Nutrition for People with Diabetes

In covering the new nutrition guidelines (a PDF file) from the ADA (American Diabetes Association) from last October, I was more than a little harsh because of the registered dietitians on the guideline committee. Yes, the guidelines are developed by a select committee of nutrition experts and the guidelines are evidence-based. Much of the evidence is from randomized clinical trials, but some is called expert opinion or expert consensus if we are to believe that is possible in dietary nutrition. When many of the authors of the ADA nutrition guidelines are beholden to Big Food and Big Ag, one must wonder if personal 'expert' opinions were not injected in the guidelines.

There are some new concepts not in prior guidelines. This may be the most positive aspect to come out of the 2013 guidelines.

Eating patterns. This has not been discussed in guidelines before and for people with diabetes, this is a milestone in change. Be recognizing that there are many types of eating patterns, this makes individualizing a meal plan more realistic. The types of meal plans include:

• The DASH (Dietary Approaches to Stop Hypertension) eating plan
• The Mediterranean-style eating plan
• Vegetarian and vegan diets
• Low-fat diets
• Low-carbohydrate diets

This allows room for other eating plans and making people with diabetes feel more relaxed about their food plan. Just because a friend may like a vegan diet, does not mean that your personal preferences have to be the same. It is your personal food plan that is important to you. It will make your likes and dislikes, cultural background, religion, economic situation, and glycemic goals more important for your eating pattern.

Macronutrients. These are carbohydrate, protein, and fat.

Carbohydrate – I have been one to criticize the American Diabetes Association for promoting high carbohydrate diets, but I need to consider that with the new guidelines that their promotion has changed.

Until I see the Academy for Nutrition and Dietetics (AND) stop promoting Big Food, the people with type 2 diabetes will still need to be very careful in what the registered dietitians are promoting in the number of carbohydrates they recommend. Many are still promoting 60 grams of carbohydrates for each meal and 15 to 25 grams of carbohydrates for snacks. One that I heard about recently was promoting almost 280 grams of carbohydrates per day. Most of us with type 2 diabetes cannot consume that many and will gain weight rapidly doing this.

Many of the registered dietitians have switched to promoting percentages to mask the number of carbohydrates they are promoting. They have been recommending that it is up to the individual, but they still promote a higher percentage of carbohydrates. With most type 2 diabetes patients needing to lose weight (about 85 percent), reducing the number or percentage of carbohydrates consumed is the most efficient method and if possible adding exercise to this.

Another trick dietitian's use is alternating between grams of carbohydrates and percentage of carbohydrates to confuse those they are supposedly teaching. But more often, they are just issuing mandates and mixing the terms in to make it sound like they are individualizing the treatment for you.

The two following paragraphs are typical examples of the language used to make the type 2 patient think they are doing what is best for them.

“There’s a considerable amount of space in these recommendations devoted to lower-carb eating plans and some of the research does, indeed, show positive effects of lower-carb eating patterns, particularly in terms of weight loss. However, the authors of the guideline do point out that one of the downsides with low-carb diets is that there isn’t a standard definition of “low carb.” The authors describe “very low” carbohydrate intake as being from 21 grams to 70 grams of carbohydrate per day and “moderate” carbohydrate intake as comprising between 30% and 40% of total calories. But there’s no general consensus about this.”

“The recommendations also, for the first time, recommend limiting the intake of sugar-sweetened beverages. Monitoring carbohydrate intake, whether by counting carbs or watching portions, is still considered an effective means of controlling blood glucose. And substituting low-glycemic-index carbohydrate for high-glycemic-index carbohydrate may modestly improve glycemic control.”

Since there are no existing guidelines for the different carbohydrate levels, I only offer these as a suggestion from a previous blog. If you believe differently, I have no objection, but please be consistent and follow your personal chart. I will have more in the next blog for protein and fat.

