Reversing diabetes?

Here is this week's question from FOODPICKER.org:

Tammy S. asks: My 45 year-old husband was diagnosed with type 2 diabetes a few months ago.  Is it true that you can reverse diabetes?

Answer:  Confusion abounds regarding whether or not type 2 diabetes can be reversed! The short answer is no. Diabetes is a chronic condition that cannot be cured - it can, however, be managed. There is a distinct difference.

Type 2 diabetes occurs when the pancreas either does not produce enough insulin, or the body's cells do not respond to insulin properly (insulin resistance). In either case, the not enough glucose is moved from the bloodstream into the body's tissues, and you are left with high blood glucose levels.

Let's look at an example: 2 hours after a meal, blood glucose should be below 140 mg/dl. When your blood glucose is over 140 for longer than 2 hours, other constituents of blood are skewed: triglyceride levels increase, fibrinogen (used in clotting) decreases. Over time (in terms of years) this will increase your chances of damaging the tiny blood vessels in eyes, kidneys and nerves - leading to a host of other problems.

A person without diabetes can eat chocolate cake or a salad for lunch - in either case, 2 hours after a meal his/her blood glucose will be below 140 (probably more like 120). The pancreas will compensate depending on what is eaten. In a person with type 2 diabetes, like your husband, eating chocolate cake for lunch (and nothing else) puts a huge glucose load on his bloodstream. His pancreas kicks into overdrive to compensate, but it just can't keep up. Two hours later his pancreas is still trying to clear all the blood of the sugar from lunch. It's like using a spork to eat soup - it sort of works, but is not totally efficient! Now, if your husband had eaten a salad and maybe some broiled fish or chicken followed by a smaller portion of chocolate cake, his blood glucose might be within a normal range 2 hours later.

Does that mean his diabetes is cured? No! If he goes back to eating cake for lunch, his diabetes manifests again.

However, diabetes complications should not be considered manifest destiny! This does not mean that you cannot live a healthy, long life with diabetes. Treatment of type 2 diabetes includes a healthful diet, physical activity, blood sugar monitoring and medication. 

The most successful person with type 2 diabetes takes control of their treatment by:

• testing blood sugar as recommended
• following a meal plan to control blood sugar
• exercising on a regular basis
• taking medications as prescribed
• maintaining a healthy body weight (or losing weight, if needed)
• visiting healthcare providers on a regular basis - endocrinologist, dietitian, CDE, etc.)

Possible diabetes? Fasting glucose question

Below is a question I recently received from FOODPICKER.org

Susan D. asks: My fasting glucose number was 127.  Does this sound like pre-diabetes or diabetes?  What should I do to control by blood sugar?

Answer:  Diabetes is usually diagnosed if your blood glucose level exceeds 125 mg/dL during a fasting plasma glucose test. This test is usually conducted on more than one occasion to confirm the diagnosis. Three types of blood tests are to diagnose diabetes: 

• A Fasting plasma glucose test measures your blood glucose after fasting (not eating anything) for at least 8 hours. 
  
  
• An oral glucose tolerance test also starts with you in the fasted state, then you drink a glucose-containing beverage and your blood glucose levels are monitored for 2 hours afterwards.
  
  
• A random (or casual) plasma glucose test measures blood glucose at any point in time, without regard to when you last ate. 

Here is some more information regarding diabetes diagnosis from the NIH's National Diabetes Informational Clearinghouse. Since a blood glucose of 127 mg/dL is just above the cutoff, your doctor will likely repeat the fasting test or have you complete an oral glucose tolerance test before officially diagnosing you.

If your diagnosis of diabetes is confirmed, you should speak to your doctor regarding treatment. Generally, this involves blood glucose monitoring, oral medications, exercise and diet changes. Most notably, you will need to take care to spread carbohydrates evenly throughout the day. This may seem overwhelming, but there is a lot of help available! Often the best way to get started is by attending a diabetes education class or making an appointment with a Certified Diabetes Educator or Registered Dietitian. Check out this post from a few weeks ago for some more ideas in finding help. 

Send your questions to diabetes@foodpicker.org or directly to me at jjznutrition@gmail.com

Prediabetes, weight loss and fruits & vegetables

Here is a question I recently received from FOODPICKER.org:

Bob R.: I have pre-diabetes and am trying to lose weight.  How many servings of fruit and veggies should I have each day?

Answer: Prediabetes is a condition in which blood glucose levels are higher than normal, but not high enough to be diagnosed as diabetes. It's great that you have already decided to take the first step to better health! According to the American Diabetes Association losing as little as 5-10% of your body weight (approximately 10-15lbs), along with engaging in regular activity, may help you delay or prevent the development of type 2 diabetes.

