If I have so much sugar in my blood why do I feel so tired and hungry all the time?

When you have diabetes, glucose (the type of sugar that we call 'blood sugar') is trapped in the blood in high amounts. Your cells aren't absorbing glucose 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 diabetes management. Click this link to watch the pancreas in action.

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 these cell 'doors' 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 glucose in the blood, the more insulin has to be produced so you can properly absorb the sugar. Diabetes occurs when a person is no longer able to produce enough insulin or the insulin that is produced is ineffective in delivering glucose into the cell.

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 insulin '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 swallowed).

Doctors conducting research into the cause have uncovered 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 the mucus lining of the gut. 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 destroyed. Follow this link to read the research study. Type 1 Diabetes is Associated with Enterovirus Infection in Gut Mucosa.

Which type is more common?

Type-2 diabetes, sometime called noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes, is by far the most common type. According to the World Health Organization, 347 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 glucose in your blood indicates that your body has lost its ability to properly absorb the fuels you eat. A 12-hour fasting blood sugar test is the standard diabetes screening test. The normal amount of glucose found circulating in the blood 12 hours after eating is normally 99 or less (measured in milligrams of glucose in each deciliter of blood). Glucose levels in the 100 to 125 range indicate that your body is struggling to control blood sugars and is called 'pre-diabetes'. A level of 126 or higher in two separate tests, or a single reading above 200, establishes the clinical diagnosis of diabetes. Your doctor may order a Glucose Tolerance Test to better assess how well your body reacts to a load of glucose. Blood sugars above 200 two hours after drinking 75 grams of glucose indicates diabetes. A reading between 140-199 indicates pre-diabetes. A reading below 140 is considered normal.

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 sugars, 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 blood sugar 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 asthma attack.

Corticosteroids, such 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 may have accelerated 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 they cured?

Maybe. We usually say they are in "remission" because diabetes reoccurs about 30% of the time within five years. 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 is 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.

The sugar glucose is the main fuel for your body. It's found naturally in both simple forms like honey (glucose/fructose mixture), sugar cane (sucrose: glucose/fructose bonded together), and complex forms called starches. Starches, like bread, rice, pasta, and potatoes, are made up of long chains of sugars that are digested into individual sugars (glucose). We all need some sugar in our blood. Glucose is a chemically reactive fuel that usually leaves your stomach and travels through the blood (usually less than 2 hours), and then is absorbed into your hungry cells and burned for energy. The issue for maintaining good health is managing how much glucose is in the blood at any time and for how long. You see glucose is a great energy source, but it's also chemically reactive. Trapped glucose in the blood accelerates 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! Glucose (the type of sugar that we call 'blood sugar') bonds with proteins in the body and weakens the structure (the chemical reaction is called glycation). We can measure the corrosive damage caused by glucose 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 glucose 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 effects of glucose 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 glucose levels 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 5M's of diabetic self-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 diabetic complications.

Then wouldn't it be better to try to lower my hemoglobin A1c to 6?

Certainly, reducing your hemoglobin A1c would produce less damage to blood vessels, but it may be difficult to achieve because of the risk of hypoglycemia (low blood sugar). Nature controlled your blood sugar very closely (a little like cruise control keeps the speed in your car steady). You will not be able to be that accurate so you will see greater swings in your blood sugar readings. Your target for achieving a hemoglobin A1c of 7 means your blood sugar readings will be between 70-130 before meals and less than 180 two hours after a meal. To maintain a hemoglobin A1c of 6 you would likely see blood sugars drop to the 50's which is very dangerous and requires immediate attention. Read below at the 'rule of 15' to learn how to deal with low blood sugar.

My hgbA1c is just about 7, why does my glucometer say my 30 day average is 132?

Most people check their blood sugar 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 glucose in the blood both before and after a meal that would account for the amount of hemoglobin damage seen.

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 glucose 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 avoid problems). Use your monitor as a tool to learn when your blood sugars tend to be high or low, and determine what caused them to be high or why they dropped low. You can also use your monitor to gauge the effect that exercise has on your blood sugars. It's an important tool that will help you connect the dots and better understand the factors that affect your health.