Diabetes Doesn't Have to Mean Complications

Allen and I are having sessions with a person with diabetes that has basically given up on living. Allen has Barry and Ben both helping him with research and they came up with this from WebMD. Since Ben is not yet comfortable with an intervention, I asked Tim to help us. After reading all of this we decided to talk with Dr. Tom before going forward.

As soon as Dr. Tom heard the name, he called his office manager and asked if the person had an appointment for the next afternoon. He was informed that the appointment had been cancelled that afternoon. He asked that the last appointment be moved up and that time be reserved for the patient. Then Dr. Tom asked if we could see that he showed up. He gave us the time and said he would call us if there happened to be a problem. Tim said he would be unable to be there the next afternoon, but Allen, Ben, Barry, and I said we would have him there.

The next afternoon, it took some shenanigans, but we had him there and the office manager met us and escorted us to the office. We were a couple of minutes late, but Dr. Tom was waiting for us.

As soon as we were all seated, Dr. Tom told the patient that he understood why he had given up. He said that his father had type 2 diabetes and did not take care of it and died about 18 months after diagnosis. Then he asked the patient how long his mother had lived after diagnosis. He hesitated, but finally admitted that his mother had only lived about three months, but it was cancer that had killed her.

Dr. Tom then asked Allen when his diagnosis happened. Allen said just over 10 years, and Dr. Tom pointed to Barry and asked us to continue. Barry said he was diagnosed almost 9 years ago. I stated that I was less than four months to 11 years, and Ben stated he was at 10 years. Next Dr. Tom asked us to tell the patient the complications we had. All of us stated we had neuropathy and nothing more serious. I said I have sleep apnea, but that is not part of diabetes, but could make managing diabetes more difficult.  I had some heart problems, but had not had any problems in the almost 11 years since.

Dr. Tom then explained that with the number of years each of us have had diabetes, why he was giving up when he was not yet 60 years old. Dr. Tom explained that we were all in our 70's. Now the patient was thinking. He turned to Allen and asked why he had neuropathy. Allen said he had neuropathy because he had been vitamin B12 deficient and he could not speak for the rest of us. Barry and Ben agreed that was the cause of their neuropathy. I said mine could have been from diabetes before my diagnosis, but I had wondered if I had some chemical exposure at the time.

Dr. Tom then asked if he wanted a copy of his test results. No was the answer and both Allen and I told him to take a copy. He asked why when he was not planning to control his diabetes. Everyone looked at him and finally Barry asked him why with all of us here and our years of successfully managing diabetes, would he throw his life away? Dr. Tom then asked him why with a wife and three sons, would he not want to live to see his grandchildren.

Dr. Tom told him that just because his father had not managed his diabetes, this did not mean that he could not. Dr. Tom told him that the four individuals in the room with him were managing their diabetes and he could as well.

Allen took out a copy of the WebMD article and said this should provide him some ideas and why life is worth living even with diabetes. Allen told him to read it and think about it. We had taken enough of Dr. Tom's time. I will see you this weekend and I expect some questions about what we can do to help and educate you about managing your diabetes. I asked him if he would mind giving me a copy of the lab results for me to go over them and set them up on a spreadsheet for him to use.

He hesitated and finally asked Dr. Tom to give me the last three results if he would. Dr. Tom asked the manager to make copies and give them to me. Then he turned to the patient and told him this was a good start and with the assistance of the support group, he should be able to live a long life. Then Dr. Tom told us that he would expect reports on his progress and was available if needed. Barry thanked him and we left.

Researchers Challenge Diabetes Guidelines

Now universities are promoting less care for the elderly. Yes, I know many of the elderly have memory problems and trouble with many medications. But to advocate that we not be cared for and die seems like advocating for death panels to rid them of troublesome patients.

When researchers for the University of Michigan make the statement, “Harm to quality of life outweighs benefits of treatment for older patients and those with negative feelings about side effects, burden of medication,” this not only harms patients with their words, but also shows that they could care less about the elderly.