In general, adults should consume about 3 cups of vegetables and 2 cups of fruit everyday.  But what counts as a cup? This may be confusing. In general, 1 cup of raw or cooked vegetables or 2 cups of raw leafy greens should be considered 1 cup of vegetables. For fruits, 1 cup of chopped fruit or ½ cup of dried fruit can be considered 1 cup. Here is a handy vegetable chart and a handy fruit chart from MyPyramid.gov that should help clear things up a bit.

You'll notice that both vegetable juices and fruit juices are also on the MyPyramid charts. In terms of watching your blood glucose levels, juices have two major strikes against them: they contain little to no fiber, and are a concentrated source of sugars. Drink juices in moderation! Also be sure to look out for starchy vegetables like potatoes, corn and peas. Starchy vegetables are much higher in carbohydrate than their non-starchy or cruciferous counterparts. Go for vegetables like broccoli, kale, lettuce, cabbage, cauliflower, chard, bok choy and bell peppers. Check out http://www.choosemyplate.gov/  for menu planning tips and to track and assess your food intake. Also visit FruitsandVeggiesMoreMatters.org for recipe ideas.

Don't forget that regular, moderate exercise is an important part of a healthy lifestyle. You don't have to join a gym - try walking for 30 minutes, 5 days a week. It will make a difference.

New Type 2? Think there's nothing to eat?

Question of the week from FOODPICKER.org:

Susan A.: I was diagnosed with type 2 diabetes last month.  I’m having difficulty understanding how many carbs and sugar I can have each day.  I’m finding that nearly everything contains carbs and sugar!  Can you help me with this?
 
Answer: Asking for help is the first step in learning diabetes self-management. You might start by asking your endocrinologist or primary care doctor to refer you any classes in your area. Also please refer to last week's question & answer for help in finding a Certified Diabetes Educator (CDE) or Registered Dietitian (RD) to work with you. For newly diagnosed persons, I highly recommend personalized sessions with a CDE or RD. It will be very helpful in starting you off on the right track to great diabetes self-care and good long-term health.

There are 2 main meal planning methods taught to people with diabetes: carbohydrate counting and the exchange system.  I find carb counting a much easier method to learn and teach, but you may find you like exchanges better. Be sure to ask about these two methods so you can discover which will work better for you.

In general, the body needs a minimum of 130 grams of carbohydrate each day. Carbohydrates are not the enemy here - your body runs on carbohydrate and needs adequate amounts to survive! For someone with diabetes, the issue is that the body cannot handle a large amount of carbohydrate at one time. It is important for you to spread carbohydrates throughout the day. You will find it easier to do this (and easier to maintain blood glucose control) if you eat several smaller meals and snacks instead of only 2 or 3 meals per day.

For example, say you are aiming for approximately 150 - 160g of carbohydrate per day. You could divide as follows:

• Breakfast: 25 -30g
• Snack: 15 - 20g
• Lunch: 30 - 45g
• Snack: 15 - 20g
• Dinner: 30 - 45g
• Snack: 15g

This type of breakdown of grams/carb per meal is typical in the carb counting method of meal planning.

When reading food labels, the "Total Carbohydrate" amount is the most important one to consider (sugar is included in the "Total Carbohydrate" amount). For foods without labels (the best type to eat!), you can try searching the USDA's nutrient database or FOODPICKER.org. You can also track and assess your diet for free with USDA's SuperTracker.

In general, the faster your blood glucose rises, the higher it is likely go. You'll want to concentrate on carbohydrates that take longer to digest. This includes carbohydrate choices with lots of naturally-occurring fiber: whole grains (brown rice, quinoa), whole fruits (not fruit juices) and non-starchy vegetables (broccoli, lettuce, spinach, green beans, peppers, tomatoes, etc.).

There are a few common starchy vegetables to look out for: corn, peas, white potatoes and sweet potatoes. While nutritious, these veggies are more concentrated sources of carbohydrates. Enjoy them in smaller portions than you would non-starchy vegetables. Low-fat dairy products (milk & yogurt) are also nutritious carbohydrate choices, but be sure to check the "Total Carbohydrate" amount, especially on fruit-flavored yogurts. Some are loaded with added sugars, which will drastically increase the amount of total carbohydrate. 