*** Rule of 15 - 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 1/2 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 glucose level stable.

My doctor told me I'm only borderline diabetic and that I don't have to do anything right now.

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 glucose 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 weight.

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 increased 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 (fat in the blood)
• HDL cholesterol less than 40 for men and 50 for women
• 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 glucose levels by employing your other tools: Monitoring, 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 like a living shield to 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 while nursing on 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 an active culture Greek yogurt or find a healthier probiotic source. Culturelle, containing the bacteria Lactobacillus rhamnosus GG and Align which contains Bifidobacterium infantis are two such brands. A product named VSL#3, a high dose blend of 8 probiotic strains, is designated as a “medical food” used in treating medical conditions such as ulcerative colitis rather than a nutritional supplement for general health. It is intended to be used under the supervision of a registered dietician or physician, however it is sold over the counter. Probiotics are often recommended to patients who have recently taken antibiotics to rebalance the gut.

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.

Carbohydrates are 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 benefit by eating 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.

One very good 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.

Another popular diet that might produce similar results is 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.

Would a gluten free diet help me control blood sugars?

No, gluten sensitivity is a separate issue. It’s important to eat whole grains because of the fiber and nutrients they contain, however some grains contain gluten. Gluten is the protein part of common grains like wheat, barley and rye (certain grains, such as oats, can be contaminated with wheat during growing and processing). Three million Americans have celiac disease, an autoimmune form of gluten intolerance that causes inflammation and damage to the small intestine. People with gluten intolerance must eat a gluten-free diet for life. Other people may not have celiac disease, but may be allergic or sensitive to gluten to a lesser degree, and would benefit from a gluten free diet. Try a gluten free diet for a few months and see if you feel any difference. If you have no intolerance to gluten protein, there’s no need to eliminate it from your diet.

What's so 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 (fiber) which slows digestion and helps you feel full, and starch a complex carbohydrate made of glucose that is 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. Glucose, from the broken down starches, floods into the blood like freeway traffic at rush hour leaving blood sugars high for hours after your meal.

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, and maybe a piece of whole fruit each day. Eat brown rice instead of white sticky rice or a whole grain pasta like those from Dreamfields. Switch from white potatoes to a red skin potato, new potato, or try a yam or sweet potato and see how each affects after meal blood sugars. If you like cereal for breakfast, be sure to stay away from sugary brands and instead choose whole grain and bran cereals, or steel cut oats instead of instant. These natural, high fiber 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. Here's a link to a good article on the importance of fiber in the diet. A Tale of Two Fibers.

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 in the sequence leads to a blood disorder called sickle 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 protein sources, 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. 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 causing scars that then allows cholesterol to stick and begin 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 L-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:

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 the same test subjects 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, turkey and fish with their lower levels of carnitine. Here is the link to an interview with the author of the study Dr. Stanley Hazen from the Cleveland Clinic. Red Meat's Heart Risk Goes Beyond The Fat .

Earlier you mentioned healthy fats? I thought all fat was bad for you.

Fats aren't 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 (Jif and Skippy have sugar added). Make room in your diet for these healthy fats by getting bad fats out!

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? 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 all 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 (like too many minerals in the water clog your shower nozzle). This buildup increases 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. Smokers have more heart attacks and strokes because of the damage smoking does to the inner lining of the blood vessel. The resulting scars allow cholesterol to build up much faster. One million heart attacks and half a million strokes occur in this country every year because of clogged blood vessels. Smoking and diabetes make for a deadly combination. Stop smoking and 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 (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 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 or restaurant tips?

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. Compare labels and try to make better choices. Look for fiber (3 grams or more per serving), fat (3 or less grams per serving), and Total Carbohydrate. Remember the word starch is not found on the label. The amount of starch in each serving is the difference you get after you subtract fiber and sugar from the total carbohydrate. The most important tip is to buy fresh natural whole food whenever possible.

Restaurant meals are much too large to be eaten all at one sitting. Don't eat large meals! Besides raising 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 (out of sight, out of mind). Of course if you are with someone, simply sharing one meal is a great solution to portion distortion. Restaurant food is usually loaded with salt. Salt won't affect your blood sugar, but it may affect your blood pressure. Don't be shy about asking the waiter for lower salt versions. Many restaurants have tried to accommodate health conscious customers by noting on the menu that a meal is heart healthy, or by adding senior sized meals.