What else they say shows their ignorance about diabetes. They claim that patients with type 2 diabetes that are over age 50 should not have frequent insulin shots because the side effects of weight gain trumps the benefits of drugs. Why can't they teach patients about cutting carbohydrates and how to exercise? All they can emphasize is insulin and how this harms patients. The fear of hypoglycemia rules their thinking.

As a person with type 2 diabetes and over 70 in years, this is an insult and says I should not be on insulin. Well, I intend to stay on insulin and these researchers can take a hike. The study by the University of Michigan Health System, the VA Ann Arbor Healthcare System, and University College London was published in the Journal of the American Medical Association Internal Medicine. They claim that for many, the benefits of taking diabetes medications are so small that they are outweighed by the minor hassles and risks.

I would like to know when the benefit of diabetes medications depended less on blood glucose and more on hassles. Yes, safety and side effects are important, but when these factors of hassles becomes all important, I think these researchers have their priorities scrambled.

To my way of thinking, these researchers are challenging the diabetes guidelines for the wrong reasons and because they are setting the age of 75 as their goal for people to have reduced treatment because of hassles seems very arbitrary and smacks of discrimination against the elderly. When our elders develop dementia and Alzheimer's disease, there needs to be concern and different guidance for treating them.

However, to pick an age of 75 and put a one-size-fits-all equation in place is not practical and basically says – let people over 75 die. This is discrimination of the worst type and researchers at universities are trying to set parameters on treatment of the elderly to help them die. Their tactics need to be recognized for what they are and opposed at every turn.

I suggest that the elderly that develop memory problems be seen by someone that can properly assess them and then be allowed to develop community assistance programs that would help them in their treatment and prevent the hassles those of the university say exist.

A Companion at Your Doctor's Appointment May Be Important

Should you have a spouse, a trusted friend, or a patient advocate accompany you to a doctor's appointment? This will vary by the person and the situation. Some spouses do not work well enough together, some don't have a trusted friend, or even a trusted family member. Many cannot afford to pay a patient advocate. What are they to do?

That is part of the reason for saying acompanion. The discussion applies to anyone that could accompany a person to a doctor's appointment. Remember, going to the doctor with someone is a gift.

First, if you are asked, think about what you must do. How do you become the best

companion? You will need to listen, record (please ask first), and ask questions. You will need to ask the person you are going with why you are going. Ask what the person wants to accomplish during the appointment? Don't forget to ask why they want you to accompany him/her?

Next, there are many types of doctor visits. Routine visits, routine physical, unknown issues, new acute issue, or a follow up appointment for an acute issue or a chronic condition.

It is a good idea to prepare for any type of appointment:

#1. Have a list of current medications, both prescription and over-the-counter, and any questions the patient has about them. Make sure for a list that the information is all there and when they are taken. If necessary, bring the medications in their containers to the appointment.

#2. Have a list of all the members of the patient's health team, both medical and non-medical.

#3. Record anything medical or health related happening that has occurred since the last visit with this doctor or clinic.

#4. Record questions that come up during this preparation and seek answers.

At the appointment be an active listener and make sure you understand. Repeat back what you hear. Ask if you can record the session. If possible, use your phone or bring a tape recording machine. Ask for a copy of the doctors notes. If someone brings up HIPAA as a reason for not sharing this information, remind him/her that the person needs this and they have a right to the information. HIPAA mandates the sharing with the person having the appointment. Before leaving, ask the person with the appointment if he/she understands what the doctor has said and if they have any final questions.

As soon as possible after the appointment, go over what happened and what both of you learned. Recall for most people can fade quickly. That is why to discussion needs to take place, recording or not.

Some Tips for Diabetes Food Plans

Choosing the right food plan is a major part of managing diabetes. It is easier to keep track of what you’re eating when you’re the one in charge of putting nutritious meals on your plate.