Do you know someone with diabetes?  They can send their questions to: diabetes@foodpicker.org

Diabetes Education Help

Question of the week from FOODPICKER.org

Nancy M. asks: "I am trying to find a class for our grandson. He is 19 and has a part-time job but no insurance. He just found out last week that he is a type 1 diabetes after losing a lot of weight and his blood sugar was 523. He is on insulin but needs to go to a class to manage his diabetes without going hungry. Where do we start? Any suggestions would help us a lot."

Answer: Learning you or someone you love has diabetes can turn your world upside-down, but know that help is available and you are not alone! There are many resources to check, even without medical insurance. Diabetes cannot be cured, but it can be managed. People with diabetes can enjoy healthy, long life filled with delicious foods - but education is the first step. It is extremely important for your grandson to start taking an active role in his health right away.

First, where was your grandson diagnosed? I would check with the doctor, healthcare provider or clinic that actually made the diagnosis. Also check with other other local hospitals and clinics. It is very likely they have many resources already in place for people just like your grandson.

Second, your best bet would be to find a certified diabetes educator in your area. You can locate a diabetes educator through the American Association of Diabetes Educators. A certified diabetes educator (CDE) is a healthcare professional with additional training and specialized knowledge in diabetes self-management education. A variety of healthcare professionals may also be CDEs - doctors, nurses, registered dietitians, pharmacists, etc.

Another resource is the American Dietetic Association, through which you can find a registered dietitian (RD) in your area. Registered dietitians are food and nutrition experts. An RD will assess your grandson's nutritional needs, work with him to provide knowledge and facilitate lifestyle changes that fit within his current work schedule and activity level.

Note that both websites above will generate a list of providers, from there you can contact the individual diabetes educator or registered dietitan to see what s/he offers in terms of classes, one-on-one education sessions, and find out about cost. Some RDs and CDEs work alone, some are part of a larger healthcare facility or network of facilities.

Also, be sure to check out the American Diabetes Association for more resources and information on diabetes basics, lifestyle and events.  Finally, you might also want to tell your grandson to check your state Department of Health's website. For example, New York State DOH has a diabetes page filled with information and available resources.

Good luck!

Snacking and Diabetes

Question of the Week from FOODPICKER.org:

Tom R. asks: "I have been diagnosed with type 2 diabetes. During the day at work I eat very little, but in the evenings and weekends, I can't seem to stay out of the kitchen. Do you have any suggestions to control my snacking in the evenings and weekends?"

Answer: Before I offer some snacking tips, we should take a step back to examine your food pattern. Not eating much during the day sets yourself up for two problems: 1) unstable blood glucose levels and 2) excessive eating/snacking later in the day. Unfortunately, many popular snack foods are loaded with carbohydrates and fat, and contain very few nutrients and fiber, e.g. potato chips, corn chips, pretzels, etc.

It is especially important for people with diabetes to eat small meals throughout the day to keep blood glucose and energy levels stable. If you are not used to eating breakfast or lunch, I would suggest starting with something small, like a piece of whole grain bread with natural peanut butter. Plan to bring some healthy snacks with you to work. Some examples include:

• Almonds, walnuts or other nuts - plain or lightly salted
  
• Low-fat string cheese
• Hard boiled egg
• Apple or piece of fruit
• Hummus with carrot and celery sticks
• Greek yogurt - much lower in sugar and higher in protein than regular yogurt!
  
• Light or plain microwave popped corn

I think you'll find that slowing altering your eating pattern to include several small meals spread throughout the day will help with both issues I mentioned.

However, I do have some suggestions for snacking at home. First, when you find yourself hankering for a snack, take a few minutes to decide if you are really hungry or if you just "want" something - there may be a difference. If you aren't sure, start with some unsweetened, flavored seltzer water, sugar-free gum or herbal tea and then see how you feel.

I also suggest altering the availability of snack foods in your home - get rid of it or don't buy it! As I mentioned, most typical snack foods have few nutrients and they are designed to be tasty and leave you wanting more. They are hard for anyone to resist. Until you establish new habits, it is easiest to simply not have it available. Unless you live alone, this may take some family negotiations - see if you can limit the amount available if not everyone is on board.

Instead of chips or candy, have low-calorie, high fiber items around such as popped corn (you can make it and flavor it yourself on the stovetop or in the microwave) and fresh crunchy veggies (carrots, celery, broccoli), which are satisfying to chew. If you absolutely need to have something sweet, frozen grapes make a great treat, or you can try some sugar-free jello or a piece of high-quality dark chocolate (70% cocoa) - you'd be surprised at how satisfying a small piece can be. Good luck!

