Diabetes

---

Diabetes

51 Ways to Keep It Under Control

Yenta, the matchmaking insulin hormone, attaches herself to lonely, befuddled Mr. Glucose, a bachelor sugar molecule, and goes knocking at Miss Cell's door. Familiar with Yenta's knock, the spinster Miss Cell opens the door. "Have I got a match for you," Yenta tells Miss Cell, and pushes Mr. Glucose inside. Together, Mr. Glucose and Miss Cell make beautiful energy.

That is how the body's energy production is supposed to work. But for 11 million Americans with adult onset (Type II) diabetes, it doesn't. Yenta the matchmaker can't find the door (the cell's receptor) because there isn't one, or there aren't enough matchmakers to handle all the bachelor sugar molecules, or the would-be matchmakers aren't very good at their jobs. Adult onset diabetes mellitus is the result.

As a person with diabetes, you know that you are at risk for heart disease, kidney disease, atherosclerosis, nerve damage, infection, blindness, and slow healing. Each person reacts to diabetes in his own way. This means each person has to be under a doctor's care and constantly monitored. This need cannot be overstated. What's good for your diabetic friend may be bad for you.

But every diabetic's goal is to maintain his or her blood sugar and blood fat as close to normal levels as possible. A diabetic regimen has three cornerstones: nutrition, weight control, and exercise. The good news is that you can virtually eliminate all symptoms of diabetes—in other words, "control" it—by carefully following the regimen you and your doctor work out.

Here's how to begin. If you're planning any changes in your current regimen, talk it over first with your doctor.

Start with the ADA diet. The American Diabetes Association (ADA) revised its nutritional guidelines in 1986. Although knowledge of dietary needs is continually expanding, these guidelines are based on current consensus thinking. "Each person's diet should be tailored to fit individual needs and lifestyles," says registered dietitian Marion Franz, M.S., R.D., vice president of nutrition at the International Diabetes Center in Minneapolis, Minnesota. The ADA diet includes the following principles:

Load up on carbohydrates. The ADA recommends that a Type II diabetes diet include up to 50 to 60 percent of calories from carbohydrates. "Generally, the recommendation will be somewhere around 50 percent," Franz says. Carbohydrates are either simple (sugars) or complex (starches). Each gram of carbohydrate produces 4 calories.

MEDICAL ALERT Three Dangers for Diabetics There are three potentially dangerous acute effects of diabetes needing medical attention: hypoglycemia, hyperglycemia, and wounds. And diabetics need a doctor's care in certain circumstances when they have the flu. Here's what the experts say. Hypoglycemia occurs when blood sugar drops too low. You can treat mild symptoms yourself (See "Self-Treatment for Mild Hypoglycemia" on page 203). Severe symptoms include headache, confusion, combative behavior, or unconsciousness. Get to a hospital emergency room immediately, where a doctor will give you intravenous glucose. "If you're having frequent hypoglycemic reactions," says Karl Sussman, M.D., American Diabetes Association past president, "see your doctor because you may need to change your regimen." Hyperglycemia is when blood sugar rises too high. Its mild symptoms are excess urination, excess appetite or thirst, blurred vision, or dizziness. "You can be hyperglycemic and not have any symptoms, so you won't even know unless you're monitoring your blood glucose," Dr. Sussman says. Severe hyperglycemic symptoms include loss of appetite, stomach cramps, nausea and vomiting, dehydration, fatigue, deep rapid breathing, and coma. Wounds and sores, especially on the feet and legs, get infected easily in a person with diabetes. Have them treated by a doctor. When you think you have the flu, call your doctor right away; or get to a hospital emergency room if: You're vomiting or having abdominal pain. You have large amounts of sugar or acetone in your urine. Your blood sugar levels are above 200 milligrams. Your temperature is 100°F or more.

Go easy on the protein. The ADA says protein should amount to about 12 to 20 percent of your calories. Each gram of protein equals 4 calories.

