Frequently Asked Questions

Diabetes is a chronic condition. It’s not yet curable. But we do know some secrets to help you stay healthy and avoid diabetic complications. Your doctor is a very important part of staying healthy, so visit and have blood tests 2-3 times each year so you can spot potential problems early and to make sure you're still on track. But also remember what you do for yourself when you leave the doctor is just as important as anything your doctor can do. The secret involves Taking Control of your diabetes by following the 5 M’s of diabetic care. Sounds simple, but you all know that diabetes is a complex and frustrating medical condition. There’s a lot to learn, but the more you know, the easier it will be to stay healthy. I hope this section helps answer some of your questions and sets you on the road to good health.

If I have so much sugar in my blood why do I feel so tired and hungry all the time?

When you have diabetes, sugars are trapped in the blood in high amounts. Your cells aren't absorbing sugar properly, and that’s why you may feel hungry and lack energy much of the time. Your body cells are crying out for nourishment despite having sugar all around them. It’s easy for a person with diabetes to overeat in response to these “hunger feelings” and gain weight. This weight gain, especially when the weight is held in the belly area, actually predisposes a person to diabetes and makes it harder to control once you have it because it increases insulin resistance. This inability to use insulin properly causes the pancreas to work harder and tire sooner. Lowering insulin resistance is one key to successful diabetes management.

What are the different kinds of diabetes?

There are two major types; 1 and 2. Both types result in the loss of blood sugar control and involve the action of the hormone insulin, but each type has very different root causes. Insulin is a hormone produced by cells on the pancreas, an organ that sits just behind your stomach. Insulin works like a chemical key to open pores in the cell membrane. All cells in your body have a covering that holds them together, but because cells are alive, nutrients must be allowed to pass through this covering and move into the cell. It’s the job of insulin to open this “door” so that foods you eat can pass from the blood into the cell and be burned for energy or used for growth and repair.

Insulin, the key to the door, is normally released by the pancreas every time blood sugars begin to rise. The more sugar in the blood the more insulin has to be produced so you can properly absorb those sugars. Diabetes occurs when a person is no longer able to produce enough insulin or the insulin that is produced is ineffective in keeping blood sugars under control. In other words the body is either missing the key (type-1) or because of insulin resistance the key simply doesn’t work very well any more (type-2).

I know a young child that was diagnosed with diabetes. Is this type-1 diabetes?

Yes, most likely. Type-1 diabetes is sometimes called juvenile diabetes because it usually affects children and young people, under the age of 20. It occurs when the pancreas stops making insulin altogether (they are missing the “key”). This is the result of an autoimmune reaction within the body. The persons very own protective immune system mistakenly targets insulin-producing cells on the pancreas and kills them. Normally your immune system is programmed to attack only foreign cells like bacteria and viruses and knows not to attack cells that are part of your own body. We don’t know why the body gets confused, but once the insulin-producing cells are targeted and killed, insulin will have to be supplied to the body by way of injection. (Insulin is destroyed by stomach acid, so it can’t be swallowed).

Which type is more common?

Type-2 diabetes, sometimes called adult-onset diabetes, is by far the most common type. Of the 21 million people in the U.S. with diabetes 20 million have type-2. It usually occurs later in life, typically after the age of 40 (Though due to the dramatic increase in childhood obesity, many younger people are now being diagnosed with type-2 diabetes. Ninety percent of all people with type-2 diabetes have gained significant weight around their mid-section prior to diagnosis). In type-2 diabetes insulin is still being produced by the pancreas, but it’s no longer effective in lowering blood sugars because the cell receptors that open the doors to the inside of the cells seem to be stuck shut. This condition is called insulin resistance.

Trapped sugars in your blood indicate that your body has lost its ability to properly absorb the fuels you eat. The normal amount of sugar found circulating in the blood 12 hours after eating would be 99 or less (measured in milligrams of sugar in each deciliter of blood). A 12-hour fasting blood sugar of 100 to 125 indicates that your body is struggling to control blood sugars and is called “pre-diabetes”. A level of 126 or higher in two separate tests establishes the clinical diagnosis of diabetes.

