Diabetes Month Tip of the Workday

Question

Thanks for a month’s worth of information.  But now, how can I use this information to help my friends and family members with diabetes and not feel like I’m being too intrusive? (In other words, how can I not be a “that guy” to people with diabetes?)

Answer

So glad you asked!   Here’s a summary of some tips offered by William Polonsky, Ph.D., a psychologist who specializes in treating people with diabetes (full article below).

1. Recognize that managing diabetes is a lot of work; it will help you be more empathetic toward that person.  That person might also be coping with pain or other chronic conditions that make it hard to manage self care activities, and the diabetes is just that much more to cope with.
2. Do not offer unsolicited advice about nutrition (“Should you be eating that?”) and other aspects of diabetes care. Treat adults like adults who are capable of making their own informed choices—including the choice to eat high carbohydrate foods sometimes. If they are Type 1, chances are they have thought long and hard about how much insulin they need to take to compensate for the pecan pie or whatever it is they are eating.
3. Do offer to join in when someone is making healthy lifestyle choices.  Bring healthy food to share at work instead of the high carbohydrate leftovers from your pantry.
4. Don’t share horror stories about other people you know with diabetes (unless they ask, of course). Diabetes is scary enough, and hearing about your dead grandmother or your amputee aunt isn’t going to help make it any less scarier.
5. Do simply ask “how can I help you?” Maybe they’ll give a suggestion, or maybe they’ll tell you they are fine.
6. Don’t look horrified when the other person checks their glucose or uses insulin. They are just using a set of tools to stay healthy—it’s not much different that using a fork to eat or a wheelchair to move around in.
7. Do offer a supportive environment, particularly for food choices. Throwing a dinner party?  At least have them look over the proposed menu.
8. Don’t give thoughtless reassurances. If you haven’t been through it, you probably don’t want to say “It can’t be that hard….”
9. Don’t peek at or comment on blood sugar numbers without asking.  Those numbers are private and an extension of a person’s body.  Don’t invade their privacy.
10. Do offer loving encouragement—sometimes the other person just likes knowing you care.

Full article: Here

More humor about what NOT to say to a person with diabetes:

10 things NOT to Say to a Person with Diabetes.

29 Annoying Things Said to People with Diabetes.

Diabetes Month Tip of the Workday

Question

This lifestyle information has been interesting, but I know there are a lot of people on medicine or insulin to control their blood glucose.  Why are there so many different types of medicine or insulin?

Answer

I could spend a whole week talking about that, so let’s see if I can condense. Your friendly pharmacists can give you a good answer too!

Remember that our blood sugar is regulated by a complicated process influenced by how much insulin you make, how well you make insulin, how well you “use” insulin, how well you absorb your food after digesting, how much glucose your liver stores and releases into the blood stream, and how sensitive you are to insulin suppressing hormones (Whew!).

Each different type of medicine works on a different part of the regulation process—and not every person with diabetes has a “deficiency” in all areas of regulating glucose.  The amount and type of medication you take will depend on what part of the process needs correcting. For example, if someone has Type 2 diabetes, and their doctor thinks it is caught early, they will often start on a medication like Metformin (aka Glucophage) to keep the liver from releasing too much glucose into the bloodstream and help them "use" insulin better. They will still be encouraged to change their carb intake and become more active, but some people just need extra help. I've had a lot of trouble over the years with people assuming they have "failed" diabetes because they require medication and/or insulin to keep blood glucose under control. This is simply not true, medication is just another tool in the toolbox that some of us need. This type of shaming and ignorant attitude is particularly dangerous for people with Type 1 diabetes--I had at least one friend go into diabetic ketoacidosis while recovering from surgery because he didn't get his insulin.

As far as insulin is concerned—remember that those of us who don’t have diabetes have a certain amount of insulin in our blood stream all the time.  This is usually referred to as a basal or “background” insulin.  When we eat carbohydrate our pancreas will give a short burst (or bolus) of insulin the moment the carbohydrate hits our tongue, and then another burst/bolus of insulin once that glucose hits our blood stream.  People with Type 1 diabetes (remember, they don’t make any insulin at all) will usually need to take a shot of basal insulin (once or twice per day depending on the type) and a “bolus” type insulin whenever they eat.  People with Type 2 might “only” need a bit of bolus insulin, or if they’ve been diabetic for a long time, they might need a combination of the two.  Some insulins also contain a mixture of background and bolus insulin or people have to mix the two in a syringe.  Again, it depends on how much “correction” a person needs and how well they eat, etc.