Face the fats. The ADA wants you to cut the fat out of your diet budget. Calories from fat should account for no more than 30 percent of your calories. Each gram of fat produces 9 calories. Every chance you get, replace artery-clogging saturated fat with polyunsaturated or, better yet, monounsaturated fat, or with complex carbohydrates, Franz says.

Eat food with fiber. Natural fiber in food has been found to have a host of beneficial effects on everyone. That goes double for people with diabetes. The ADA advises you to gradually head for 40 grams at day. Whole wheat products, barley, oats, legumes, vegetables, and fruit are the best sources of fiber, as well as essential nutrients.

One possible benefit fiber provides diabetics is lower cholesterol levels. "The water-soluble fibers found in legumes, oats, barley, and fruit, when eaten in a low-fat diet, have been shown to lower blood fat levels," Franz says. "Because they form a gel in the gastrointestinal tract," they may also cause the energy (sugar) in food to be absorbed at a slower rate, giving your insulin a chance to keep your blood sugar on a more even keel.

Fiber also helps keep you from feeling hungry. "I think one of the main benefits of fiber is that it adds bulk to the diet," Franz says. "For Type II people who are trying to control their weight and so are on restricted calories, bulk lets people feel fuller."

Besides giving you that pleasantly satiated feeling, fiber foods are good for you. "They're often high in important vitamins and minerals," Franz says.

Cut your cholesterol. The ADA recommendation is that you should eat no more than 300 milligrams of cholesterol daily. This means cutting way down on organ meat and egg yolks and restraining yourself when it comes to meat and dairy fats. It also means adding fiber to your diet. (For more information, see Cholesterol on page 135.)

Substitute for sugar. Research shows that sucrose and table sugar, when used in equal amounts with starches, doesn't hike blood sugar levels any more than other starches, such as potatoes and wheat. Thus the ADA says you can have modest amounts of refined sugars if your diabetes is under control and you're not too overweight. But otherwise, check out alternative sweeteners. "They're certainly safe to use," Franz says. The ADA has approved noncaloric sweeteners, like aspartame and saccharin, and sweeteners with calories, like fructose and sorbitol.

Don't Let Your Feet Fail You Except for insulin, a diabetic's weakest link is the foot. Nerve damage from diabetes lessens the sensation of pain, so diabetics may not know they've injured their feet. Blood vessel damage means injuries and infections don't heal like they should—a little sore can become gangrenous, leading to amputation. "And once you lose one leg as a result of diabetic amputation," says podiatrist Marc A. Brenner, D.P.M., past president of the American Society of Podiatric Dermatology, "there's a 75 percent chance you'll lose the other leg within three to five years." As a diabetic, you have to develop foot consciousness. And here's how to keep your feet doing what they should—walking off weight, walking on fitness. Take a load off the dogs. Need another reason to lose weight? Consider the pounding your feet take. "Obviously, if the feet are your foundation and you have more weight on that foundation, you're going to have more wear and tear on that foundation," Dr. Brenner says. "We in podiatric medicine see more heavy people than thin people by far." Become a foot inspector. "Inspect your feet two or three times a day," Dr. Brenner says. "Have someone else do this for you if you don't have good eyesight." Make sure there's no redness, bruises, cuts, blisters, cracks, heat, swelling, or infection. Keep them clean. Wash your feet well with mild soap and pat them dry every day. Keep them dry. Use a good foot powder between the toes, and change your socks frequently. Keep them well-maintained. Cut your toenails short and straight across. Treat athlete's foot and other minor problems promptly. Never go barefoot. Buff your calluses with a pumice stone. Don't soak your feet for prolonged periods. Keep them warm on cold days. But don't use a hot-water bottle or heating pad because they can burn you without your knowing it. Make sure your shoes fit well. Research has indicated that the running shoe may be better for protecting the feet of people with diabetes than expensive custom-made shoes costing hundreds of dollars. "The research and development put into both running and walking shoes has far exceeded that of the dress shoe industry," Dr. Brenner says. The running or walking shoe of today is part of the whole "foot-support system," he says. "As a result of the research put into them, you're buying a very biomechanically sound piece of equipment for your feet." Don't forget the socks. Before you slip on one of those biomechanically sound shoes, however, make sure your socks are up to the task. "Socks are also part of the foot-support system," Dr. Brenner says. For athletic or casual wear with either walking or running shoes, Dr. Brenner recommends Thor-Lo socks, which come in 11 sports-specific varieties. Most boast thick, cushioned heel and toe pads that help protect the feet of those with diabetes. While there are no dress socks currently being made for people with diabetes, Dr. Brenner says it's quite possible a specialized dress sock will be developed in the near future.