Question of the Week: Sugar Substitutes and Diabetes

Here is this week's question from FOODPICKER.org:

Q: What is the best sugar substitute to use for baking and daily use for diabetics?

A: These days, you have a choice of many sugar substitutes, unlike years ago when people with diabetes were stuck with saccharin. There are many more available today: Aspartame (NutraSweet or Equal), acesulfame potassium (Sunett and Sweet One), saccharin (Sweet'n Low), sucralose (Splenda), rebaudioside A (also called rebiana or reb-A, which is derived from the stevia plant) and various sugar alcohols (maltitol, xylitol, erythritol and many more). Truvia, a new sweetener on the market, is a combination of erythritol and rebiana.

If by "daily use" you mean for use in coffee or tea, the choice is really up to your tastebuds. However, please know that some artificial sweeteners do contain a small amount of carbohydrate. When used in moderation, these sweeteners should not hugely impact your blood glucose - but only you will know how it affects you when you check your blood glucose levels. Please be aware that sugar alcohols are not absorbed in the small intestine, and may cause gas or diarrhea - proceed with caution until you know how they affect you.

Since most sugar substitutes are many times sweeter than sugar, this creates volume and texture problems when making baked goods. However, there are some good options out there: Splenda and Truvia make a crystalline product which measures out the same as sugar, cup-for-cup. I would check each manufacturer's website for information on use in baking and recipe ideas.

While you may lower the carbohydrate content of baked goods by using a sugar substitute instead of sugar, be aware that flour is itself a source of carbohydrate. Just keep this in mind when planning your meals, and you can find a way to have some treats while also managing your blood glucose levels.

A final, personal note:

It is a myth that people with diabetes must buy special "diabetic" food (or supplements) and cannot have sweets. People with diabetes can eat a healthful diet of real foods - yes, treats too - just like everyone else should! The difference is in the planning and combination of foods, which is why it is essential for people with diabetes to meet with a Registered Dietitian (RD) or Certified Diabetes Educator (CDE) to formulate a meal plan.

Artificial sweeteners are often a hot-button issue. I respect the choice to use them, but I am not a huge fan of any of them. Our palates are quite malleable and, given the opportunity, will adjust to varying levels of tastes. Artificial sweeteners undermine this process by keeping the palate used to a heightened level of sweetness. I usually advise slowly cutting back on sugar and/or sugar substitutes bit by bit - try it, you might be surprised at what you can adapt to!

Ever wonder why you don't see those 'drink milk/eat dairy to lose weight' ads anymore?

Yeah, me too. I recently discovered why: it is no longer legal to make this claim. Oh, there are ways around it, sure - now the message is only implied in advertisements, not explicitly stated. In class last week, we examined what used to be the most oft-cited research to support the claim that dairy foods aid weight loss. Let's take a look at:

Zemel MB, Thompson W, Milstead A, Morris K, Campbell, P. Calcium and dairy acceleration of weight and fat loss during energy restriction in obese adults. Obesity Research 2004;12:582-590

This was a randomized, placebo-controlled trial (a very strong study design) that sought to determine the effects of increasing dietary calcium (read: dairy products) during caloric restriction in humans. In other words, does dairy or calcium help weight loss? The trial lasted 24 weeks. The subjects were healthy, obese men and women between the ages of 18 and 60. 34 women and 7 men started the trial (n=41), and 27 women and 5 men actually completed the trial (n=32).

Subjects were randomized into 3 diet groups: high dairy diet (providing 1200-1300mg calcium), calcium-supplemented diet (approx 500mg calcium from food + 800mg from a supplement), and control diet (identical diet to calcium-supplemented diet, except with a placebo supplement). All 3 diets were designed to create a 500kcal/day deficit.

Main outcomes included overall change in body weight, total fat loss (as measured by a DXA scan), fat loss from trunk region (measured by waist circumference and DXA scan). All of this seems well and good. Strong study design, monitoring with reliable tests...the authors even state on p. 584 that "all subjects maintained complete daily diet diaries throughout the study, and compliance was assessed by weekly subject interview, review of the diet diary, and pill counts." Impressive! Too bad they don't report this data. We have no idea what the subjects were actually doing.

Now, for the results: As expected, all subjects lost some weight. For overall body weight (which is the only outcome I will discuss here, for the sake of time and space, and the space-time continuum): the control group lost 6.4 +/- 2.5% of their body weight. The calcium-supplemented group lost 8.6 +/- 1.1%, and the high-dairy group lost 10.9 +/- 1.6% of their body weight. Ok, the high dairy group lost the most weight. Seems like the end of the story, right? I'll get back to that in a minute.

