and
viruses and knows not to attack cells that are part of your own body. We
don't know why the body gets confused, but once the insulin-producing cells
are targeted and killed, insulin will have to be supplied to the body by
way of injection. (Insulin is destroyed by stomach acid, so it can't be
into the cause of has found a promising link between a viral infection and
type-1 diabetes. In one recent study 83% of children newly diagnosed with
type-1 showed the presence of an enterovirus in their system. Only 7% of
healthy children had the virus. This is certainly not conclusive evidence,
there are no doubt other factors involved, but this discovery is a hopeful
sign that one day early signs of risk can be identified and corrective
measures taken before the insulin producing cells in the pancreas are
Which type is more
sometime called noninsulin-dependent diabetes mellitus (NIDDM) or
adult-onset diabetes, is by far the most common type. 285 million people
worldwide suffer from type-2 diabetes. India has the greatest number with 50
million. Of the 25 million people in the U.S. with diabetes 24 million have
type-2. It usually occurs later in life, typically after the age of 40
(Though due to the dramatic increase in childhood obesity, many younger
people are now being diagnosed with type-2 diabetes. Ninety percent of all
people with type-2 diabetes have gained significant weight around their
mid-section prior to diagnosis). In type-2 diabetes insulin is still being
produced by the pancreas, but it's no longer effective in lowering blood
sugars because the cell receptors that open the doors to the inside of the
cells seem to be stuck shut. This condition is called insulin resistance.
Trapped sugars in
your blood indicate that your body has lost its ability to properly absorb
the fuels you eat. The normal amount of sugar found circulating in the
blood 12 hours after eating would be 99 or less (measured in milligrams of
sugar in each deciliter of blood). A 12-hour fasting blood sugar of 100 to
125 indicates that your body is struggling to control blood sugars and is
called 'pre-diabetes'. A level of 126 or higher in two separate tests
establishes the clinical diagnosis of diabetes.
I've just been
diagnosed with type-2 diabetes; will I have to inject myself with insulin?
Probably not for many
years, though you may benefit from some oral diabetic medications (pills).
We will discuss diabetic medications in detail later in your reading.
Ironically, most people with type-2 diabetes actually have elevated insulin
levels in the years prior to diagnosis. During this time the body is
over-producing insulin in an effort to keep blood sugars under control
(Insulin has lost its effectiveness because of insulin resistance. Normal
amounts of insulin can no longer get the job done). Excess belly fat
surrounding organs in the abdomen, clearly plays some role in insulin
resistance. Whether this belly fat is the cause or the result of insulin
resistance is unclear.
What does seem clear
is that a sedentary lifestyle, and years of eating diets loaded with sugar,
refined carbohydrates, and unhealthy fats (animal and trans-fats), causes
us to gain weight, especially in the belly. This accumulated fat may simply
gum up the doors to the cells. This puts so much pressure on the pancreas
that it wears out prematurely. Your pancreas has been working overtime,
probably for many years, making extra insulin to keep your sugars down.
It's only after the pancreas tires and begins to slow down, a condition
called "insulin fatigue," that blood sugars begin to rise
and diabetes is diagnosed. Focus now on reducing insulin resistance to
reduce the pressure on your pancreas. This may help preserve its function
and prevent further damage.
I'm sure that my
diabetes was caused by the steroids my doctor gave me when I had a bad
as prednisone, are sometimes necessary to reduce inflammation in the body.
This can occasionally lead to "steroid induced diabetes". In my
experience this usually only happens to people who have already suffered
some loss of function in their pancreas. The steroids increase insulin resistance
so that the pancreas has to work even harder and this tips the balance and
leads to outright diabetes. So I'd say that the steroids didn't cause your
diabetes, but they did accelerate your progression to it.
My doctor just
diagnosed me with gestational diabetes. Will it go away after my son is
born? Does it mean I will get diabetes for sure later in life?
Signs of diabetes
(elevated blood sugars) will often disappear following birth, but this
doesn't mean that all's well. In the research I've seen, 23% of women with
gestational diabetes progressed to clinically diagnosed type-2 diabetes
during the ten year period following birth. Because of the weight gained
during pregnancy and the added stresses on the body, the pancreas has shown
that it is somewhat vulnerable. Whether you progress to full blown diabetes
in the future has a lot to do with how you take care of yourself. Pamper
your pancreas. The "early warning" message you got during
pregnancy should spur you to be diligent with healthy eating habits,
exercise and weight loss throughout the rest of your life.
I know someone
that had weight loss surgery and their blood sugar went back to normal. Are
Maybe. We usually say
they are in "remission". During their surgery, called bariatric
surgery, the stomach is divided and a small pouch is created for food. The
small intestine is then cut and re-routed. The lower part of the intestine
(ileum) is connected to the newly formed pouch while the upper part
(duodenum) is reattached further down. Why this normalizes blood sugars is
still unclear. The switch may prompt a change in the type of bacteria in
your gut (more on that below), or have something to do with the hormones
made in the intestine. We know that a gut hormone called glucagon-like
peptide-1 (GLP-1) secreted by the intestine plays a key role. The GLP-1
hormone is now being used as a therapy in type-2 diabetes. Byetta
(exenatide) and Victoza (liraglutide) are examples.
Note-I want to stress
to my readers that this surgery should not be taken lightly. It
irreversible and not without risk of post-surgery complications. It should
only be considered when all other health related factors indicate that a
patient has greater health risks without the surgery.
My doctor says
that excess sugars in my blood will eventually damage my body.
Sugar is the main
fuel for your body. We all need some sugar in our blood. Sugar is a
chemically reactive fuel that's supposed to leave your stomach, travel
through the blood (usually less than 2 hours), and then be absorbed into
your hungry cells and burned for energy. The issue for maintaining good health
is managing how much sugar is in the blood at any time and for how
long. You see sugar is a great energy source, but it's also chemically
reactive. Trapped sugars in the blood accelerate the corrosive damage to
blood vessels and leads to the breakdown of important body tissues and to
the diabetic complications that cause failing health.
If sugar is so
corrosive why don't all people have damage to their bodies?
They do! Sugar
(glucose) bonds with proteins in the body and weakens the structure (the
chemical reaction is called glycation). We can measure the corrosive
damage caused by sugar in everyone, even if they don't have diabetes, by
using a simple blood test called hemoglobin A1c (abbreviated
HgbA1c). Hemoglobin is the protein that carries oxygen and makes your red
blood cells. (You may be familiar with this test and I hope you're able to
have it done 2-3 times each year). When sugar bonds to hemoglobin it
changes to hemoglobin A1c. Your red blood cells live about 3 months, so
this is a convenient way to measure the amount of hemoglobin A1c present
and determine average blood sugar levels during the 3 months before the
test. A person without diabetes will have between 4.5% and 5.5% hemoglobin
A1c present in their blood from the corrosive effect of sugar. This is a
normal level of blood sugar and though is causes some damage it is easily
repaired in a healthy person. I've worked with uncontrolled diabetic
patients with hgbA1c damage as high as 17%. This means that blood sugar has
been nearly 500 for the past 3 months.
Remember that this
test also tells us that the protein structure of your blood vessels
themselves is being damaged in the same way, and it's this high level of
blood vessel damage that leads to diabetic complications. I like to use rusting
to describe what goes on in your blood when sugars are not controlled.
Rusting is a slow destructive process that takes time to develop and is
easy to overlook. But if allowed to progress unchecked, it can cause the
eventual destruction of things like a bike or mower. Knowing this, we
protect our possessions by keeping them out of the elements. That way we
reduce the risk that rust is going to do any serious damage. In the same
way knowing how to use the 5 M's of diabetic care to help self-regulate
your blood sugars and keep them in a healthier range, you'll be able to
avoid most of the corrosive damage associated with diabetes and lower our
risk of complications. A healthy hgbA1c for a person with diabetes is
somewhere below 7%. That means blood sugars are averaging about 155. This
is still in a range that is considered diabetic, but research shows that
when corrosive damage is kept low like this, your body can keep up with the
repair to your blood and blood vessels and the risk for diabetic
complications is significantly lower. So it's fair to say that it's uncontrolled
diabetes that leads to damage and failed health, because the damage is
happening faster than your body can repair it.