Proceed with caution. People with well-controlled diabetes can use fructose and sorbitol with little problem, the ADA says. Fructose raises blood sugar the least of the caloric sweeteners. But, warns New York City practitioner Stanley Mirsky, M.D., an associate clinical professor at Mount Sinai School of Medicine of the City University of New York, "in people with low insulin reserves, fructose will raise triglyceride levels." And in large amounts, Dr. Mirsky says, both fructose and sorbitol can cause diarrhea.

Beware: calories ahead. Calorie-rich fructose and sorbitol, both found in fruit (sorbitol breaks down in the body to form fructose), are not exchanges for the noncaloric sweeteners. So if you've added fructose and taken out saccharin, you've still added calories to your diet.

Eat smaller meals more often. The diabetic body can handle smaller meals more easily because the smaller the meal, the less insulin is needed to handle the glucose influx from each meal, Franz says. Less glucose equals less insulin equals more constant blood sugar levels. Some diabetes meal plans call for three meals a day or three small meals plus one or two small snacks between meals. Franz says she favors more actual meals because "often if people go too long between meals they get so hungry they can't control what they eat at the next meal." She also recommends snacks like a piece of fruit or a couple of crackers between meals.

Use care with alcohol. The ADA recommends you drink no more than 2 ounces of liquor twice weekly. That's 3 ounces of distilled beverage, 8 ounces of wine, or 24 ounces of beer. Take your drink with food. Light beer and dry wine may be the way to go because they have fewer carbohydrates.

Treat booze like fat. Exchange alcohol calories for fat calories, the ADA says, because alcohol is high in calories per gram and because it's metabolized like fat.

Don't take fish oil. Omega-3 capsules may help prevent atherosclerosis, another diabetes complication. "But it's been shown to increase blood glucose levels if you take too much of it, simply because it's high calorie," says New York City physician Ronald Hoffman, M.D., medical director of the Hoffman Center for Holistic Medicine. One study showed what the researchers called a "rapid metabolic deterioration" when 5.5 grams of omega-3 were taken daily for a month. But eating fatty fish is encouraged.

Lose weight. "Weight loss is the number one priority," Dr. Mirsky says. Eighty percent of Type II diabetics are overweight. They tend to live a sedentary life and eat a lot. Obesity may obliterate insulin receptors so sugar can't enter the cells and remains in your blood. If you're overweight, diet and exercise will almost certainly help you lose some weight and get your blood sugar back to normal, and that may be all you need, Dr. Mirsky says. "Sometimes, all you have to lose is 5 to 10 pounds and you're fine."

Don't go to extremes. Maybe you've tried every fad diet, even tried fasting, and still haven't lost weight. There's some evidence that it might be harder for a person with diabetes to shed pounds than for a person without diabetes, Franz says. She prefers to advise weight control , "which may or may not include weight loss, but always includes improved eating habits and exercise. And that helps control blood sugar and blood fat levels."

Don't let frustration drive you to a fad diet, Franz warns. "If all the fad diets worked, we wouldn't need new ones all the time. They may not be nutritionally sound, and they may be so restrictive people can't stick with them. Plus, they don't help you change your eating behavior in the long run."

For a Type II diabetic who isn't on insulin or oral antidiabetic drugs, "fasting for a day is probably no more dangerous than it is for anyone," Franz says. If you're controlling your diabetes with diet and exercise, fasting "won't hurt, but if probably won't help either. You won't lose even 1 pound of fat by fasting for a day, and the danger is that you'll often overcompensate the next day by eating too much."