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 long.

Most dieticians 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 when 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?

Artificial sweeteners aren't digestible, so they don't raise blood sugars. 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 chemically 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. Water is the drink that quenches thirst, but daily coffee or tea with a sweetener or a diet soda once in a while as a treat, is not likely to cause any problems. Multiple diet sodas a day is way too much and not a healthy habit. Remember the bacteria in your gut are being dosed with these chemicals too.

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 your 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 regarding the taste, but give it a try and see if you like it.

I've heard that supplements help treat diabetes?

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, 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". This website run by the U.S. Department of Agriculture is a good place to start researching food and supplements: Food and Nutrition Information Center.

** If you decide to try a supplement to aid in blood sugar control, consult your physician and then proceed with caution. Have a plan in mind, since trying several at once will prevent you from assessing which may be producing side effects and which are showing effectiveness.

The following supplements have shown some promise in treating diabetes. I've supplied links to research that supports their usefulness in controlling blood sugars.

I’ve heard Agave Nectar is a good substitute for regular sugar?

No it's not. While high fructose corn syrup, found in soft drinks and processed foods, is 55% fructose, agave nectar is up to 90% concentrated fructose. In my blog, Fed up with Fructose: The Metabolic Consequences of a High Fructose Diet , I discuss the differences in how various sugars are broken down and the effects they have on metabolism. Glucose, as you have learned, is delivered to cells by the action of insulin. Fructose is not a direct energy source for the cell and is unique among sugars because it’s metabolized only in limited amounts in the liver (Ironically, since fructose doesn’t cause a rise in insulin, it has been suggested in the past to actually be helpful in diabetic blood sugar control). Evidence is accumulating that high amounts of fructose in the diet directly contributes to Metabolic Syndrome (with insulin resistance) and type-2 diabetes. Insulin resistance leading to increased belly fat, fatty liver, low HDL and high triglycerides may be due to metabolic changes in the liver.

A recent research study using healthy subjects demonstrated that humans only have the capacity to absorb up to 25 grams of fructose, and exhibit symptoms of malabsorption, with bloating and diarrhea, above 50 grams. One cup of blueberries has 7gms of fructose, an apple 11gms. One 12oz soda has 25gms. Unabsorbed fructose continues through the intestine to the colon where it may stimulate the growth of harmful bacteria. Historical intake of fructose, mostly in the form of fruit and honey, was limited and seasonal. Prior to the turn of the 20th century, the average consumption was only 5 lbs. per person per year. Today we use sugar as though it was a spice. Per capita sugar consumption in the U.S. is now over 100 lbs. yearly and present as ‘added sugar’ in almost all processed foods. High fructose corn syrup (55% fructose), the usual sweetener in soft drinks, juices and sport drinks, accounts for 50% of our added sugar intake, while desserts and candy account for an additional 25%. This amounts to 32 teaspoons of sugar per day, of which 64 grams is fructose.

The dietary mantra since the 70’s has been to eat low fat. But this by default led to higher carbohydrate diets as sugar replaced fat. During this time obesity rates have tripled and chronic conditions like diabetes have skyrocketed. The pendulum has now swung back so that today low carb is the orthodoxy with dietary starches found in potatoes, breads, rice, cereals, pasta and beans, seen as bad foods. Diabetics are told to count carbohydrates to avoid spikes in blood sugar, and this is necessarily true. But the rise in blood sugar from the intake of these complex carbohydrates may be simply the end result of a metabolic disturbance that arises much earlier in the liver from the intake of too much fructose, and resulting obesity may be a marker of the damage caused by its toxic effects. This may explain why a change to a natural plant based diet has shown success in the remission of diabetic symptoms. Fruit is good for you in limited amounts, but juices, energy drinks and sodas are too much of a good thing. Avoid concentrated fructose by eating whole natural foods in balanced amounts and avoiding processed foods containing added sugars.

Can I drink alcohol?

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 you.

Sometimes I find myself eating when I'm not really hungry. What can I do about overeating?