The graph below shows
how the risk of complications increases as blood sugar rises. Work hard to
keep your hemoglobin A1c below 7% and you will most likely avoid severe
My hgbA1c is just
about 7, but my glucometer says my 30 day average is 132. What gives?
Most people check
their sugars before meals, so the average shown on your meter is measuring
blood sugars at their lowest. The tests your doctor uses also takes into
account the rise in blood sugars after your meals. This measurement is
called eAG (estimated average glucose) and it relates to your hemoglobin
A1c (hgbA1c). It is the average amount of sugar in the blood both before
and after a meal that would account for the amount of hemoglobin damage
So how do I
regulate my blood sugars?
You must learn to
control your blood sugars manually. For most of your life your body was on
'cruise control' and the amount of sugar in your blood was controlled in a
very narrow range. But now this sugar cruise control is broken. Your
pancreas is no longer automatically controlling your blood sugars. Now you
need to take control, and to do that you need to understand the factors
that affect blood sugar and how you can make healthy changes that will make
it easier for you to self-regulate your sugars and keep them in a
healthier range. The first step is twice a day Monitoring of your
blood sugars (like driving a car with broken cruise control you need to
check your gauges to monitor your speed and then make manual adjustments to
*** Remember low
blood sugar is more immediately dangerous than a mildly elevated reading.
If your blood sugar is less than 80 when you check, it's time to eat
something. If your sugar reading is less than 70 or you're experiencing
symptoms and feeling shaky, sweaty or weakness, eat 15 grams of fast acting
sugar (30 grams if it's below 50), such as 1/3 can of regular soda, or half
a glass of orange juice or 4 glucose tabs, available at any drug store,
then check again in about 15 minutes. If it's still low take 15 more grams.
The general rule is that 15 grams of sugar should raise your blood sugar
about 50 points, so don't overdo it (a full can of soda has 40 grams of
sugar!). After your blood sugar reading is over 80 or symptoms subside, eat
a small snack with some protein in it to keep your sugar stable.
My doctor told me
I'm only borderline diabetic and that I don't have to do anything right
All due respect to
your doctor, but this is precisely the time to do something! When your
fasting blood sugar is between 100 and 125 the proper term is pre-diabetes.
Your pancreas is clearly struggling to control the amount of sugar left in
the blood from your previous meal. There is strong evidence that reducing
the insulin resistance that's making your pancreas overwork can halt or
reverse progression to diabetes. You're not alone in this. The American
Diabetes Association estimates that there are about 85 million people in
this country with pre-diabetes. Get started today by beginning a sensible
exercise program, eating a nutritious well balanced diet and losing some
Are there any
warning signs that might tell me I'm close to having diabetes?
Yes, in fact early
indications of this are apparent in a condition called Metabolic
Syndrome. People that have three or more of the following
symptoms have this metabolic disorder and are at risk for diabetes.
- Waist size of 40 inches for men and 35 inches for
women (or waist size that equals or is larger than your hips)
- 12 hour fasting blood sugar in the
pre-diabetes range (100-125)
- Triglycerides in the blood greater than 150
- HDL cholesterol less than 40 for men and 50 for
- Blood pressure greater than 130/85 or taking
blood pressure medications
This is why diabetes
is classified as a metabolic disorder. Your body isn't metabolizing or
"burning" your food properly.
I really don't
want to take pills until I have to. Can I control my diabetes without them?
Yes, often you can,
especially in the early stages of diabetes when blood sugars are only
mildly elevated. It's even possible to get off Medications after you've
started by working hard on the other aspects of blood sugar control.
Understand that you're not ignoring your diabetes, but rather you're
keeping Medication in reserve, as a safety net, and controlling sugars by
employing your other tools: Monitor, Meals, Motion, and Motivation.
Ultimately, with or without medications, success is measured by maintaining
healthy blood sugar levels.
Which of your 5M's
is the most important?
I think nothing is
more important for effective blood sugar control than eating a nutritious
well balanced diet. I'm not suggesting that you "go on a diet."
The healthy diet I'm talking about could best be described as the total of
all nourishment you supply to your body. It includes materials for
activity, growth, repair, and enough energy to complete that work. Of
course it's also undeniable that we eat for reasons other than nourishment
and fuel, and these important issues will be discussed below. But from the
perspective of basic biology, what you eat, when
you eat, and how much you eat are the factors that must be
confronted if you are going to get control of your blood sugars.
My problem is that
everything I eat seems to turn to fat
You might be right!
Researchers have discovered that the kind of bacteria in your intestines
(your gut), has a strong influence on whether you burn off your calories or
store them as fat. Two main types of bacteria live in your gut,
Bacteriodetes (good guys), and Firmicutes (bad guys). These gut bugs aid in
digestion and the breakdown of waste products, but they may also affect
metabolism, hormone signaling, fat storage, and inflammation. Important
mucus loving bacteria are needed to line the intestine and prevent a
condition called 'leaky gut syndrome' that creates a low grade whole-body
inflammation. Evidence is mounting that the balance of these gut microbes
determines whether a person will be lean or obese. This diverse colony of
healthy bacteria, initially transmitted to newborn babies through the birth
canal and mother's milk, may also lower the risk for inflammatory
conditions like asthma and allergies. If you would like to learn more about
this, I've written a piece and provided the sources of research for you at
my Diabetes Blog: Gut
Check: How Intestinal Bacteria Affect Health and Diabetes Risk.
The exciting part of
this news is that the balance of these gut bacteria is largely determined
by factors in your environment; the misuse of antibiotics which kill the
good bacteria along with the bad, and your diet. 'What you
eat is proving to be one of the major determinants of...the community of
bacteria living in your intestine,' says microbiologist Justin Sonnenburg
of the Stanford University School of Medicine. We have some control over
these factors! If this new research proves to be true, then the use of prebiotics,
foods that encourage the growth of good bacteria, and a good probiotic
supplement, which contains live "good guy" bacteria, might help
influence this balance of power and help swing us back to a healthy state.
Active culture yogurts, now being heavily advertised, also contain these
good bacteria; however these so called low-fat treats are certainly not low
in sugar. A small serving contains about 6 teaspoons of sugar. I advise my
patients to try Greek yogurt or find a healthier probiotic source.
So in the end, we
really are what we eat, and the microbes in our gut eat what we feed them,
so feed the good guys and starve the bad guys by eating healthy! To learn
more about this new research click on these links: Bacteria and Obesity,
and this one: Gut Flora (scroll down to read the
section on obesity), and finally this new article from July 2010 Newsweek
magazine: How bacteria could make you fat.
I've heard that
eating a low carb diet can help control diabetes.
I'd qualify that and
say that eating a lower carbohydrate diet can help control
blood sugars. Carbohydrates, classified as either simple (sugars) or
complex (starches), are the simplest food type and so require the least
amount of processing in the digestive tract. They are usually released into
the blood quickly (15 minutes) where they stimulate the release of insulin
from the pancreas, which allows them to be absorbed into the cells for
energy. A healthy pancreas has little problem doing this, but for someone
with diabetes, or at risk for diabetes, this puts tremendous stress on an
already weakened pancreas.
Well then, why not
avoid carbohydrates altogether.
fuel foods, and we all need energy. Carbohydrates should be eaten in
quantities that match your circumstances (i.e. - activity level and
metabolism). A young person playing soccer might get 65% of their calories
from carbohydrates. But clearly they have enormous energy demands they have
to meet. Most adults, with slower metabolic rates, and a less active
lifestyle usually shoot for about 50% of their intake of food in the form
of carbohydrates. I think someone with diabetes could eat less, maybe as
low as 40% carbohydrate, but it's not really that simple. Besides
controlling the amount of carbohydrate in your diet, you need to pay
attention to the quality of your "carbs" as well. High quality
carbohydrates are natural and unprocessed, and contain plenty of vitamins,
minerals and most importantly fiber.