Self-Treatment for Mild Hypoglycemia Hypoglycemia occurs when blood sugar drops too low. Because keeping their blood sugar at normal levels requires quite a balancing act, diabetics are particularly prone to hypoglycemia. People with adult-onset diabetes usually get hypoglycemia from skipping or delaying meals, or from unplanned-for strenuous exercise. Symptoms of mild hypoglycemia include numbness in the mouth, cool wet skin, a fluttering feeling in the chest, and hunger. To treat it yourself, says American Diabetes Association past president Karl Sussman, M.D., associate chief of staff for research and development at the Veterans Administration Hospital in Denver, Colorado, "you need to take some form of sugar that's readily available." Drink something sweet like orange juice or soda, or eat a candy bar, he says, and be ready for it by carrying candy or mints with you.

Nor should you skip meals in hopes of losing weight, Franz says. This "mini-fasting" is ultimately self-defeating. "So many people skip breakfast and lunch. Then they go on an eating binge later." Fads, fasting, and skipping meals won't work, and sooner or later you could end up losing control of your diabetes altogether.

Make it a family affair. "If the whole family doesn't make these nutritional changes to improve eating habits and control weight," Franz says, "it will be hard, if not impossible, for the person with diabetes to do it alone."

The Alternate Route One Doctor's Supplement Regimen While the American Diabetes Association diet is adequate in Recommended Dietary Allowances of vitamins and minerals if followed carefully, says Ronald Hoffman, M.D., diabetes increases the need for certain nutrients to help maintain normal blood sugar levels and prevent complications. Depending on your individual needs, as determined in consultation with your doctor , you may want to take one or more of these supplements. Always take them immediately after meals, unless otherwise noted. Aware that these supplements can have potent, even toxic, effects, Dr. Hoffman monitors his diabetic patients closely. Don't even consider taking these supplements without your doctor's approval and close supervision. Also, don't exceed your doctor's recommended dose. Chromium G.T.F. G.T.F. stands for glucose tolerance factor, Dr. Hoffman says. It's sold in health food stores. "What it seems to do is enhance the effect of insulin," he says. Dr. Hoffman recommends chromium picolinate, the form that's most "bioavailable." Many forms of chromium are from brewer's yeast, "so those with candida or with yeast allergy should avoid yeast sources of chromium." Niacin. This important B vitamin "helps potentiate the effects of chromium," Dr. Hoffman says. Take it in the middle of your meals. He warns, however, that high levels of niacin can be harmful, especially to people with diabetes, so limit your intake and have it monitored by a physician. Inositol. Another B vitamin, found in lecithin, "inositol is helpful in protecting the nerves from damage by high sugar levels," Dr. Hoffman says. Anthocyanic acid. Also called blueberry extract, anthocyanic acid lowers blood sugar levels, he says. Vitamin C. This vitamin helps fight infection, heal wounds, and form collagen (the body's building blocks of protein, found in all tissues). Zinc. "It's very important in diabetes," Dr. Hoffman says. "It's helpful for immunity and tissue repair." The picolinate or gluconate form is best. Magnesium. "Diabetics tend to lose magnesium through the kidneys," he says. "Magnesium is very important for cell energy production." Take the chelated form. Vitamin B6. "B6 is an important co-factor in many cellular reactions, and many diabetics seem to have a higher requirement for it," Dr. Hoffman says. B6, however, is toxic in high doses and its use must be monitored by a physician. Thiamine (vitamin B1.) "B1 is especially important in sugar metabolism," he says. Garlic. "Diabetics tend to develop yeast infections more because yeast thrives in a high-sugar environment," Dr. Hoffman says. "Garlic suppresses yeast," he says. Deodorized capsules are best. Acidophilus. This organism "helps keep the intestinal flora away from favoring yeast multiplication," Dr. Hoffman says. It comes in capsule form.