I’ve just been diagnosed with type-2 diabetes; will I have to inject myself with insulin?

Probably not for many years, though you may benefit from some oral diabetic medications. Ironically, many people with type-2 diabetes actually have elevated insulin levels in the years prior to diagnosis. During this time the body is over-producing insulin in an effort to keep blood sugars under control (insulin has lost its effectiveness because of insulin resistance and a normal amount of insulin won’t get the job done). Excess body fat stored in the omentum which surrounds organs in the abdomen is thought to be responsible for this insulin resistance by blocking the receptors that open the doors to the cell (A little like having gum jammed into the lock in the front door of your house. You have the key, but it no longer opens the door, so you can’t get inside).

It’s clear that a sedentary lifestyle, along with years of eating diets loaded with unhealthy fats (animal and trans-fats), processed sugars, and other refined carbohydrates causes us to gain weight, especially in the abdomen, which gums up the doors to the cells. This puts so much pressure on the pancreas that it simply wears out prematurely. Your pancreas has been working overtime, probably for many years, making extra insulin to keep your sugars down. It’s only after the pancreas tires and begins to slow down, a condition called "insulin fatigue," that blood sugars begin to rise and diabetes is diagnosed. Pamper your pancreas to preserve its function and prevent further damage.

My doctor says that excess sugars in my blood will eventually damage my body.

Sugar isn’t poison. It’s the main fuel for your body. We all need some sugar in our blood. Sugar is a highly reactive fuel that's supposed to leave your stomach quickly, travel through the blood, and then be absorbed into your hungry cells and burned for energy. The issue for maintaining good health is managing how much sugar is in the blood at any time and for how long. You see sugar is a great energy source, but it’s also corrosive. Trapped sugars in the blood accelerate the corrosive damage to blood vessels and leads to the breakdown of important body tissues and to the diabetic complications that cause failing health.

I like to use rusting to describe what goes on in your blood when sugars are not controlled. Rusting is a slow destructive process that takes time to develop and is easy to overlook. But if allowed to progress unchecked, it can cause the eventual destruction of things like a bike or mower. Knowing this, we protect our possessions by keeping them out of the elements. That way we reduce the risk that rust is going to do any serious damage. In the same way knowing how to use the 5 M's of diabetic care to help self-regulate your blood sugars and keep them in a healthier range, you'll be able to avoid most of the corrosive damage associated with diabetes and lower our risk of complications.

If sugar is so corrosive why don’t all people have damage to their bodies?

They do! We can measure the corrosive damage caused by sugar in everyone, even if they don’t have diabetes, by using a simple blood test called hemoglobin A1c (abbreviated hgbA1c). Hemoglobin is the protein that carries oxygen and makes blood red. (You may be familiar with this test and I hope you’re able to have it done several times each year) Your red blood cells live about 3 months, so it’s a convenient way to measure the amount of damage (glycation) present and determine average blood sugar levels during the 3 months before the test. A person without diabetes will have between 4.8% and 5.5% damage to their red blood cells (hemoglobin) from the corrosive effect of sugar. This causes little damage and is easily repaired in a healthy person. I've worked with uncontrolled diabetic patients with hgbA1c damage as high as 17%. This means that blood sugar has been nearly 500 for the past 3 months.

Remember this test also tells us that blood vessels themselves are being damaged in the same way, and it’s this high level of blood vessel damage that causes diabetic complications. A healthy hgbA1c for a person with diabetes is somewhere below 7%. That would be about 140 on your blood sugar monitor. This is still in a range that is considered diabetic, but research shows that when corrosive damage is kept low like this, your body can keep up with the repair to your blood and blood vessels and the risk for diabetic complications is significantly lower. So it’s fair to say that it’s uncontrolled diabetes that leads to damage and failed health, because the damage is happening faster than your body can repair it.