All that said, each person with diabetes should spend some time with their doctor going over what the medicine is used for, what the side effects are, and the risks/benefits. Way easier said than done in this day and age of doctors having limited time to spend with you. If your insurance allows it, try to get into and endocrinologist or a diabetes center that will allow you to spend more quality time with a diabetes specialist and/or a diabetes educator to help you understand how to best take your medicine/insulin.

Diabetes Month Tip of the Workday

Question

What is the best type of exercise for someone who has Type 2 diabetes?

Answer

The short answer is a combination of strength training and cardiovascular exercises, but any exercise helps if it is done safely. Naturally, people need to consult their providers and whenever possible, a qualified physical therapist so they have an idea of both how much exercise they can do safely and what they can do safely. If you have a chronic illness and/or already have complications from diabetes, you will want to be especially careful when seeking out a personal trainer. Here is a short post on what to look for if you are seeking help from a personal trainer.   

People should also be reminded that if they are trying to lose weight that most of the weight loss will come from changing the diet as opposed to exercise.  Let me repeat that, if you are trying to lose weight your diet will make more of a difference than your exercise.  Unless you are a triathlete, professional athlete, competitive body builder, etc, you really don't have much wiggle room to take in extra calories or need extra protein. Anyone who tells you otherwise is probably trying to sell you something you don't need.

Even if exercise doesn't help with weight loss as much as you thought it did, there are still plenty of of benefits to exercising.
1) Overall lower blood sugar in people with diabetes. Exercise that builds and maintains muscle will help you become more "sensitive" to insulin and help your overall blood sugar better.
2) Increased lean body mass or muscle. Starting in your late twenties and early thirties you lose lean body mass unless you do something to prevent it.
3) Increased strength and balance, this is particularly important for older folks who might already have other issues affecting their ability to walk safely.
4) Prevention bone loss in older people
5) Help your emotional well-being.

Dr. Yoni Freedhoff of Weighty Matters, a physician who specializes in weight loss, has blogged about this topic of "exercise for health, not for weight loss" quite a bit. Here is one of his videos that he did a few years ago, and if you like that video, he has a lot more information. Happy watching and reading!

Diabetes Month Tip of the Work Day--Part Two

Question

What about alcohol? I've gotten a lot of different "opinions" on this one.

Answer

You've probably gotten a lot of different opinions on this one because a) the consumption of alcohol has a huge social/societal component to it, and many of us in healthcare let that color our answer, sometimes more than we should and b) people with diabetes have a lot of things to consider before they take that first drink. I've included a list of considerations below.

*Moderate drinking to maintain good health is defined as no more than two drinks maximum for a larger person and one drink a day for a smaller person.  

1. Is my blood glucose level in what I consider good control or poor control?
1. For people that already have blood sugar levels well above goal or tend to “swing” wildly; you probably shouldn’t add empty calories and extra carbohydrate into that mix.
2. Do I have any other conditions that do not mix with alcohol?
1. Many people with diabetes have other conditions like kidney disease, neuropathy, congestive heart failure, etc that are aggravated by alcohol consumption and might be better off avoiding it.
3. Do I take any medications that do not mix with alcohol?
1. Again, many people with diabetes will taking other medications that do not mix well with alcohol.  Ask your provider or pharmacist about your medications if you can, as the internet might give you a lot of seemingly conflicting information too.
4. Do I have access to food for when I take that first drink of alcohol?
1. Our bodies engage in many wondrous complex regulatory processes, including a process called gluconeogenesis, which allows the liver to store glucose and release glucose into the bloodstream when your blood glucose levels drop.  Alcohol can hinder that same process and cause the blood sugar to drop if you drink on an empty stomach.  
2. On a related note, if you have diabetes and are going to be drinking with friends or family, make sure they know that you need to eat with alcohol.  That way if your food intake is delayed, and you become “wobbly,” your friends can remind you to check your glucose instead of just assuming you are tipsy. Keep easily chewed and swallowed carbohydrate sources with you, and make sure you are wearing your medic alert bracelet or necklace.
5. How many extra calories and carbohydrate grams am I getting?
1. Most alcoholic beverages do not have a label on them to tell you this—so again, yay for the internet (calorieking.com) and smartphones to help you figure this information out. Again, planning ahead before you go out to a place that doesn't have good internet service is a good idea.
2. In general, dry red wines and lite beers have only 2-4 grams of carbohydrate and distilled liquors (like vodka) have none. You still have to count the calories though.
3. Mixed drinks (like margaritas) will often have the most calories and carbohydrates.
6. What is my past experience with alcohol/can I truly moderate my drinking?
1. Have you had trouble stopping after one or two drinks in the past?  Did a fun night of drinking result in a hospital visit?  Probably not a good idea for you personally to be drinking then.