Exercise. The benefits of regular exercise for everybody, diabetic or not, are well recognized. But diabetics have even more reason to get their arms and legs moving and their hearts pumping. Exercise strengthens the heartbeat, helps control blood sugar levels, and increases circulation to the body's extremities. Exercise can cut the level of cholesterol and triglycerides while raising the level of high-density lipoproteins (the "good" cholesterol that protects against heart disease). It helps you control your weight, increases your stamina, and lets you sleep more soundly. And it really helps shore up your emotional fortitude. "Regular exercise has been shown to have beneficial effects on mood, especially for depression," says health psychologist Paula Hartman-Stein, Ph.D., of the Akron General Medical Center in Ohio.

There's also some evidence that exercise increases the number of insulin receptors on cell surfaces, which means insulin can find a place to put glucose where it's needed—inside the cells. In fact, to a person with diabetes, exercise is like a dose of insulin.

Repetitive, rhythmic movements involving your large muscles—arms and legs—are best for diabetics. That means walking, jogging, swimming, rowing, or bicycling. You have to exercise regularly and at least three times a week for 20 to 30 minutes, the experts say. Your doctor may even prescribe exercise five to seven times a week. Studies show that even a two- or three-day layoff from exercise reverses its beneficial effects in diabetics.

Start walking. "The best exercise for people with diabetes is brisk walking," says diabetes specialist Henry Dolger, M.D., former chief of the Diabetes Department of Mount Sinai Medical Center in New York City. "It's by far the safest, least stressful, and most productive of all exercises. It improves the efficiency of every unit of insulin taken in or produced by the body," Dr. Dolger explains. "That means you get more effectiveness out of every grain of food you eat than you would without exercise. It also gives you a great sense of well-being and requires no equipment." If you walk a mile a day, burning 100 calories, in a year you'd shed more than 10 pounds.

Check with your doctor. If your diabetes isn't under control or you have complications, exercise can make it worse. If you have high blood pressure, that also needs to be controlled first. Your doctor may want you to take a stress test. He'll want to judge the effects of any medication you're taking.

Exercise not to do. Don't lift weights or anything else that involves pushing or pulling heavy objects. It raises your blood sugar levels and blood pressure, and can make diabetic eye disease worse.

Take care of your teeth. "A diabetic has to maintain an absolutely immaculate mouth," says Roger P. Levin, D.D.S., president of the Baltimore Academy of General Dentistry. "Because diabetics are much more susceptible to infection, they are also more susceptible to gum disease, which is a bacterial infection." Everything a nondiabetic person should do for dental health, a diabetic person should do even more conscientiously. This means more frequent visits to your dentist and especially conscientious brushing and flossing to control plaque and tartar. (See Tartar and Plaque on page 583.)

A perfect fit is important. "Restorations must be very well contoured in a diabetic," Dr. Levin says. Poorly fitting dentures, bridges, or crowns can cause mouth sores, which can become serious because of inefficient wound healing. And because wounds don't heal well, the diabetic is not a candidate for the newer techniques like dental implants.

Reduce stress. "Stress and anxiety can destabilize diabetic control in two ways," Dr. Hartman-Stein says. "Some people's blood sugar can skyrocket, others' goes way down. And when diabetics are depressed or anxious, frequently they don't adhere to their regimen very well," relapsing into a fat and sugar pig-out and couch potatohood.

Diabetes, with its constant emotional and physical demands, is a stressful disease. "If a person is having some very stressful life events they're having trouble coping with, they should seek the help of a mental health professional," Dr. Hartman-Stein says. Here are some ways you can help yourself relieve stress.

Relax. Dr. Hartman-Stein tested relaxation therapy and cognitive therapy for diabetes control and found these techniques "may be helpful." Relaxation techniques focus on controlled breathing and visualization, and can be learned from professionals or books.