If you are interested
in trying this, check out the South Beach Diet. It's
a lower carbohydrate diet that encourages eating lean protein, healthy
fats, and high fiber natural "good carbs". I think on balance it
offers a sensible lower carbohydrate plan.
A similar reduced
carbohydrate plan comes from the Mayo Clinic. It's based on their
"Healthy Weight Pyramid" that emphasizes not only a healthy diet,
but also exercise, weight loss and health promotion. The diet itself
recommends filling up on vegetables, whole fruit, high fiber carbohydrates
and healthy fats. This diet is not specifically designed for diabetics
however, so I think you should be prudent and limit your intake of fruit. A
word of caution here; there has been "fake" mayo clinic diets
around for some time. These diets are not associated with the actual Mayo
Clinic and are what I would call "fad" diets not based on healthy
eating principles. You can read more about the Mayo Clinic approach at
their official website: Mayo Clinic Diet.
important about fiber?
Fiber plays many
roles in a healthy diet. First, fiber slows digestion, and this slows the
amount of sugar that's released into the blood at any one time. Remember
the old saying; 'The whiter your bread, the sooner you're dead?' Well
that's just a way of saying we need more fiber in our diet. Americans
average only about 17 grams of fiber a day, but we need about twice that
amount. Grains have three parts: the germ, full of healthy oil and
protein; the bran, or fiber, which slows digestion and helps you
feel full, and starch a complex carbohydrate made of sugars that are
linked together in long chains. White bread is made with only the starchy
part. Whole grains provide the natural balance that nature intended. When
you eat starchy foods like white potatoes, or refined starches with the
fiber taken out, it raises blood sugars nearly as fast as pure sugar,
putting a real strain on your pancreas. Sugars, from the broken down
starches, flood into the blood like freeway traffic at rush hour.
One way to combat
this blood sugar "traffic jam" is to increase the fiber in your
diet by eating fresh vegetables; beans, legumes, peas and lentils; whole
grains and bran cereals; and maybe a piece of fruit each day. To help
increase your daily fiber intake try a whole grain cereal, steel cut oats
instead of instant, high fiber pasta like those from Dreamfields. Eat brown rice instead of white
sticky rice. Switch from white potatoes to a red skin potato, new potatoes,
or try a yam or sweet potato. If you like cereal for breakfast be sure to
stay away from sugary brands. Try a healthy high fiber cereal like those
These carbohydrates take longer to digest and enter the blood, reducing
that after meal blood sugar spike.
Another trick is to
eat your starches al dente, or slightly chewy. Undercooking starches
helps keep the starch from turning gooey and breaking down right in the
pan. Aim for 30-35 grams of fiber per day, but add it slowly, maybe 5 grams
at a time, and note your body's response. Fiber helps to keep you regular
and avoid constipation, but too much fiber too quickly may cause gas,
bloating or diarrhea. Plants, natural sources of fiber, are of course best,
(remember this is the food supply for those healthy bacteria) but you can
add additional fiber in supplement form like Benefiber, or Metamucil. They
have soluble fiber which also helps lower your cholesterol.
If I reduce my
"carbs" don't I have to increase my fat and protein intake?
Yes, it all has to
add up to 100%, but it's not as bad as it sounds. Increasing your lean
protein and healthy fat intake can provide real benefits if done
correctly. The sugar traffic jam I described above touches on an important
concept, so let's get into detail by reviewing some basic principles of
nutrition first. All edible foods fall into three categories; proteins,
fats and carbohydrates. That means that everything we eat is
made up of one of these types or is a combination of the three. Each is
different in its complexity requiring different amounts of time to
disassemble it (digest it), and each has its own special purpose in the
body, so finding a proper balance is very important.
This idea is better
known as Glycemic Index, and though dieticians in this country have
been slow to embrace it, I think it offers a good strategy to follow if
you're struggling with your meal planning. The idea is based on a simple
observation: Foods don't digest and supply usable energy at the same rates.
Some foods digest slowly and some digest quickly. The concept might be more
obvious to you if you think about starting a fire in your fireplace.
You know to be careful with lighter fluid because it burns so quickly.
Kindling burns slower but helps to stoke the fire and get it going and a
log or coals burn most slowly and provides slow continuous energy. In the
same way we need to find a healthy balance in the types of foods we eat.
Choose to eat the right balance of foods so your body is supplied with the
type and the amount of energy we need; Lean protein and healthy fat will
provide you with steady energy so you feel full and satisfied, complex
carbs will stoke your internal fire and give you energy when you need it.
And fast burning sugars? Well, unless you're training for a marathon, those
are troublesome and you're going to have to go easy.
Let's discuss protein
in more detail. Protein is not a primary energy food so it doesn't raise
blood sugar very much. It's what we're made of; muscle, skin, hair, blood,
brain, bone, and all of our internal organs are made of protein. So when we
eat protein we do so primarily to bring in building supplies for growth and
repair. All protein is made up of building blocks called amino acids.
Just as words are formed with the 26 letters in the alphabet, all known
proteins, plant and animal, are made from these 21 different building
blocks. Each protein differs only in the type, length, and arrangement of
its amino acids (Normal hemoglobin, your blood protein, for example
contains 574 of these amino acid building blocks in precise sequence. One
error leads to a blood disorder called cycle cell anemia). Protein supplies
us with four calories of energy per gram, the same as carbohydrates, but
protein is so complex it requires more time for digestion (imagine the time
it takes disassembling a toy Lego castle so that you can rearrange the
pieces to make a Lego fort). Protein burns slowly providing that satisfying
full feeling longer. This is the food that "sticks to the ribs"
and helps stabilize blood sugars. Every meal should include some high
quality lean protein. Protein in the meal will slow the absorption
of the carbohydrates helping to reduce after meal blood sugar spikes (The
same way food in the stomach slows the absorption of alcohol).
If you are thinking
of adopting a plant based diet (vegetarian/vegan) be aware that plants have
"incomplete" proteins, meaning that each plant protein is missing
one or more of the required amino acids to build human protein. This
deficiency is easily overcome by "widening your search". It
simply requires a wider variety of choices to "complete" the job
of building our body's protein structure (for example eat: nut/seed,
bean/rice, quinoa/different bean, etc). Once all of the amino acid pieces
are available the protein that's made is the same regardless of where they
came from. A well balanced plant based diet provides all of the amino acid
building blocks needed for growth, repair and overall good health. Good
sources of plant based protein are whole grains, beans (and tofu), peas,
lentils, nuts and seeds.
In addition to these,
omnivores and "flexitarians" add food choices like low-fat dairy,
Greek yogurt, cheese, and lean meats like fish and skinless chicken or
turkey to provide protein for the diet. Egg whites are also a good source
of protein (only the yolk is high in cholesterol). A healthy diabetic diet
will average about 20-25% protein to account for the lower carbohydrate
intake. A word of caution here however, if you're suffering from kidney
disease your protein intake will need to be lowered to accommodate
decreased function. Ask your doctor to be sure exactly how much protein you
should include in your diet.
Beef and pork, like
all meats, are high in protein, but experts have long urged people to avoid
or reduce "red meat" intake because of the observed association
these meats have with high cholesterol, heart attacks and poor overall
cardiovascular health. Certainly an association is not the same as a cause,
so many were not persuaded. A recent scientific study however has finally
found a biological mechanism that could explain how this might happen. The
story takes us back to our gut where our bacterial colony is being
nourished by the food choices we make. Different organisms prefer different
foods including the bacteria in our gut. The researchers were investigating
a chemical called trimethylamine oxide (TMAO) known to negatively affect
cholesterol levels and cause damage to the smooth lining on the inside of
our arteries thus allowing cholesterol to build up. They found that among
people who eat a 'western diet' there is a certain type of gut bacteria
that feeds on a substance called carnitine and converts it to TMAO causing
levels in the blood to rise. So let's look at where carnitine is found.