Se you tomorrow for some information about exercise!

Diabetes Month Tip of the Workday--part one

I meant to publish this the day after Thanksgiving, but Google apparently did not save my document correctly. I was out of town and too frustrated to fix on Spouse's laptop. Then this morning the cat literally walked over the keyboard and erased what I had written. So here is a twofer for you.

Question

I live in the United States and I did not want to check my blood glucose this morning as I had a pretty carbohydrate heavy day yesterday. I started thinking about all the carbohydrate heavy holidays spanning from Halloween to Valentine's Day, and I want to find a good "halfway" strategy that doesn't involve beating myself up about my eating habits for months on end or devolve into me not caring so I wind up in the emergency room. How can I start to do this?

Answer

Good for you for wanting to do the hard work of truly taking care of yourself both mentally and physically during the holidays.

1. Start with congratulating yourself for wanting to take care of yourself. You might have to do this every morning by journaling or whatever you do to take care of you!
2. Do your homework on your favorite carbohydrate rich holiday foods before your next big family gathering (or before that particular work day when you know you're co-workers are going to bring in certain foods. Websites like calorieking.com can give you a pretty good idea of how much carbohydrate is in what you like to eat. It can also get you started estimating portion sizes which, unless you're a trained chef, is always a challenge and may take a little more measuring.
3. Figure out which carbohydrate foods you “need” to have to have a happy holiday and which foods can live without or don’t really like anyway. Maybe you really "need" your favorite Uncle's cornbread stuffing to have a good day, but you really don't want your other Uncle's mushy corn casserole. If your gatherings are big enough, someone is probably letting "that uncle's" casserole sit by itself anyway.
4. Intentionally pick which days are going to be carbohydrate heavy so you don't mindlessly take in more than you want from from Halloween to Valentine’s Day.
5. If you have trouble with “food pushing” family members (or co-workers), try getting advice from your favorite mental health professional or your favorite culture sharing supportive group of friends on how to safely negotiate challenging family situations and/set boundaries with friends and co-workers. You might need to sneak away or surreptitiously text or call an understanding friend to vent.
6. Have your own snacks and lunch items available at work, even if it means combining what you eat with what is brought.
7. Focus on traditions that don’t involve food (like going for a walk or playing games or try to form some new family traditions or travel. And if you can make that walk about having fun and getting out of the house, and not burning calories, even better! 
8. Experiment with some lower carb versions of your favorite foods to see if there is a worthy substitute.  Preferably on a day that is not before the family gathering if you can help it. I have some pumpkin muffins that I make with coconut flour that are so moist and tasty that even my texture sensitive spouse likes them. And I've also had some low carb baked goods that I've thrown in the trash.  If your exciting food experiment turns out to be not so exciting (or edible), don’t be afraid to be glad you tried, laugh, and move on.  Enjoy the regular item in a smaller amount.
9. Have a plan to donate or freeze leftovers, or even spend some time working at soup kitchen or other charity. A lonely neighbor, or a local homeless shelter or giveaway group might want to have something homemade. Sometimes you might also find that if your cookies (or whatever) are in the freezer you are less likely to eat them. And if you are like me, you might not want to have tempting items in the house anywhere.
10. Have a plan in place for if you do overindulge and your blood sugars are raging out of control. Keep some protein/veggies in the freezer so you can have a carb free meal until everything settles down. Have more test strips on hand to check more often and monitor the situation.

Diabetes Month Tip of the Workday

Question

How many times per day should a person with diabetes eat?

Answer

The answer to this question ultimately depends on what type of medication and insulin regimen the person is on (if any), what other medical problems they might have that can interfere with nutrient absorption, and to a certain extent, how old they are.  

If you are trying to control your blood glucose without any type of medication (pills or injectables), you might benefit from eating at least three times a day to keep your carbohydrate and your protein intake spread throughout the day.  Some people can get away with keeping in spread through two meals a day, others need to have something in the morning to keep them from overeating later.  Whatever helps you achieve your basic carbohydrate/protein intake, create a caloric deficit if you are trying to lose weight, and keep from being miserable because you are skipping meals.

If your provider has you on a medicine like metformin (aka Glucophage), you will probably have to take this medication with a meal that has protein in it to reduce your chance of side effects like nausea and diarrhea. To keep yourself from being miserable, it is better that you have 2-3 meals a day.

If you take a medication like Victoza orExenatide to help with blood glucose control and weight loss, you will have to be careful to avoid overeating at meals to keep from having nausea and vomiting as well.  Even if you are trying to lose weight you need to get enough nutrition, ergo, you will be better off eating three times per day.