Learn how to think. Cognitive therapy teaches you to "recognize the kinds of thinking you engage in that might be affecting you mood," she says. "You might have thoughts like, 'My legs are really ugly because of the marks from injecting insulin' or 'I feel like a freak every time I have to test my urine.' You can turn those negative thoughts about the regimen into a more rational way of looking at it. You can instead think, 'Nobody's noticing those little marks in my skin but me,' or 'Testing my urine is a chemistry experiment.' " Dr. Hartman-Stein recommends a self-help book by David Burns, Feeling Good . "It's very good for mood problems," she says.

Improve your perspective. You are more than a case of diabetes. "Some people do focus on it too much. They label themselves as having this chronic illness, and it colors everything," Dr. Hartman-Stein says. "Well, it doesn't have to color everything . You do have to be more disciplined about your daily life in terms of your eating schedule, but it doesn't have to hamper you. You need to add uplifts to your daily life for a better perspective. Those with diabetes can't eat a box of cookies to make themselves feel better. One lady told me she rents video tapes and indulges herself when she's feeling depressed or stressed. Do something you enjoy doing—buy yourself something new, call a friend you haven't talked to in a long time, any little treat that isn't expensive and you don't have to plan weeks for, but that you can do on a daily or weekly basis."

Test your blood. Over-the-counter blood glucose testing kits can run into money—up to $750 a year if you test your blood four times a day. "But it's very worthwhile," Franz says. "Urine testing for Type II diabetes is quite inaccurate, because you can get quite a high blood sugar level before sugar spills into the urine," especially if you're older. Blood testing can tell you when you have hyperglycemia (high blood sugar) without symptoms. If your diabetes is mild or controlled, Franz says, you may not need to test your blood as often as four times a day. But you do need to know how often and how to test accurately.

Use care with OTCs. Some over-the-counter drugs (OTCs) contain sugar and other ingredients that can disturb blood sugar levels. Dr. Mirsky offers a simple warning: "Watch out for over-the-counter stuff." Always check the label for any warning directed to people with diabetes, but don't stop there. Ask the pharmacist if you're not sure, and be sure to monitor your reactions after taking any OTC medication. And, of course, check with your doctor.

Here are a few ingredients to be wary of.

Aspirin. Large quantities of aspirin taken for chronic pain can lower blood sugar levels. Occasional small amounts, such as two tablets for a headache, are not enough to worry about.

Caffeine. The main ingredient in OTC appetite suppressants is caffeine, which can raise blood sugar levels when taken in large amounts. Many headache and cold medications also are loaded with caffeine.

Ephedrine or epinephrine. These are used in preparations that treat respiratory illnesses, but they can increase blood sugar in people with Type II diabetes. So can phenylephrine, a drug found in nasal sprays and cold preparations.

PANEL OF ADVISERS

---

Marc A. Brenner, D.P.M., has a private practice in Glendale, New York, is past president of the American Society of Podiatric Dermatology, and author of The Management of the Diabetic Foot .

Henry Dolger, M.D., is former chief of the Diabetes Department of Mount Sinai Medical Center in New York City.

Marion Franz, M.S., R.D., a certified diabetes educator, is vice president of nutrition at the International Diabetes Center in Minneapolis, Minnesota, and chairman of the Council on Nutritional Sciences and Metabolism of the American Diabetes Association.

Paula Hartman-Stein, Ph.D., is a clinical psychologist in the departments of Medicine and Surgery at the Akron General Medical Center in Ohio, specializing in health psychology with a focus on diabetes.

Ronald Hoffman, M.D., is a nutritional physician and medical director of the Hoffman Center for Holistic Medicine in New York City. He is host of a weekly radio show in New York City and is coauthor of the book Diet-Type Weight-Loss Program .

Roger P. Levin, D.D.S., is president of the Baltimore Academy of General Dentistry and a guest lecturer at the University of Maryland in Baltimore.

Stanley Mirsky, M.D., is a private practitioner in New York City and an associate clinical professor at Mount Sinai School of Medicine of the City University of New York.

Karl Sussman, M.D., is associate chief of staff for research and development at the Veterans Administration Hospital in Denver, Colorado, and professor of medicine at the University of Colorado Health Sciences Center School of Medicine in Denver. He is past president of the American Diabetes Association.