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.
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.
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.
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.
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
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?
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?
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.
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?
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
- 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
- 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
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?
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
Which of your 5M's is the most important?
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
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
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
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
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
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
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:
Beef = 105 milligrams
Pork = 30 milligrams
Chicken, Turkey 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 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
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
Okay, so which ones are the unhealthy fats I should avoid?
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
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
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?
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?
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
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
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
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?
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.
Cinnamon - Research has shown that as little as 1 gram
of cinnamon may in fact help lower blood sugars. The active ingredient in
cinnamon is Proanthrocyanidin, the water soluble part of cinnamon.
It is thought to function by activating insulin receptors on the
surface of the cell allowing the cell to absorb glucose 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.
- Mayo Clinic.
Red Wine Vinegar - Research studies over the past 10 years have clearly shown benefits from vinegar consumption. Vinegar can improve glycemic control both fasting and postprandial (after-meal) glucose levels.
Salacia oblonga -
Salacia extract significantly lowered the postprandial (after meal) blood sugar and insulin levels. The study results suggest that Salacia may be beneficial in the treatment of type-2 diabetes.
- PubMed - National Institutes of Health/American Journal of Clinical Nutrition.
Bitter Melon (Momordica charantia) - Bitter melon has been widely used as a traditional medicine treatment for diabetic patients throughout Asia. Studies comparing metformin to bitter melon demonstrated significant blood sugar lowering effects with both, however, the hypoglycemic effect of bitter melon at a dose of 2,000mg/day was less than metformin 1,000 mg/day.
- PubMed - National Institutes of Health.
Research supports the use of chromium supplements (chromium picolinate) for blood sugar control. Studies show that chromium has a positive effect on fasting insulin values and on Hemoglobin A1C.
- American Journal of Clinical Nutrition.
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.
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
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
My doctor wants me to exercise, and I would if I only had
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.
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?
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
Can you describe how each of these pills works to lower my
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
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
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
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?
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
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?
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
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
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
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 listen to others,
except to the diet and
they just don't get it.
Avoid loud and
they are vexatious to good glycemic
If you compare your HbA1c with others,
you may become vain or
for always there will be greater and lesser numbers than
Enjoy your achievements as well as your plans.
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,
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
and everywhere life is full of Joslin
Be yourself. Especially do not forget your insulin.
cynical about the bond between fellow sufferers,
for in the face
of all aridity and disenchantment,
it is as perennial as the
Take kindly the counsel of the old timers,
optimistic about the future for the young.
Nurture strength of
spirit to shield you should your retinopathy scan not be
But do not distress yourself with dark
Many fears are born of looking at the wrong sites on
Beyond a wholesome discipline,
treat yourself from time to
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
Therefore be at peace with your endocrinologist,
lacking in knowledge you perceive him to be.
And whatever your
labors and aspirations,
in the noisy confusion of life,
sure you have enough test strips.
With all its sham, drudgery, and broken dreams,
it is still a
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?
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
Here are some other helpful books and websites that will help you
stay motivated and on track.