Carnitine found in 4 ounces of:
Beef = 105 milligrams
Pork = 30 milligrams
Chicken and Fish = 5 milligrams
Milk and Cheese = 5 milligrams
Plants = almost none
Red meat has loads of
carnitine! When meat eaters were fed beef or a carnitine supplement common
in many energy drinks (L-Carnitine), their blood levels of TMAO went
up. Researchers wanted to be sure of what was causing the change in TMAO
levels so the group was then given a course of antibiotics to kill all of
the gut bacteria. This time when they were retested with beef or a
carnitine supplement TMAO levels did not go up (the carnitine loving
bugs in the gut were killed by the antibiotics). Interestingly when
vegetarians/vegans were fed the same foods, there was no rise in TMAO. It
seems that people eating a plant based diet have literally starved this
type of bacteria to death.
This research is very
new (June 2013). Since we need carnitine in the body, (we make all we need)
more research is necessary to firmly establish a causative link to heart
disease. It may well be that the damage to blood vessels is caused from surges
of carnitine from heavy red meat consumption. Maybe one day we will find a
way to selectively rid ourselves of this carnitine loving gut bug, but for
now it might be a good idea to pass on the beef and pork and eat a plant
based diet or if you choose to eat meat, stick to chicken and fish with
their lower levels of carnitine.
mentioned healthy fats? I thought all fat was bad for you.
bad for you; bad fats are bad for you! Healthy fats are, well,
healthy. Fat is the richest form of food in our diet, supplying nine
calories of energy per gram. Bite for bite that's more than twice the
calories of any other food. It's complex and slow burning so it mostly
provides us with a slow steady background fuel for our body's daily
metabolic needs. It's also our savings account for times when food is
scarce, so we come by our craving of fatty foods naturally. The ability of
our ancestors to store fat during times of plenty is certainly one of the
most important biological adaptations ever made, but our intake needs to reflect
the changes our culture has made and today's new realities. I've heard it
said that 'We don't eat any more calories than our grandparents; the
problem is we don't do what our grandparents did.' In other words listening
to this ancestral urge to store extra fat for lean times needs to be
balanced with the reality that we don't live in lean times any more.
Nowadays we're storing too much fat and it's killing us. The average
American brings in about 40% of their calories from fat, and most of that
is from unhealthy sources. I think 30-35% is a better number and remember
these should come from healthy sources. Natural fats from plants in the
form of oils should be the main source of fat in our diet. Olive oil,
Canola oil (Canadian Oil Low in erucic Acid: from
the rapeseed plant), the oils from nuts and seeds, omega-3 oils, and yes,
even avocados are cholesterol free and full of healthy fat. They're easy to
digest and use for fuel rather than storing around the waistline. Peanut
butter is a great snack, but be sure to get the natural kind (with oil on
the top). Make room in your diet for these healthy fats by getting bad fats
Okay, so which ones
are the unhealthy fats I should avoid?
Bad fats come from
two sources, one natural, the other man-made. They are - animal fats and
trans-fat. These types of fat are easily recognizable because they're solid
at room temperature- white and greasy. They're like this because of their
chemical structure. The carbon chain that makes up the backbone of these
fat molecules is surrounded, or saturated, with hydrogen. This
hydrogenated fat is structurally stable and therefore difficult to break
down. Good for frying, bad for digesting. Remember too that cholesterol
only comes from animals, so animal fat is loaded with it. Trans-fats are
artificially saturated with hydrogen. These hydrogenated (or
partially-hydrogenated) fats are made by forcing hydrogen onto a plant fat
(oil) where nature didn’t have one before. Crisco first made 'shortening'
in 1911. This new form of man-made fat, hardened plant fat, was more
resistant to breakdown and didn't turn rancid as fast. This allowed the
commercial food industry to box foods and put them on the shelves without
fear of spoilage. The problem? We now understand that the bond that's
created in this process, the trans-bond, is difficult to digest (in Latin
the word 'trans' means across). The carbon chain twists, leaving the added
hydrogens across from each other - a trans-fat). Trans-fats, being
resistant to breakdown, tend to build up around the waist and lead to many
of our current health problems. If you don't burn it, you wear it.
While trans-fats have
no cholesterol themselves they do cause your bad cholesterol to go up, your
good cholesterol to go down, and also increase insulin resistance and blood
vessel inflammation that leads to an acceleration of the diabetic
complications we discussed earlier. In January of 2006 the U.S. government
began requiring that food labels show the amount of trans-fat in all
packaged goods (although less than .5 grams can be counted as zero). Fast
food restaurants however have been slow to get the message and are probably
the greatest source of these artery-clogging fats. Bad idea. Avoid them! If
you're unconvinced about this or need reminding, play this clip from the
documentary Fast Food Nation, or this
clip from the movie Super Size Me. It's a real
eye opener. It's about a young man who ate three meals a day from McDonalds
for a full month. Not a happy ending. Trans-fats really need to be
avoided in all foods. Read food labels and choose wisely.
What about butter
and margarine? Which is better for you?
Butter is an animal
fat and has loads of cholesterol so use it sparingly. You need some
cholesterol, but your liver makes all that your body needs. Cholesterol
isn't bad, it's actually necessary to help strengthen cell walls and also
to make bile and certain hormones your body needs. Too much cholesterol
however accelerates the build up that clogs arteries increasing your risk
of heart attack and stroke. Remember when you have diabetes the extra
sugars in the blood damage the smooth inner lining of your arteries. In the
same way that rough, damaged spots on a Teflon cooking pan cause food to
stick, rough spots in your blood vessels give cholesterol a chance to stick
and begin to clog (like too many minerals in the water clog your shower
nozzle). One million heart attacks and half a million strokes occur in this
country every year because of clogged blood vessels. Watch your cholesterol
levels! Margarines on the other hand are made from liquid vegetable oils,
which have no cholesterol. The problem here is that these oils are being
hardened into a spreadable form. It's this process of artificial hardening
called hydrogenation that turns them into unhealthy trans-fats (I
remember stirring the yellow food coloring into Oleo). Manufacturers of
margarines however are trying to make healthy changes. New spreads that
don't use trans-fats are appearing on the market and these may be healthier
choices. Look on the label before you buy and choose brands that use
healthy fats. Benecol or Smart Balance are are examples of these.
I usually skip
breakfast to help keep my sugars down. Is this a good idea?
No, it's actually a
very bad idea to skip breakfast. It seems to defy logic, but studies have
shown that people who skip breakfast actually weigh more than people who
eat breakfast. People who skip breakfast because they're not 'hungry' or
because they think they can save a few hundred calories and help their
weight loss plan; actually do more harm than good. Skipping breakfast means
you will likely go 16 hours without food. This sets off a reaction in your
body similar to a starvation reaction. Your metabolism slows and your body
begins to crave food. During times of starvation your body actually starts
to burn lean muscle tissue and tries hold on to its precious supply of high
energy fat. When you do finally eat your body is so 'starved' that you tend
to eat too much and often eat the wrong foods. Large meals alternating with
periods of starvation set up a "roller coaster effect"
with blood sugars ranging high then low then high again. Stay off the
roller coaster! Eating smaller meals, more often will help to stabilize
blood sugar swings and provide just enough fuel that you don't feel hungry
or deprived. In fact getting into the habit of eating a little something
every 3 or 4 hours during the day makes a lot of sense. Hunger is a
survival mechanism. By the time you feel 'hungry' your body is already
making unhealthy metabolic changes that are working against you.
I know it would
help if I bought better foods. Any help with grocery shopping?
Be especially careful
when you’re going grocery shopping or heading out to a restaurant to eat.
Grocery shopping when you're hungry often leads to poor choices and the
purchase of foods you know will sabotage your diet plan. Make a list
before you go and be careful of adding 'impulse items' while you are
shopping. Heeding the old saying "shop around the outside of the
market" is pretty good advice. Nowadays restaurant meals are much
too large to be eaten all at one sitting. Don't eat large meals! Besides
affecting your blood sugars, heartburn and related conditions are made
worse when you eat too much because abdominal fat doesn't allow room for
your stomach to expand very much. The pressure created on the stomach
causes food to be forced back up into your throat where sensitive tissue is
burned by stomach acid. You can protect against 'portion distortion'
by asking for a carry-out box when your meal is brought to the table.