Learn how to use your blood glucose meter with test strips to monitor your blood glucose levels to prevent people from convincing you to eat too many carbohydrate-rich foods. Certain educators and dietitians will try to push carbohydrates and this is when you will need this knowledge.

#1. Watch the level of whole grains you can tolerate.

A few of you will be able to consume higher levels of whole grains and others should probably avoid them. Use your meter to serve as your guide. Many of us find that eliminating all wheat products serves us best and some find that limited quantities will meet their needs.

#2. Try to add more fiber to your meal plan.

Consider at least 8 grams of fiber per meal, or more if you can consume carbohydrate-rich foods. Select vegetables such as peas, beans, artichokes, celery, parsnips, turnips, acorn squash, brussels sprouts, cabbage, broccoli, carrots, cauliflower, asparagus, and beets. Eat some fruits, but don't over eat from these - apples, mangoes, plums, kiwis, pears, blackberries, blueberries, strawberries, raspberries, peaches, citrus fruits, and figs.

A fiber-rich diet also curbs the risk of heart disease, which is higher in people with diabetes.

#3. Replace some carbs with good fat.

Monounsaturated fats meaning nuts, avocado, olive, and sunflower oils can help lower blood sugar. Add nuts and avocado to salads and entrees. Use olive and sunflower oils to cook dinner dishes. Look for products that contain either oil, such as salad dressings, marinades, marinara, and pesto(if needed make your own). Still, keep portions modest, so you don't get too many calories.

#4. Eat foods that won't spike blood sugar.

Foods that aren’t likely to cause a significant rise in blood sugar include meat, poultry, fish, avocados, salad vegetables, eggs, and cheese. Eating these foods will help balance carbohydrate foods excluded in your meal.

#5. Choose recipes with moderate saturated fat.

Look for the following – fish, beef (grass fed if available), pork, chicken, full fat dairy, and avoid soy products.

#6. Know the nutritional values in the recipes you use.

There are digital scales that can help. Find out the amount of carbohydrates, fiber, and fat per serving. Then stay close to the appropriate portions by serving up your food on smaller plates.

#7. Use butter and shortening with sunflower or olive oil.

Both sunflower oil and olive oil are better choices. Read my blog here about them. There may be other quality oils, but avoid canola or vegetable oils.

#8. Prep for salads ahead of time.

Store a large spinach salad or vegetable-filled romaine lettuce salad without dressing in an airtight container. You can have crisp, wonderful salad with your dinner or as a snack for the next several days.

#9. Make an easy fruit salad.

With a few chops of a knife, you can turn a few pieces of fruit into a beautiful fruit salad. Drizzle lemon or orange juice over the top. Then toss to coat the fruit. The vitamin C in the citrus juice helps prevent browning.

#10. Choose drinks wisely.

Instead of soda, sweetened drinks, or fruit juice, drink protein-rich drinks such as whole milk. Or sip no-calorie tea, coffee, or water.

#11. Slow down or don't eat so fast.

Fast eaters tend to eat more. It takes at about 20 minutes for your brain to get the message that your stomach is officially “comfortable” and that you should stop eating. So, eat slowly and chew your food thoroughly. As you do, you'll become more aware of the textures and flavors and feel more satisfied.

#12. Avoid late-night snacks.

Avoid late night snacking unless your blood sugar is too low and your doctor or certified diabetes educator recommends having an evening snack. Only do this is your blood glucose is too low. Drink a cup of no- caffeine tea instead. Talk to your doctor if you are always experiencing high fasting blood glucose levels or the dawn phenomenon.

Personalized Medicines

Finally, it is great to see a federal agency advocating for personalized medicines. The agency is the National Institute of Health, Senior Health. I am especially thankful with the opening statement - Medicines: One Size Does Not Fit All (Bold is my emphasis). Studies have shown that even properly prescribed medicines cause a number of hospitalizations each year.