So how do I regulate my blood sugars?

You can control your blood sugars, but you must do it manually. For most of your life your body was on “cruise control”, and the amount of sugar in your blood was controlled in a very narrow range. But now this sugar cruise control is broken. Your pancreas is no longer automatically controlling your blood sugars. Now you need to take control, and to do that you need to understand the factors that affect blood sugar and how you can make healthy changes that will make it easier for you to self-regulate your sugars and keep them in a healthier range. The first step is twice a day Monitoring of your blood sugars (like driving a car with broken cruise control you need to check your gauges to monitor your speed and then make manual adjustments to avoid problems).

*** Remember low blood sugar is more immediately dangerous than a mildly elevated reading. If your blood sugar is less than 80 when you check, it's time to eat something. If your sugar reading is less than 80 or you're experiencing symptoms and feeling shaky, sweaty or weakness, eat something with fast acting sugar, such as 1/2 can of regular soda, a glass of orange juice or 3-4 glucose tabs, available at any drug store, then check again in about 15 minutes. If it's still low take 15 more grams. The general rule is that 15 grams of sugar will raise your blood sugar about 50 points, so don't over do it. After your blood sugar reading is over 80 or symptoms subside, eat a small snack with some protein in it to keep your sugar stable.

What are the steps I need to know about to help control my blood sugars?

You can take control and live well with diabetes by learning the 5 M’s of diabetic care and following them.

Monitor-Meals-Motion-Medications-Motivation.

• Monitor – Learn how to check blood sugars and use those numbers to gauge your progress and know when to make healthy changes to your plan.
• Meals – Eat healthy nutritious meals. Learn which foods help stabilize blood sugars and what foods to eat with care. Learn the importance of portion control to avoid Portion Distortion.
• Motion – Use physical activity and exercise to lose weight; to increase your strength, stamina, and balance; to help burn off excess sugars, and increase your energy levels.
• Medications – Learn what each medicine does and which ones may be most appropriate for you. Learn how and when to take them so they are most effective and minimize the possibility of side effects.
• Motivation – Living with a chronic condition is difficult. Many people feel overwhelmed and struggle to take action. Every day you face challenges that can wear you down. Depression is three times more common in people with diabetes than in the general population. Learn strategies for making healthy lifestyle changes and maintaining them.

My doctor told me I'm only borderline diabetic and that I don't have to do anything right now.

All due respect to your doctor, but this is precisely the time to do something! When your fasting blood sugar is between 100 and 125 the proper term is pre-diabetes. Your pancreas is clearly struggling to control the amount of sugar left in the blood from your previous meal. There is strong evidence that reducing the insulin resistance that's making your pancreas overwork can halt or reverse progression to diabetes. You're not alone in this. There are about 50 million people in this country with pre-diabetes. Get started today by beginning a sensible exercise program, eating a nutritious well balanced diet and losing some weight.

Are there any warning signs that might tell me I’m close to having diabetes?

Yes, in fact early indications of this are apparent in a condition called Metabolic Syndrome (Syndrome-X). People that have three or more of the following symptoms have this metabolic disorder and are at risk for diabetes.

• Waist size of 40 inches for men and 35 inches for women (or waist size that equals or is larger than your hips)
• 12 hour fasting blood sugar in the pre-diabetes range (100-125)
• Triglycerides in the blood greater than 150
• HDL cholesterol less than 40 for men and 45 for women
• Blood pressure greater than 130/85

This is why diabetes is classified as a metabolic disorder. Your body isn't metabolizing, or burning, your food properly.

I really don't want to take pills until I have to. Can I control my diabetes with just diet?