Divide the portion before you start eating and you won't struggle with the
issue of when to stop eating. Of course if you are with someone, simply
sharing one meal is a great solution to portion distortion.
I've heard about
portion distortion. So how do I know how much to eat?
That's tricky. When
patients ask me 'how many calories do I need to eat each day?' I respond by
saying 'it depends.' Not a satisfactory answer I know, but they would get
the same answer if they asked me 'how much gas do I need in my car each
day?' You know that depends on how much fuel your car burns and how far you
drive each day. How much you eat should be based primarily on need. Your body
needs fuel based on two things, your basal metabolism, and your activity
level. Basal metabolism is how much you burn at rest. In general you can
figure it this way: Your body is burning about 1 calorie of energy every
minute just to carry on basic life processes. Since there's 1,440 minutes
in each day, you would need to provide that much fuel in balanced amounts
to maintain your present weight. Any more fuel than that will be stored as
fat for future needs and you gain weight, less fuel than that and you will
have to withdraw some energy from your fat cells to make up the difference
and you'll lose weight.
Of course you don't
sit or sleep every minute of the day, so each minute that you're more
active you're burning more than one calorie per minute. Walking burns about
5-7 calories per minute and more vigorous activities burn even more,
perhaps 10-15 calories per minute. Remember seeing what the Olympic swimmer
Michael Phelps ate? He needed 7,000 calories a day to meet his metabolic
needs. Now that he's retired and only playing golf, he has to cut back and
eat only what his less active body needs. You need to find the range that
meets your caloric needs. I'm guessing that for most of you it will be
between 1,500 and 1,800 calories per day. This amount is enough to supply
good balanced nourishment, and also enough food that you don't feel
deprived. Never eat less than 1,200 calories each day unless you are under
direct care from a medical doctor or registered dietician. Don't try to
starve yourself! Diets that are too strict are destined to fail because
they are so restrictive it's virtually impossible to stay on them very
recommend carbohydrate counting and limiting intake to 45-60 grams of carb
in each of 3 meals with perhaps one 15 gram snack. This recommendation is
usually pretty close and can be helpful in making better choices by
comparing labels. I like a more personalized approach. Here's a way you can
see if your meals are balanced as to carb-protein-fat content and are the
proper portion size. Check your blood sugar before you eat and then again 2
hours after your meal. Your blood sugar goal before meals is 70-130. Two
hours after a meal your target is to be less than 180. Check like this
often to satisfy any doubts you have and learn which meals are well
balanced, and which recipes need to be re-worked by perhaps lowering the
carbohydrate amount, changing the type of carbohydrate, or simply reducing
the portion size.
What about sugar
substitutes? Can I use them without raising my blood sugar?
aren't digestible, so they don't raise blood sugars, though some research
suggests that the sweetness causes insulin release. However be careful that
you're not setting a trap for yourself. These sweeteners may become
triggers that encourage cravings for more sweets. Eating things that are
unnaturally sweet raises the sweetness bar, making it less likely you'll
find satisfaction eating a naturally sweet food. Read more on this topic by
reading "What Chance
Does an Apple Have?" at my Diabetes Blog.
All in all, I think
that sugar substitutes like Sweet-n-low, Equal (NutraSweet),
or Splenda, as a way of cutting back on sugar, can play a useful
role in your diet if used in moderation. Some concerns have been
raised about their long-term safety. Aspartame, the sweetener found in
Equal(NutraSweet), is said to be unstable when it gets hot, causing it to
break down into harmful byproducts. I personally don't think the evidence
they cause harm is strong enough that they need to be totally avoided, but
if you believe you're having side-effects like headaches or body aches,
stop using them altogether. Of the three products available on the market,
I think sucralose, sold under the brand name Splenda, is the better choice.
The main advantage is that it's chemically stable and won't break down even
when you cook with it. This can really help those of you who are trying to
prepare satisfying meals for a family. I also think it has a more natural
taste, so no one is likely to notice the substitution. The fact that
Splenda is so chemically stable is also an advantage because since it isn't
broken down into other chemicals, isn't absorbed into the body tissues and
is quickly eliminated from the body unchanged; I see no potential for harm.
Daily coffee or a diet soda once in a while is not likely to cause any
problems, but half a dozen diet sodas a day is way too much and not a good
idea. Remember the bacteria in your gut are being dosed with these
Another group of
sweeteners, sugar alcohols like xylitol, sorbitol or maltitol, are
digestible and will raise blood sugars some, though usually half as much as
sugar itself. The thing to be careful of is how much you're getting. Some
sugar alcohols have a significant laxative effect and some people are very
sensitive to them (even sugarless cough drops have a warning on the label).
If you have bloating or diarrhea after eating sugarless ice cream, dietetic
chocolates, or any sugarless food with these sweeteners, this is likely the
cause. Go easy on these until you know how you're body is going to react.
Xylitol may be the best choice in this group.
A new product on the
market that might be useful is Stevia. Stevia is not artificial, it comes
from the leaves of a South American plant. It can be purchased by that name
or in a product called "Truvia". I've gotten mixed reviews from
my patients, but give it a try and see if you like the taste.
cinnamon? I heard it lowers blood sugar.
Research has shown
that as little as 1 gram (1/2 teaspoon) of cinnamon may in fact help lower
blood sugars. The type of cinnamon used in most of these studies is cassia
cinnamon, sometimes call Chinese cinnamon (This type is different from
Ceylon or true cinnamon). Cassia cinnamon is the most common type found in
this country, but check the label to be sure. The active ingredient in
cinnamon is Proanthrocyanidin, the water soluble part of cinnamon. It is
thought to function by activating the insulin receptor on the surface of
the cell allowing the cell to absorb sugar from the blood. Cinnamon oil did
not show this blood sugar lowering effect. I think, given these research
findings, that cinnamon supplements may be helpful if nothing more than
offering a tasty addition to food besides sugar. Talk to your doctor about
this and then proceed carefully so that you don't put yourself at risk of a
hypoglycemic (low blood sugar) event. Just in case it actually works.
What do you think
about supplements in general?
I think supplements
can be useful safeguards, but be clear with yourself; supplements are
not substitutes. There are no magic shortcuts that can take the
place of a healthy lifestyle. I view it as 95% healthy choices and maybe 5%
help from supplements, not the other way around. Over my years as a
diabetes educator I've heard about many "miracle cures" for
diabetes. I'm open, but also a bit skeptical. If you want to try some type
of herbal therapy, talk to your doctor first (some supplements can have
significant effects on things like blood thinning). Then find a reputable
company. This industry (food supplements) has very little oversight and I
have heard horror stories about purity issues, and "fake
ingredients". Here is a website link that may help direct your search:
Nutrition Data. Another site, run by the
U.S. Department of Agriculture is: Food and
Nutrition Information Center.
Can I drink
While it's not
absolutely forbidden for a healthy diabetic to drink, alcohol use may
complicate your treatment plan for a number of reasons. Drinking alcohol
will, in the short term, raise blood sugars because of the carbohydrates in
the drink, but in the hours following you may put yourself a risk for a
hypoglycemic episode (low sugar) because of the effect alcohol has on the
liver. Never drink on an empty stomach. Remember that many of your
medicines advise against using alcohol because it can increase the risk of
side effects or magnify them. This is an important discussion that you need
to have with your doctor. Together you can come to an understanding of what
your risks are and whether a glass of beer or wine with a meal is okay for
Sometimes I find
myself eating when I'm not really hungry. What can I do about overeating?