I shouldn't forget to mention some limitations of this study: small sample size (only 32 completers), mostly women, we have no idea exactly what they were consuming during the study because even though it was assessed, those data were not reported.

Now, the lead author of this research wrote a diet book, The Calcium Key, in which he states that study after study has "proven" that low-fat dairy foods work wonders for weight loss, and that you can "increase the amount of weight lost by 70%."

Hmm...

Sure, the control group lost 6.4% of their body weight compared to the 10.9% lost by people on the high-dairy diet. This is an increase of 70%, but what does it actually mean? The control group lost 6.6 kg (14.5 lbs) during the 24 weeks, the calcium-supplemented group lost 8.6kg (18.9 lbs) and the high-dairy group lost approximately 11 kg (24.2 lbs) in 24 weeks. Wow! 1 pound per week!

Remember that all subjects were supposedly eating a diet with a 500kcal/day deficit - this should promote a healthy weight loss of 1 lb per week, no matter how much dairy or calcium one consumes (3500 kcal = 1 lb; 500 kcal x 7 days = 3500 kcal). Perhaps the high-dairy group subjects were simply more compliant with the diet? Again, data not reported, so we don't know.

I hardly think this one study showing us that we can increase weight loss from 2/3 lb per week to a 1 lb per week is grounds for the dairy council plastering posters everywhere (well, they used to be everywhere). Oh, and this research was supported by the National Dairy Council. Not surprising.

What is surprising are the economics and conflicts of interest in this research (i.e. the lead author's employer holds a patent on the claim that dairy consumption improves weight loss!) check out this post from Parke Wilde, who teaches U.S. Food Policy at the Friedman School of Nutrition Science and Policy at Tufts University.

Question of the Week from FOODPICKER.org

Here is a question I received from FOODPICKER.org:

"I have type 2 diabetes and high blood pressure. Someone suggested I try “Original No Salt” which is Sodium-free instead of salt. Is it a safe alternative for my use?"

A: "Original No Salt" does not contain sodium, and thus is safe to use if you have hypertension, also known as high blood pressure. There is a direct link between sodium intake and an increase in blood pressure, which is why you are told to lower the sodium in your diet.

Products such as "Original No Salt" are good alternatives to table salt, but there are many other ways to flavor your food. You might try herbs (fresh herbs are particularly flavorful), spices, pepper, lemon and lime juice. Mrs Dash is a brand of salt-free herb flavor mixes, but you can easily create your own herb mix at home for a fraction of the cost - just buy your favorite herbs and mix together in a jar. Here are some other seasoning ideas from the American Heart Association.

You should also be aware that the majority of sodium in our diet comes from processed foods - NOT from salt added during cooking or at the table. Processed foods are loaded with sodium! Be sure to check both the serving size and the sodium content of any food you buy with a Nutrition Facts label. Foods particularly high in sodium include anything canned (soups, beans and vegetables), lunch meats, sausage, salami and cheese. Sodium content will vary from brand-to-brand, so be sure to do some comparing.

By making simple substitutions, you can dramatically reduce the sodium you eat: buy frozen or fresh vegetables instead of canned. Buy dehydrated beans (in bags) and cook your own, or rinse canned beans before eating.

You may also be interested in learning about the DASH (Dietary Approaches to Stop Hypertension) diet plan which has been shown to lower blood pressure. The DASH diet focuses on plenty of fresh vegetables, fruits, low fat dairy, whole grains, nuts and lean meats. This diet would also be appropriate for someone with type 2 diabetes. You can learn more about the DASH diet here and here is a brochure (pdf)

Do you know someone with diabetes? They can send their questions to: diabetes@foodpicker.org

Check out: www.FoodPicker.org for Diabetes Nutrition Education

I just became a nutrition editor at www.foodpicker.org - a website designed to help people with diabetes make better food choices.

I became particularly interested in counseling people with diabetes while I was a dietetic intern at the fabulous Naomi Berrie Diabetes Center in Manhattan.

In the United States, 24 million people have diabetes and an estimate 57 million have pre-diabetes. There is a direct correlation between what a person with diabetes eats and their blood glucose levels. The risk for health complications increases the longer blood glucose remains uncontrolled. Do you know what well-controlled diabetes is a risk factor for?

Nothing!

My hope in joining this project at www.foodpicker.org is to provide a credible discussion of nutrition and diabetes-related topics. I will be posting about these, in addition to my usual favorite: how health and nutrition research is distorted by the media.

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