Yes, many can, especially in the early stages of diabetes when blood sugars are only mildly elevated. I think nothing is more important for effective blood sugar control than eating a nutritious well balanced diet. I'm not suggesting that you "go on a diet." The healthy diet I’m talking about could best be described as the total of all nourishment you supply to your body. It includes materials for activity, growth, repair, and enough energy to complete that work. Of course it’s also undeniable that we eat for reasons other than nourishment and fuel, and these important issues will be discussed below. But from the perspective of basic biology, what you eat, when you eat, and how much you eat are the factors that must be confronted if you are going to get control of your blood sugars.

I've heard that eating a low carb diet can help control diabetes.

I'd qualify that and say that eating a lower carbohydrate diet can help control blood sugars. Carbohydrates, classified as either simple (sugars) or complex (starches), are the simplest food type and so require the least amount of processing in the digestive tract. They are usually released into the blood quickly (15 minutes) where they stimulate the release of insulin from the pancreas, which allows them to be absorbed into the cells for energy. A healthy pancreas has little problem doing this, but for someone with diabetes, or at risk for diabetes, this puts tremendous stress on an already weakened pancreas.

Evidence is mounting that eating a diet high in sugar and refined carbohydrates is the root cause of the insulin resistance that overworks and wears out the pancreas in the first place. Did you know that a 12-ounce soft drink or even fruit juice has 10 teaspoons of sugar in it? Sugar surges like this are very harmful to your pancreas.

Well then, why not avoid carbohydrates altogether.

Carbohydrates are fuel foods, and we all need energy. Carbohydrates should be eaten in quantities that match your circumstances (i.e. - activity level and metabolism). Lance Armstrong, the famous bicycle racer, got 70% of his calories from carbohydrates. But clearly he had enormous energy demands he had to meet. Most adults, with slower metabolic rates, and a less active lifestyle usually shoot for about 50% of their intake of food in the form of carbohydrates. I think someone with diabetes could eat less, maybe as low as 40% carbohydrate, but it's not really that simple. Besides controlling the amount of carbohydrate in your diet, you need to pay attention to the quality of your "carbs" as well. High quality carbohydrates are natural and unprocessed, and contain plenty of vitamins, minerals and most importantly fiber.

What's so important about fiber?

Fiber plays many roles in a healthy diet. First, fiber slows digestion, and this slows the amount of sugar that’s released into the blood at any one time. Remember the old saying; “The whiter your bread, the sooner you’re dead?” Well that’s just a way of saying we need more fiber in our diet. Americans average only about 17 grams of fiber a day, but we need twice that much. Grains have three parts: the germ, full of healthy oil and protein; the bran, or fiber, which slows digestion and helps you feel full, and starch a complex carbohydrate made of sugars that are linked together in long chains. White bread is made with only the starchy part. Whole grains provide the natural balance that nature intended. When you eat starchy foods like white potatoes, or refined starches with the fiber taken out, it raises blood sugars nearly as fast as pure sugar, putting a real strain on your pancreas. Sugars, from the broken down starches, flood into the blood like freeway traffic at rush hour.

One way to combat this blood sugar "traffic jam" is to increase the fiber in your diet by eating fresh vegetables; beans, legumes, peas and lentils; whole grains and cereals; and maybe a piece of fruit each day. To help increase your daily fiber intake try a whole grain, high fiber pasta like those from Dreamfields. Eat brown rice instead of white sticky rice. Switch from white potatoes to a red skin potato, new potatoes, or try a yam or sweet potato. If you like cereal for breakfast be sure to stay away from sugary brands. Try a healthy high fiber cereal like those from Kashi. These carbohydrates take longer to digest and enter the blood, reducing that after meal blood sugar spike.

Another trick is to eat your starches al dente, or slightly chewy. Undercooking starches helps keep the starch from turning gooey and breaking down right in the pan. Aim for 30-35 grams of fiber per day, but add it slowly, maybe 5 grams at a time, and note your body's response. Fiber helps to keep you regular and avoid constipation, but too much fiber too quickly may cause bloating or diarrhea. Natural sources of fiber are of course best, but if you want to add additional fiber in supplement form, I recommend Benefiber brand. It’s made from soluble fiber so it doesn’t taste gritty and will also help lower your cholesterol.