My final thought on
eating has to do with the constant battle of wants versus needs. Many of my
patients struggle with overeating not so much because of hunger, but
because of a lack of satiety. Satiety is the feeling of being satisfied
with a meal and is just as powerful an urge as hunger itself. Here are some
ideas on that. First, take smaller bites and eat more slowly. Really chew
your food and extract all of its flavor. The feeling of fullness after a
meal is not just in the stomach, it's also in the brain. The body produces
chemicals, which control the urge to eat. One of these hormones, leptin, is
responsible for letting the brain know when you're full and should stop
eating. The problem is that it takes about 30 minutes for this chemical to
be released and go to work. If you eat too fast you can 'over-consume' and eat
far more than your body really needs or wants. If you're eating small meals
more often, as I suggest, this will be much easier to do because you won't
feel so starved that you lose control. Emotional eating, and by this I mean
compulsive eating, is sometimes a sign of clinical depression. Talk with
your doctor or counselor about your feelings about food and eating.
Take joy in eating.
It's a good thing when it's done in a healthy way. Don't make food the
enemy or you'll be doomed to a life of struggle. Feeling guilt or
"stinkin thinkin" is not helpful.
In his book Healthy Pleasures Dr.
David Sobel suggests that if we learn to enjoy all of the pleasurable
aspects of eating we benefit by feeling greater overall satisfaction. Learn
to eat more slowly and savor your food. Use this time to talk to your
companions. Eat a wide variety of foods and take time to appreciate all the
different flavors and smells and textures. Even the process of cooking
itself is an important part of the joy of eating. Enjoy the whole
experience. It's worth the time and effort. All of these things will leave
you feeling more satisfied after meals and help you guard against mindless
My doctor wants me
to exercise, and I would if I only had more energy.
Lack of energy is one
of the most common complaints I get from my diabetic patients, but the
reason for this tired feeling might surprise you. Remember earlier I
discussed how extra sugar is trapped in the blood? You may be feeling tired
and hungry because the sugar in your blood simply hasn't been delivered. It
has to be absorbed into the cell for you to have energy. Your cells aren't
getting energy because the doors are jammed shut and insulin is having a
tough time getting them to open and accept the sugar from your blood
(insulin resistance). Using your muscles can help that. You see, because
they protect us from danger (fight or flight), muscles have a special
ability to draw those unburned sugars into the cell (like opening a door
from the inside-you don't need a key). Imagine there was a fire and you
needed to escape, you would have plenty of energy right? Well you can use
this to your advantage and the great thing is that there doesn't have to be
a real emergency to do it. The next time you feel tired and hungry check
your blood sugar level. If it's 80 or lower, it's time to eat. But if it's
above 140, you have plenty of fuel in the blood. Don't eat and add more
fuel on top of it, burn what's there by going for a walk or by doing some
other form of gentle exercise (a walk is especially helpful about 30
minutes after eating). When the muscles begin to draw these sugars from the
blood you will actually have more energy and feel better. Talk to your
doctor and get the okay; then start slowly with a type of activity that
suits your lifestyle and takes into account any physical limitations you
may have. You may find that exercising in a swimming pool will give you a
good workout without the stress on aching joints. Whatever you do,
rediscover the joy and fun you had when you were a child at play and make
it enjoyable. Click this link to read When We
Were Young We Called it 'Play' on my Diabetes Blog.
I tried exercising
and found that my blood sugar was actually higher when I got back.
This is true for many
people, but don't worry about this type of sugar rise unless it persists
long after your exercise is over. Just as breathing increases with
exercise, sugars are released from the liver when active muscles call for
it. Sugar levels, just like your breathing, will return to normal or lower
in a short time. In fact since exercise stimulates your metabolism, your
body will continue to burn excess calories long after you're activity has
finished. Right now as you sit and read this your body is burning fuel, and
just like a car, how much you burn depends on how fast you're going. Well,
your body is idling right now so you're only burning a minimum amount of
fuel, about one calorie per minute. When you're out walking, doing yard
work or house work, your body is burning about 5-7 calories of energy every
minute. If you walk for 1 hour each day you'll burn up over 2,000 excess
calories of energy each week that would have been stored as fat. In a
year's time that's over 30 pounds of fat. You can see how this really adds
up. Some very fit people can exercise at sustained levels that burn over 15
calories per minute (Don't start for these high intensity exercises,
there's too much risk of getting hurt. Start slowly and build up. Going
longer is better than going faster). Remember Michael Phelps, the swimmer?
His main concern regarding food was 'am I getting enough''. Wouldn't that
be a welcome problem to have for a change?
My blood sugar has
been rising for the past few months and now my doctor says it's time to
start taking medication to help. What do these pills do?
You may recall from
the reading above how your pancreas was damaged by overwork in the years
leading up to your diagnosis of diabetes. For many years it controlled your
blood sugars by producing extra insulin, compensating for the fact that
your cells weren't responding to this chemical key. At some point, if a
healthy diet, exercise and weight loss are no longer sufficient to keep
blood sugars stable, you will need the additional help that diabetic
medications offer. There are three main types of oral (pills) medications,
each designed to work in a different way. One type stimulates your pancreas
to produce a little extra insulin for mealtimes, another works by
preventing your liver from inappropriately dumping unneeded sugar into the
blood, while others sensitize the cells to respond better to the insulin
you are producing.
Can you describe
how each of these pills works to lower my sugar?
There are three
classes of oral medications commonly used to treat high blood sugars
(hyperglycemia). The first class of drugs is called secretagogues because
they stimulate the pancreas to produce (secrete) extra insulin. These are
best taken about 30 minutes before a meal to give the pancreas time to
react and produce the extra insulin needed for the upcoming meal. Tolinase
(tolazamide), Glucotrol (glipizide), Micronase (glyburide), Orinase
(tolbutamide), Prandin (repaglinide), and Starlix (nateglinide) are
examples of these. (Note - Drugs have two names and this may sometimes seem
confusing. The capitalized word is the name the company gave it, their
registered trademark. The other is the actual generic drug name). Of the
medications mentioned in this class, Prandin and Starlix are shorter acting
for those who tend to have after-meal blood sugar spikes that drop back
into the normal range quickly. This shorter acting formulation lessens the
risk of blood sugars being lowered too much in the hours after your meal.
The second drug
commonly used is Glucophage (metformin). This medication slows the release
of sugars that are stored in the liver. One of the many jobs of the liver
is to store extra sugars and release them during emergencies (fight or
flight reaction) and when blood sugars drop during the night. Many of you
may experience this 'Dawn Effect' and find that your morning sugar readings
are higher than when you went to bed. Glucophage will help lessen this
effect. Take this medication with food and start slowly to avoid the
possibility of stomach distress. Most patients start with a single 500 mg
(milligram) tablet once a day (dinner). If your doctor prescribes more than
a single pill daily, wait until your body gets used to the lower dose
before adding more. Usually add the second pill after one week (breakfast).
If there is a third pill to take, wait until the third week then add it to
your lunchtime/diner meal as your doctor directs. Glucophage also helps
lower insulin resistance and sensitize the cells so they use insulin more
efficiently by opening the 'doors' that have been stuck shut. This
sensitizing effect makes this drug an effective option for people with
'metabolic syndrome' because of added abdominal body fat. It can also be
used in combination with any of the medications from the first group of
drugs mentioned above (e.g. glipizide) to help lower blood sugars even more
effectively than using one class of drug alone.
The third most
commonly prescribed oral medication is Actos (pioglitazone). This
medication works as an insulin sensitizer to reduce insulin resistance and
make your insulin work better. Remember the key (insulin) and lock (cell
wall) analogy? Actos is all about getting the lock to open more easily.
Actos tends to cause water retention, so it must be used with care in
patients with congestive heart failure. Also make sure to have periodic
liver function tests to monitor any negative reaction to your diabetic
medications. For patients struggling to maintain stable blood sugars, Actos
can also be added to the others to make a triple combination therapy,
though most often a patient will begin adding insulin injections at this point.
UPDATE: A new
research study has just been released regarding Actos (March 2011). The
study found that progression from pre-diabetes to diabetes was reduced by
over 70% in those taking actos. Drug prevents type-2 diabetes in majority of
high risk individuals. "It's a blockbuster study," said
senior author Ralph DeFronzo, M.D., professor in the School of Medicine and
chief of the diabetes division at the UT Health Science Center San Antonio.