The feeling of fullness after a meal is not just in the stomach, it's also in the brain. High triglycerides, common with metabolic syndrome, impair the transport of the hormone leptin. Leptin controls the urge to eat and is responsible for letting the brain know when you're full (satiety), so if leptin doesn’t reach the brain, the brain doesn’t get the signal to stop eating. Many of my patients struggle with overeating not so much because of hunger, but because of this lack of satiety. Satiety brings with it 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 savor the flavor. Leptin takes 30 minutes to reach the brain, so if you eat too fast you can 'over-consume' and eat far more than your body really needs. Also, 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.

My final thought on eating has to do with the constant battle of needs versus wants. 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 one of life's great pleasures 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 over-consumption.

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 glucose is trapped in the blood? You may be feeling tired and hungry because the glucose 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 glucose 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 glucose 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 the glucose 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 (always carry some fast acting sugar with you just to be safe). 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, glucose is 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 with these high intensity exercises, there's too much risk of getting hurt. Start slowly and buildup. 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 glucose 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). One concern with this class of medication is hypoglycemia. These drugs, taken before a meal, cause your pancreas to release insulin which will lower blood sugar from the coming meal. If you take it and don't eat or eat less than usual, your blood sugar may drop too low. 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 glucose that is stored in the liver. One of the many jobs of the liver is to store extra glucose 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. Metformin 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. Metformin 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.

Note-Avandia (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 consumers.

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 glucose 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?

Not necessarily. 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 glucose 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.

My doctor says my lab test found protein in my urine. Should I stop eating protein?

No, don't stop eating protein. Protein is what we're made of and is always circulating through the blood. The question is how it got from the blood into the urine. Your kidneys are like a net that lets some things through and holds other things back. When your kidneys filter your blood (about 50 gallons per day) impurities and waste are removed and released as urine. Proteins are very big and do not normally escape. The lab test looks for the presence of one of the smallest proteins (microalbumin). If an unusual amount of this protein is present in the urine sample it leads us to believe that some kidney damage has occurred (tiny breaks in the blood vessel net lets protein escape). High blood sugar that damages blood vessels is primarily the problem, but high blood pressure on weakened blood vessels compounds it. Your doctor will likely recommend a blood pressure medication like lisinopril to control blood pressure and help protect the kidneys. Some people get a little nagging cough when taking lisinopril. If this happens your doctor will switch you to another drug called Cozaar.

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 blood sugars.

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 coming danger.

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 stimulating way.

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, do it often and come back renewed.

I received an email recently about a motivational speaker who came to the stage with a bottle of water in her out stretched hand. She asked her audience how heavy it was. After a number of answers were shouted out she said "It doesn't matter. It depends how long you hold it. In five minutes it will be a lot heavier, in five hours you won't be able to hold it. The longer you hold onto things the heavier they get. Yet if you set them down for a time and rest they won't be as heavy when you pick them up the next time." Life is complex and full of real concerns, but face your concerns without worry. Concerns can be addressed and solved at the proper time. Worry is what you do in between those times of action and simply wear you down. Center your Self without becoming self-centered. Find a natural balance and take care of yourself.

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.

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: "Do not distress yourself with dark imaginings. Many fears are born of fatigue and loneliness. Beyond a wholesome discipline, be gentle with yourself."

This humorous adaptation was offered to me by one of my friends at Diabetic Connect. I hope it makes you smile.

Desiderata for Diabetics

Go placidly amid the noise and the haste,
And remember that stress and cortisol may raise your levels.

As far as possible, without surrender,
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.

Be yourself. 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 be perfect.
But do not distress yourself with dark imaginings.
Many fears are born of looking at the wrong sites on the internet.

Beyond a wholesome discipline,
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. Can you recommend any books or websites that will help me stay on track?

Your condition, diabetes, is considered chronic, it's not yet curable. This means that you will probably be living with diabetes for many years. 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.

Here are some other helpful books and websites that will help you stay motivated and on track.

I've written on the subject of eating factory made, pre-packaged, highly processed 'plant' food on my Diabetes Blog. For Better Health Stop Eating 'Plant' Food.

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.

Copyright - HealthDoc.org All rights reserved