If I reduce my "carbs" don't I have to increase my fat and protein intake?

Yes, it all has to add up to 100%, but it's not as bad as it sounds. Increasing your lean protein and healthy fat intake can provide real benefits if done correctly. The sugar traffic jam I described above touches on an important concept, so let's get into detail by reviewing some basic principles of nutrition first. All edible foods fall into three categories; proteins, fats and carbohydrates. That means that everything we eat is made up of one of these types or a combination of the three. Each is different in its complexity requiring different amounts of time to disassemble it (digest it), and each has its own special purpose in the body, so finding a proper balance is very important.

This idea is better known as Glycemic Index and I think it offers a good strategy to follow if you’re struggling with your meal planning. The idea is based on a simple observation: Foods don’t digest and supply usable energy at the same rates. Some digest slowly and some digest quickly and when we mix them we can alter the effect (like making sure you have food in your stomach when you drink alcohol - it slows the effect on the body). The concept might be more obvious to you if you think about starting a fire in your fireplace. You know to be careful of lighter fluid because it burns so quickly. Kindling burns slower and helps to stoke the fire and get it going, and a log burns most slowly and provides slow continuous energy. In the same way we need to find a healthy balance in the types of foods we eat. Choose to eat the right balance of foods so your body is supplied with the type and the amount of energy we need; Lean protein and healthy fat will provide you with steady energy so you feel full and satisfied, complex carbs will stoke your internal fire and give you energy when you need it, and fast burning sugars? Well, unless you're training for the Tour de France, those are troublesome and you’re going to have to go easy.

Let's discuss protein in more detail. Protein is what we’re made of; muscle, skin, hair, blood, our internal organs; all protein. So when we eat protein we do so primarily to bring in building supplies for growth and repair. Protein supplies us with four calories of energy per gram, the same as carbohydrates, but protein is very complex and therefore burns slowly providing that satisfying full feeling longer. This is the food that sticks to the ribs and will help stabilize blood sugars. Every meal should include some high quality lean protein. Good sources of protein are beans, peas, lentils; low fat dairy, and yoghurt; lean meats like chicken, turkey and fish; and nuts and seeds. Even lean cuts of beef and pork can be included in modest amounts. Eggs are also a great source of protein. Although the yolk is high in cholesterol, I think their bad reputation is undeserved. One egg per day shouldn’t cause problems for your cholesterol levels. I believe a healthy diabetic diet should include about 20-25% protein. A word of caution here however, if you’re suffering from kidney disease your protein intake will need to be lowered somewhat to accommodate any decreased function. Ask your doctor to be sure exactly how much you should include in your diet.

Healthy fats? I thought fat was bad for you.

Fats aren't bad for you; bad fats are bad for you! Healthy fats are, well, healthy. Fat is the richest form of food in our diet, supplying nine calories of energy per gram. Bite for bite that’s more than twice the calories of any other food. It’s complex and slow burning so it mostly provides us with a slow steady background fuel for our body’s daily metabolic needs. It’s also our savings account for times when food is scarce, so we come by our craving of fatty foods naturally. The ability of our ancestors to store fat during times of plenty is certainly one of the most important biological adaptations ever made, but our intake needs to reflect the changes our culture has made and today’s new realities. The television psychologist Dr. Phil says it this way: “We don’t eat any more calories than our grandparents; the problem is we don’t do what our grandparents did.” In other words listening to this ancestral urge to store extra fat for lean times needs to be balanced with the reality that those lean times don’t happen much any more, so nowadays we’re storing too much fat and it’s killing us. The average American brings in about 40% of their calories from fat, and most of that is from unhealthy sources. I think 30-35% is a better number and remember these should come from healthy sources. Natural fats from plants in the form of oils should be the main source of fat in our diet. Olive oil, canola oil, the oils from nuts and seeds, and yes, even avocados are cholesterol free and full of healthy fat. They’re easy to digest and use for fuel rather than storing around the waistline. Peanut butter is a great snack, but be sure to get the natural kind.