"The 72 percent reduction is the largest decrease in the conversion
rate of pre-diabetes to diabetes that has ever been demonstrated by any
intervention, be it diet, exercise or medication." If you have
pre-diabetes ask your doctor if this drug makes sense for you as part of
your preventative strategy.
(rosiglitazone), a diabetes medication chemically similar to Actos, has
been linked to heart attacks and heart failure and now requires a special
"black box" warning label. There has been a lot of back and forth
lately (June 2013) on the validity of this finding. Some believe that the
research was flawed and that the results can’t be justified. Talk to your
doctor about this before starting this medication. Check out this website
to learn more about this drug and efforts to recall it and remove it from
the market: Avandia Side Effects.
Newer drugs to hit
the market attempt to control blood sugars by manipulating gastrointestinal
hormones called incretins. Insulin is quickly released into the
blood, even before blood sugar begins to rise, due to the action of two gut
hormones called glucagon-like peptide-1 (GLP-1), and glucose-dependent
insulinotropic peptide (GIP). Both of these hormones play a key role in
blood sugar control by stimulating the release of insulin, inhibiting the
release of the counter-regulatory hormone glucagon, and by slowing how fast
food is released from the stomach. Two incretin analogs (drugs that mimic
GLP-1 hormone), are now being used as a therapy in type-2 diabetes. Byetta
(exenatide) and Victoza (liraglutide) are examples. One drawback with these
two drugs is that they must be injected. Difficulties were encountered when
trying to fully utilize these incretins however because in the body they
are quickly inactivated by the enzyme dipeptidyl peptidase-4 (DPP-4). This
has led researchers to create drugs like Januvia (sitagliptin), or Onglyza
(saxaglyptin), which inhibit the action of
DPP-4. These are
taken in pill form.
One word of
caution. DPP-4 enzyme is also known to be involved in tumor
suppression, and though there is no direct evidence that it does, it leads
some researchers to fear that inhibiting this enzyme may spur the growth of
certain cancers. Speak to your doctor about this if you're taking DPP-4
inhibitors or considering it.
One other drug worth
mentioning is Symlin (pramlintide). This drug is an analog (chemically
similar) to the natural hormone amylin which is made in the pancreas by the
same beta-cells that make insulin. It is thought to partner synergistically
with insulin to lower blood sugar. It is indicated only for those who use
mealtime insulin, and is administered by a separate injection. Severe
hypoglycemia is a major concern and a 30% reduction in the units of insulin
is usually required. Because it has been shown to decrease appetite, it may
also activate the satiety centers in the brain.
I encourage you to
learn as much as you can about the drugs your take. Don't forget,
what you do to control your blood sugars outside the clinic is just as
important as anything that happens there. Work on your M's (Meals,
Motion, Monitoring, and Motivation) first to lessen the need for
medications. A good website to gather information about the medications you
may be taking can be found at: Drugwatch. It features
up-to-date information on the drug side-effects of prescription and over-the-counter
medications and publishes alerts to aid in the protection of patients and
My doctor wants me
to start insulin, but I'm afraid. My grandmother started insulin and ended
up having kidney damage. Doesn't insulin cause complications?
No, it doesn't cause
complications, in fact it will prevent them. All animals need insulin to
survive (my neighbor's cat needs two shots of insulin each day). Your
grandmother's kidney complication was the result of damage that occurred
before she started insulin. When natural insulin production gets very low,
and oral medications are no longer effective in controlling sugar levels,
supplemental injections of insulin are necessary. This need for insulin
shouldn't be seen as a failure on your part (any more than wearing glasses
to compensate for weakening eyesight), and it doesn't mean that your
diabetes is now "the bad type". In fact I believe that in many
cases we wait too long to begin using insulin. Research indicates that
intensive insulin therapy at the time of diagnosis may help to preserve the
function of your pancreas and make it easier to control your diabetes later
on. Have a frank discussion with your doctor about this and don't be afraid
to try insulin therapy. You will be surprised to find that the injection
itself hurts less than your daily finger stick. Good news on that front is
that a new "oral" insulin is being tested. It isn't a pill, it's
a spray that's absorbed in the mouth. Stay tuned, we should know about its
effectiveness in the next few years. The important thing, whether you take
oral medications or insulin, is that blood sugars be controlled in as
normal a range as possible.
Won't I gain a lot
of weight when I start insulin?
Often the use of diabetic medications means some added weight, but this
effect can be reduced by making healthy changes to your portion size.
Remember that some of the sugar in the blood that was not absorbed by the
cell is then lost in the urine. The ancient Greeks wrote that honey bees
were attracted to the urine of people with diabetes (diabetes mellitus translates
"sweet urine"). It's a normal urge to begin eating more when you
don't absorb all that you eat. Once you start taking diabetic medications
you should re-evaluate your portion sizes at mealtime since now you will be
absorbing your calories so much more efficiently.
I know that stress
isn't good for your health, but will it affect my blood sugar?
Yes it will.
Unrelieved stress is one of the things that will not only have an effect on
your emotions and overall health; it will have a direct effect on your
The body views stress
as an attack or challenge, and responds by preparing our bodies to fight or
flee. Adrenalin and the stress hormone cortisol are pumped
into the blood from glands just above the kidneys; your heart begins to
beat faster and blood pressure goes up; and blood sugars rise, all
to help you escape the danger at hand. In a more natural situation, real
danger would pass and our bodies would return to a normal state. But in
today's world many "dangers" do not pass, so instead of the
action found in fight or flight, our response is to simply freeze,
leaving ourselves in a state of constant anxiety. These modern day
"dangers" in fact, don't even have to be a real or immediate
threat. If we perceive it as threatening in any sense of the word;
fear, anger, even frustration or uncertainty; in any case, we're left with
the continuing feeling of anxiety, and fear. This lack of resolution of
distress leaves us literally 'stewing in our own juices'. This type of unrelieved
stress is one of the most insidious factors negatively affecting our
health and well-being. Cortisol, also known as the stress
hormone, may be responsible for the increase in belly fat seen
in many type-2 diabetics. Studies show that when a person is overly
stressed, the body reacts by storing away extra fat in anticipation of the
Before we leave this
point I want to be sure you understand what I mean by unrelieved stress. In
his book "Stress without distress" Hans Selye describes stress as
not a single thing, but rather a continuum that starts low and continues to
high. Some stress is necessary in our lives. In fact stressors are what
give our lives richness and meaning. If we had no stress in our lives, we
would have no reason to get out of bed in the morning; no reason to live. A
research study was done in Florida to determine how stress affected the
health of retirees in an 'old folk's home'. The term was used purposely
because it implies the conditions they found; an old, run down facility
where people simply sat out their last years with very limited stimulation.
When the researchers changed the environment by opening windows to let in
more light, playing music, taking the patients out into the garden,
bringing in a box of puppies and letting them play, things began to change.
Patient's depression lessened and moods became brighter, they had more
energy and began to get themselves up and take better care of their
hygiene, they slept better and laughed more and most importantly they lived
longer. All of us need some stimulation in life, some reason to live. This
level of stress is termed eustress, which means normal or good
stress. It gives our lives meaning. When we fill our lives with activities
and things that are meaningful, we increase our stress, but in a healthy
Each of us has the
ability to deal with stress in life, but everyone has limits. When
we exceed our limits we move into another zone of stress termed distress.
This term is more common to us and we all know that distress is a bad
thing. Most of us, however, don't appreciate just how damaging it is on our
health. To further complicate things, none of us enters this zone of
distress at the same time. Some people are able to perform quite
challenging, even frightening activities with no apparent distress. Take a
racecar driver for example, or a mountain climber, or bungee jumper. Most
of us would not be having fun if we were hanging from a cliff by a single
thin rope. Why do some people have the ability to stretch normal limits?
Well, we simply don't know, and for our purposes, it's really not
important. Don't judge yourself using other people's standards. All of us
have limits, even the skydiver. Listen to your body and honor your limits.