Most of the people that I work with, because of their station in life, wind up taking some of our long standing medications like Glipizide (Diabeta) and insulin 70/30, or insulin NPH. These medications/insulin require a pretty rigid schedule to prevent hypoglycemia (low blood glucose).  Therefore, people who take these medications would benefit from eating three meals per day at roughly the same time each day so that they can get enough protein, avoid hypoglycemia, and avoid overeating.  If they take Glipizide or insulin 70/30, they probably need to eat a snack at night as well.  (And sometimes a small snack can be worked in for those with a schedule that keeps more than 4-5 hours between meals).

Over the years many people with Type 2 diabetes have been told to eat six smaller meals per day.  This statement is NOT based in evidence and usually leads to weight gain, since they will likely consume more calories and never have a chance to “tap into” their fat stores.  They will also likely have even worse blood sugar control.  If someone feels compelled to eat in between meals to avoid hypoglycemia they most likely need a reduction in insulin and/or medication as no one should have to “feed” their insulin.  Leave the six meal a day recommendations to those who need to gain weight (like little kids with Type 1), have certain digestive conditions (like IBS that is diarrhea-dominant), and/or just a generally poor appetite.

The need to have a regular eating schedule to prevent hypoglycemia and to get enough protein taps into another problem that many of the people that I work with face; that of food security.  I would like to give this attention in another blog post.  But, usually if someone is having a lot of low blood glucose levels at the end of the month it might be because they are running out of food by that time.  I sometimes see people’s glucose levels go a lot higher at the end of the month because they have only higher carbohydrate staples to consume.  Eating regularly and in balanced amounts is currently something that not everyone has access to, and needs to be taken into account when we try to be compassionate towards others.

Thanks again for reading, see you the day after United States Thanksgiving!

Diabetes Month Tip of the Day

Question

I heard that people with diabetes with diabetes are supposed to eat protein with their carbohydrate because it will help “balance out” or “stabilize” the blood sugar.  Is that true?

Answer

The short answer is no. (And you were hoping that piece of chicken would cancel out the pasta, weren’t you?).  Also, the concept of “balancing out” and stabilizing are pretty much vague terms that don't really do anything except maybe help us feel virtuous about our eating. I think what some people mean is that they hope that by eating protein that they will “prevent blood glucose from spiking” or “the chicken will actually cancel out the pasta somehow.”

Eating protein with carbohydrate does not “stop” or “slow down” the carbohydrate from spiking the blood sugar, and eating protein does not bring high blood sugar down.  At one point in time I think people actually believed that protein at bedtime would somehow prevent low blood sugars from happening overnight or during the day, however, once we studied that it turned out not to be the case. Adding fat and fiber to the meal can slow down the emptying of the stomach and therefore slow the absorption of carbohydrate, but ultimately the blood sugar spike and any other fluctuations will be mostly determined by the amount of carbohydrate that someone eats.

Now, none of that should take away from the need to eat protein!  Meals that contain protein often help you feel fuller faster and for longer periods of time; meaning that for some people eating protein might help you not eat as much at that meal and help you not eat as much in between meals. Indirectly, that helps keep the blood sugar levels from being elevated because you are just not eating as much carbohydrate.  Protein also helps us maintain muscle mass and skin integrity (particularly when we are trying to lose extra body fat), and older people will absorb protein better (and be more likely to get enough) if they eat it at each meal instead of just once or twice per day. I had a co-worker also ask me about protein helping you “burn” more calories, each day, also known as the Thermic Effect of Food. Your resting metabolism might increase very slightly if you added more protein, but the minute you eat more than one or two Oreos cookies or a slice of bread, that effect is gone.  So no, adding more protein doesn’t excuse your need to reduce carbohydrate or calories.

If you’ve heard “eat a portion of protein” about the size of your palm before, it’s because that size of chicken breast, etc. is going to be about 2-4 ounces of protein.  Most adults will need about that much per meal—which also translates to 14-28 grams of protein.  And guess what?  Protein also contains calories too.  If you are trying to lose extra body fat and maintain your lean muscle, you will still have to watch the amount of calories you eat.  

So when you hear about a “balanced” meal, what that translates to is a meal that contains adequate/appropriate amounts of carb, protein, healthy fats, and vegetables.  No magical prevention of blood glucose spikes, no magical prevention of low blood glucose, just earlier satisfaction with the meal and maybe eating fewer calories during the day.

Want to keep reading?

http://blog.joslin.org/2012/04/protein-breakdown-what-it-does-for-your-diabetes/