Okay, so which ones are the unhealthy fats I should avoid?

Bad fats come from two sources, one natural, the other man-made. They are - animal fats and trans-fat. These types of fat are easily recognizable because they’re solid at room temperature; white and greasy. They’re like this because of their chemical structure. The carbon chain that makes up the backbone of these fat molecules is surrounded, or saturated with hydrogen. This hydrogenated fat is structurally stable and therefore difficult to break down. Good for frying, bad for digesting. Remember too that cholesterol only comes from animals, so animal fat is loaded with it. Trans-fats are artificially saturated with hydrogen. These hydrogenated (or partially-hydrogenated) fats are made by forcing hydrogen onto a plant fat where nature didn’t have one before. Crisco first made “shortening” in 1911. This new form of man-made fat, the solidified plant fat, was more resistant to breakdown and didn’t turn rancid as fast. This allowed the commercial food industry to box foods and put them on the shelves with less fear of spoilage. The problem? We now understand that the bond that’s created in this process, the trans-bond, is difficult to digest (the word ‘trans’ means across in Latin. The carbon chain twists, leaving the added hydrogen across from each other - a trans-fat). Trans-fats, being resistant to breakdown, tend to stick around and cause health problems. Remember if you don't burn it, you wear it.

While trans-fats have no cholesterol themselves they do cause your bad cholesterol to go up, your good cholesterol to go down, and also increase insulin resistance and blood vessel inflammation that leads to an acceleration of the diabetic complications we discussed earlier. In January of 2006 the U.S. government began requiring that food labels show the amount of trans-fat in all packaged goods. Fast food restaurants however aren’t getting the message and are probably the greatest source of these artery-clogging fats. Bad idea. Avoid them! If you’re unconvinced about this or need reminding rent the documentary "fast food nation," or watch the movie “Super Size Me”. It’s a real eye opener. It’s about a young man who ate three meals a day from McDonalds for a full month. Not a happy ending. Trans-fats really need to be avoided in all foods. Read food labels and choose wisely.

What about butter and margarine? Which is better for you?

Butter is an animal fat and has loads of cholesterol so use it sparingly. You need some cholesterol, but your liver makes all that your body needs. Cholesterol isn’t bad, it’s actually necessary to help strengthen cell walls and also to make bile and certain hormones your body needs. Too much cholesterol however will build up and clog arteries increasing your risk of heart attack and stroke. Remember when you have diabetes you have extra sugars in the blood which damage the smooth inner lining of your arteries. In the same way that rough, damaged spots on a Teflon cooking pan cause food to stick, rough spots in your blood vessels give cholesterol a chance to stick and begin to clog. One million heart attacks and half a million strokes occur in this country every year because of clogged blood vessels. Watch your cholesterol levels! Margarines on the other hand are made from liquid vegetable oils, which have no cholesterol. The problem here is that the oils must first be hardened into a spreadable form. It’s this process of artificial hardening called hydrogenation that turns them into unhealthy trans-fats, the worst kind of fat. Manufacturers of margarines however are trying to make healthy changes. New spreads that don’t use trans-fats are appearing on the market and these are considered healthy to eat. Look on the label before you buy and choose brands that use healthy fats. Benecol or Smart Balance are two that I would recommend.

I usually skip breakfast to help keep my sugars down. Is this a good idea?