What each of us must
do to avoid distress is know when we enter the distress zone. There will
likely be signs if we pay attention. When we have too much on our plates,
and become overwhelmed, sleep patterns might be affected. One person might
sleep too much, another, not at all. You might lose your appetite or eat
compulsively. Bowel movements may change from constipation to diarrhea and
back again. Some people might have headaches or difficulty concentrating.
Accidents are common from not paying attention to the moment, or from
moving too fast before we look. Depression, anger, and resentment are often
present when a person exceeds their emotional or physical limitations and
falls into a state of distress.
Sometimes it's just a
matter of getting out of our own heads. Our bodies are built for action, so
fight or flee as appropriate, just don't freeze. Take Action. Go for
a walk, read, listen to soothing music, meditate or pray, there is no one
best way. The best way is your way, the way that works for you. Find
healthy ways to relieve your distress, and do it often. The comedian Lily
Thomlin says it simply: "For fast acting relief, try slowing
Many years ago one of
my patients reminded me of our mortality by suggesting that regardless of
the state of one's health we are all just a heartbeat away from eternity.
She then said "I'm grateful for today, and hopeful for tomorrow. In
the meantime I enjoy the time I'm given".
When I'm feeling low
and overwhelmed I like to re-read the wise and comforting words found in
Max Ehrmann's famous poem Desiderata found here.
In part it reminds
us: "But do not distress yourself with dark imaginings. Many fears are
born of fatigue and loneliness. Beyond a wholesome discipline, be gentle
adaptation was offered to me by one of my friends at Diabetic Connect. I
hope it makes you smile.
Go placidly amid the
noise and the haste,
And remember that stress and cortisol may raise your levels.
As far as possible,
be on good terms with health care professionals of all types.
Speak your truth quietly and clearly;
and listen to others,
except to the diet and diabetes police;
they just don't get it.
Avoid loud and aggressive persons;
they are vexatious to good glycemic control.
If you compare your
HbA1c with others,
you may become vain or bitter,
for always there will be greater and lesser numbers than your own.
Enjoy your achievements as well as your plans.
Keep interested in your own blood sugar diary, however humble;
it is a real possession in the changing fortunes of time.
Exercise caution in
following fads and online cures,
for the world is full of trickery.
But let this not blind you to what virtue there is in GI and GL diets;
many persons strive for perfect control,
and everywhere life is full of Joslin medalists.
Especially do not forget your insulin.
Neither be cynical about the bond between fellow sufferers,
for in the face of all aridity and disenchantment,
it is as perennial as the grass.
Take kindly the
counsel of the old timers,
remaining optimistic about the future for the young.
Nurture strength of spirit to shield you should your retinopathy scan not
But do not distress yourself with dark imaginings.
Many fears are born of looking at the wrong sites on the internet.
Beyond a wholesome
treat yourself from time to time.
You are a person with diabetes
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.
Therefore be at peace
with your endocrinologist,
however lacking in knowledge you perceive him to be.
And whatever your labors and aspirations,
in the noisy confusion of life,
make sure you have enough test strips.
With all its sham,
drudgery, and broken dreams,
it is still a beautiful world.
Be cheerful. Strive to be happy.
I know that
motivation is important, but that's the one I'm having trouble with. I
sometimes get really discouraged. Besides your diabetes DVD can you
recommend any books or websites that will help me stay on track?
diabetes, is considered chronic, it's not yet curable. This means that
you'll probably live with diabetes the rest of your life (remember, your
sugar cruise control is broken). Proper management is the secret to living
well with diabetes, and to do that you need to have knowledge about your
condition, support from your doctors; your friends and loved ones; and the
motivation to carry on even when you are weary.
Remember that what
you do to maintain good health when you leave the clinic is just as
important as anything the doctor can do. In fact, you are the most
important part of the process of staying well. So find a natural balance
and take care of yourself. Don't try to be everything to everybody.
The serenity prayer
offers wisdom on the subject:
Give me the
serenity to accept the things I cannot change;
Courage to change the things I can,
And the wisdom to know the difference.
Here are some other
helpful books and websites that will help you stay motivated and on track.
Diabetes Burnout by
William H. Polonsky, is a supportive guide to keeping you on track during
For healthy eating tips I think the Mayo Clinic Healthy Weight
Pyramid is a good guide to follow, but remember you will have to
limit your intake of fruit.
Michael Pollan's book In Defense of Food: An
Eaters Manifesto is a fantastic book and will make you reconsider
everything you thought you knew about food. His advice is simple: "Eat
food. Not too much. Mostly plants." Follow his motto: "If it
came from a plant, eat it; if it was made at a plant, don't."
I've written on the subject of eating
factory made, pre-packaged, highly processed 'plant' food on my Diabetes
Better Health Stop Eating 'Plant' Food.
The Eat This Not That book
and website may be helpful when trying to make better food choices,
especially as it relates to calories.
Marion Nestle is one of the foremost experts
on food and nutrition. I trust her opinions. Her book What to Eat is an excellent in-depth
resource that explores and explains the reasons why we shouldn't simply
accept "store bought" foods at face value. "The foods
that sell best and bring in the most profits are not necessarily the ones
that are best for your health, and the conflict between health and business
goals is at the root of public confusion about food choices." She
believes that "research breakthroughs and seemingly contradictory
findings about one or another nutrient, food, or diet plan are taken out of
context. Nutrition arguments are almost invariably about single nutrients
taken out of their food context, single foods taken out of their dietary
context, or single risk factors and diseases taken out of their lifestyle
context." She suggests following 4 basic precepts: "Eat less,
move more, eat lots of fruits and vegetables, and go easy on the junk
foods." Click the 'What to Eat' link above and scroll down to read
the comments about this great book.
The South Beach Diet is a
lower carbohydrate diet that encourages eating lean protein, healthy fats,
and high fiber natural "good carbs".
Check out Toma Grubb's website and new book Toma's
Diabetic Diet - A Layman's Guide to Controlling Blood Glucose with Diet. He
includes a trial version of CyberSoft's Nutribase-7 Personal Plus
Nutrition and Fitness Software that helps you make healthy eating
choices and track the results.
One of the early pioneers of diabetes
information online is David Mendosa. His website
is an excellent source of information on all things related to diabetes.
Toma and David are both living well with diabetes and are an inspiration to
others wanting to control their blood sugars and avoid health problems by
adopting a healthy lifestyle.
A good book and resource for understanding
glycemic index and healthy eating is The New Glucose
Revolution. by Jennie Brand-Miller.
An excellent resource for understanding more about probiotics is The Probiotic
Revolution. by Gary Huffnagle, PhD.
Here is a link to a YouTube review of the book.
I also think you should get a
calorie-counting guide and begin to learn about the foods you eat. I
recommend Allan Borushek's The
CalorieKing Calorie, Fat & Carb Counter. This book is full of
great ideas and explanations about how to make healthy food choices.
There now are many smartphone
applications (apps) that will do the same thing even easier. Some count
your calories, others will tell you how far you've walked by using GPS
tracking. There are also apps that keep track of your blood sugar readings.
Check these out. They can help you reach your goals by simplifying the
For those of you who like to chat
online, I will recommend a wonderful website where you can network with
other people with diabetes, ask questions and get ideas and support at Diabetic Connect.
Finally, if you would like to get involved
with community-based programs that increase awareness about diabetes, the American Diabetes
Association website can help get you connected and active locally.
For updates and
further reading on issues surrounding diabetes, follow me at: David Hite's Diabetes Blog on
the Diabetes Product Source website.
I hope my
explanations in this section have been helpful. Be your own advocate, your
own best friend, and most importantly, don't beat yourself up over small
setbacks. Good diabetes control is not about being perfect. Believe in
yourself and in your ability to take control of your life and control your
diabetes; then take the first step toward living a healthy life. Remember,
knowledge is most powerful when it leads to positive change.
If this Diabetes Basics: Questions and Answers section was helpful
or if you have suggestions to improve it please email your comments to:
Doc@healthdoc.org. Good health. Live well.
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