The article explains that allergy medicines don't work for everyone and for others, the standard dosage of a prescription pain reliever can cause side effects that are uncomfortable or life threatening. As the person ages, fat and muscle content change. This then affects how the body absorbs and processes drugs. Other factors also affect how a person responds to medicines and some of these factors are exercise habits, diet, and general health condition.

A key factor in how we react to medicines is heredity. In other words the genes we inherit from our ancestors. These genes influence the way people respond to many types of medicines including many blood pressure and asthma medicines. Your genes affect the shape and function of your proteins. As the different drugs travel through your body, they interact with dozens of proteins.

Remember, everyone’s genes are slightly different and thus everyone’s proteins are different. Variations in some proteins can affect the way we respond to medicines. These proteins include those that help the body absorb, metabolize, or eliminate drugs.

I know this personally. I have no problems with Lisinopril, for blood pressure. However, my wife developed one of the side effects and could not shake it until one week after she stopped taking it with the doctor's order. She now takes a different medication that works for her, but I had a severe reaction to it until I was prescribed Lisinopril.

A new type of research is taking place around the country to understand how genes affect the way people respond to medicines. This research is called pharmacogenomics.

“As pharmacogenomics research progresses, it will become increasingly important to identify all the possible variations in genes that play a role in drug response. To identify which versions of these genes a person has, researchers examine DNA from that person. An easy, painless, and risk-free way to obtain DNA is from mouth cells that stick to a cotton swab rubbed on the inside of a volunteer's cheek.” If you have watched any of the CSI TV shows, you know that this is done. It takes longer than it does on TV, but the results are there.

As this research progresses, finding the differences in people's genetic backgrounds will help doctors prescribe the right medicine in the right dosage for each person. This will make medicines safer and effective for everyone.

FDA Approves Afrezza to Treat Diabetes

With everyone going ga-ga over FDA approving Afrezza, I have some serious doubts about how many people will be able to use it. I know that I will not be one of them. This is because of one thing – I would have difficulty getting the correct dose into my system because of sinus problems which can occur anytime and make breathing difficult. When this happens, I am forced to breath through my mouth.

This is not one of the problems even listed, but if you have this problem, getting the mist into your lungs may be difficult. Afrezza has a Boxed Warning advising that acute bronchospasm has been observed in patients with asthma and chronic obstructive pulmonary disease (COPD). Afrezza should not be used in patients with chronic lung disease, such as asthma or COPD because of this risk. The most common adverse reactions associated with Afrezza in clinical trials were hypoglycemia, cough, and throat pain or irritation.

With the above information, I would also be concerned about people with diabetes that develop pneumonia. In addition, nothing is mentioned about any testing for the elderly. People at all ages can have respiratory problems causing breathing problems and often the necessity for oxygen use. From the way drug reps promote drugs and doctors prescribe, I can see patients with respiratory problems being prescribe Afrezza. To me it seems that the FDA has missed some information and at a minimum left their brains at home when they approved Afrezza.

Afrezza is not recommended for the treatment of diabetic ketoacidosis, or in patients who smoke. Even then it was approved and it will work for some people and that is a good thing. At least the FDA is requiring some post-marketing studies for Afrezza. These studies include a clinical trial to evaluate pharmacokinetics, safety and efficacy in pediatric (young people under the age of 19) patients. The second study is a clinical trial to evaluate the potential risk of pulmonary malignancy with Afrezza. This trial will also assess cardiovascular risk and the long-term effect of Afrezza on pulmonary function.

Two additional trials have been ordered. They are pharmacokinetic-pharmacodynamic euglycemic glucose-clamp clinical trials, one to characterize dose-response, and one to characterize within-subject variability. Both are important and hopefully will help regulate the dosage on an individual basis.

I would hope that individuals with any of the problems mentioned above would hesitate before letting the doctor prescribe it for them. Let the people with diabetes without significant health problems be the ones to find out if Afrezza works for them.