No, it's actually a very bad idea to skip breakfast. It seems to defy logic, but studies have shown that people who skip breakfast actually weigh more than people who eat breakfast. People who skip breakfast because they’re not “hungry” or because they think they can save a few hundred calories and help their weight loss plan; actually do more harm than good. Skipping breakfast means you will likely go 16 hours without food. This sets off a reaction in your body similar to a starvation reaction. Your metabolism slows and your body begins to crave food. During times of starvation your body actually starts to burn lean muscle tissue and tries hold on to its supply of fat. When you do finally eat your body is so “starved” that you tend to eat too much and often eat the wrong foods. Large meals alternating with periods of starvation set up a "roller coaster effect" with blood sugars ranging high then low then high again. Stay off the roller coaster! Eating smaller meals, more often will help to stabilize blood sugar swings and provide just enough fuel that you don’t feel hungry or deprived. In fact getting into the habit of eating a little something every 3 or 4 hours during the day makes a lot of sense. Hunger is a survival mechanism. By the time you feel “hungry” your body is already making unhealthy metabolic changes that are working against you.

I know it would help if I bought better foods. Any help with grocery shopping?

Be especially careful when you’re going grocery shopping or heading out to a restaurant to eat. Grocery shopping when you’re hungry often leads to poor choices and the purchase of foods you know will sabotage your diet plan. Make a list before you go and be careful of adding “impulse items” while you’re shopping. Heeding the old saying "shop around the outside of the market" is pretty good advice. Nowadays restaurant meals are much too large to be eaten all at one sitting. Don’t eat large meals! Besides affecting your blood sugars, heartburn and related conditions are made worse when you eat too much because abdominal fat doesn’t make room for your stomach to expand very much. The pressure created on the stomach causes food to be forced back up into your throat where sensitive tissue is burned by stomach acid. You can protect against “portion distortion” by asking for a carry-out box when your meal is brought to the table. Divide the portion before you start eating and you won’t struggle with the issue of when to stop eating. Of course if you are with someone, simply sharing one meal is a great solution to portion distortion.

I've heard about portion distortion. So how do I know how much to eat?

That’s tricky. When patients ask me “how many calories do I need to eat each day?” I respond by saying “It depends.” Not a satisfactory answer I know, but they would get the same answer if they asked me “how much gas do I need in my car each day?” You know that depends on how much your car burns and how far you drive each day. How much you eat should be based primarily on need. Your body needs fuel based on two things, your basal metabolism, and your activity level. Basal metabolism is how much you burn at rest. In general you can figure it this way: Your body is burning about 1 calorie of energy every minute just to carry on basic life processes. Since there’s 1,440 minutes in each day, you would need to provide that much fuel in balanced amounts to maintain your present weight. Any more fuel than that will be stored as fat for future needs and you gain weight, less fuel than that and you will have to withdraw some energy from your fat cells to make up the difference and you’ll lose weight.

Of course you don’t sit or sleep every minute of the day, so each minute that you’re more active you’re burning more than one calorie per minute. Walking burns about 5 calories per minute and more vigorous activities burn even more, perhaps 10 calories per minute. Remember Lance Armstrong? He ate 7,000 calories a day to meet his needs during his bike racing days. Now that he’s retired he has to cut back and eat only what his less active body needs. You need to find the range that meets your caloric needs. I’m guessing that for most of you it will be between 1,500 and 1,800 calories per day. This amount is enough to supply good balanced nourishment, and also enough food that you don’t feel deprived. Never eat less than 1,200 calories each day unless you are under direct care from a medical doctor or registered dietician. Don’t try to starve yourself! Diets that are too strict are destined to fail because they are so restrictive it’s virtually impossible to stay on them very long.

What about sugar substitutes? Can I use them without raising my blood sugar?

Artificial sweeteners aren't digestible, so they don't raise blood sugars; however some people believe that using sweeteners triggers the urge for more sweets. I think that sugar substitutes like Sweet-n-low, Equal (NutraSweet), or Splenda, as a way of cutting back on sugar, can play a useful role in your diet if used in moderation. Some concerns have been raised about their long-term safety. Aspartame, the sweetener found in Equal (NutraSweet), is said to be unstable when it gets hot, causing it to break down into harmful byproducts. I personally don’t think the evidence they cause harm is strong enough that they need to be totally avoided, but if you believe you’re having side-effects like headaches or body aches, stop using them altogether. Of the three products available on the market, I think sucralose, sold under the brand name Splenda, is the best choice. The main advantage is that it’s chemically stable and won’t break down even when you cook with it. This can really help those of you who are trying to prepare satisfying meals for a family. I also think it has a more natural taste, so no one is likely to notice the substitution. The fact that Splenda is so chemically stable is also an advantage because since it isn’t broken down into other chemicals, isn’t absorbed into the body tissues and is quickly eliminated from the body unchanged; I see no potential for harm. Daily coffee or a diet soda once in a while is not likely to cause any problems, but half a dozen diet sodas a day is way too much and not a good idea.

Another group of sweeteners, sugar alcohols like sorbitol or maltitol, are digestible and will raise blood sugars some, though usually not as much as sugar itself. The thing to be careful of is how much you’re getting. Sugar alcohols have a laxative effect and some people are very sensitive to them. If you have diarrhea after eating sugarless ice cream, or dietetic chocolates, this is likely the cause. Go easy on these until you know how you’re body is going to react.

Can I drink alcohol?

While it's not absolutely forbidden for a healthy diabetic to drink, alcohol use may complicate your treatment plan for a number of reasons. Drinking alcohol will in the short term raise blood sugars because of the carbohydrates in the drink, but in the hours following you may put yourself a risk for a hypoglycemic episode (low sugar) because of the effect alcohol has on the liver. Never drink on an empty stomach. Remember that many of your medicines advise against using alcohol because it can increase the risk of side effects or magnify them. This is an important discussion that you need to have with your doctor. Together you can come to an understanding of what your risks are and whether a glass of beer or wine with a meal is okay for you.

Sometimes I find myself eating when I'm not really hungry. What can I do about overeating?

My final thought on eating has to do with the constant battle of wants versus needs. Many of my patients struggle with overeating not so much because of hunger, but because of a lack of satiety. Satiety is the feeling of being satisfied with a meal and is just as powerful an urge as hunger itself. Here are some ideas on that. First, take smaller bites and eat more slowly. The feeling of fullness after a meal is not just in the stomach, it’s also in the brain. The body produces chemicals, which control the urge to eat. One of these hormones, leptin, is responsible for letting the brain know when you’re full and should stop eating. The problem is that it takes about 30 minutes for this chemical to be released and go to work. If you eat too fast you can “over-consume” and eat far more than your body really needs or wants. If you’re eating small meals more often, as I suggest, this will be much easier to do because you won’t feel so starved that you lose control. Emotional eating, and by this I mean compulsive eating, is sometimes a sign of clinical depression. Talk with your doctor or counselor about your feelings about food and eating.

Take joy in eating. It's a good thing when it’s done in a healthy way. Don't make food the enemy or you'll be doomed to fight your whole life. Guilt is just "stinkin thinkin”.

In his book Healthy Pleasures Dr. David Sobel suggests that if we learn to enjoy all of the pleasurable aspects of eating we benefit by feeling greater overall satisfaction. Learn to eat more slowly and savor your food. Use this time to talk to your companions. Eat a wide variety of foods and take time to appreciate all the different flavors and smells and textures. Even the process of cooking itself is an important part of the joy of eating. Enjoy the whole experience. All of these things will leave you feeling more satisfied after meals and help you guard against mindless over-consumption.

My doctor wants me to exercise, and I would if I only had more energy.

Lack of energy is one of the most common complaints I get from my diabetic patients, but the reason for this tired feeling might surprise you. Remember earlier I discussed how extra sugar is trapped in the blood? You may be feeling tired and hungry because the sugar in your blood simply hasn’t been delivered. It has to be absorbed into the cell for you to have energy. Your cells aren’t getting energy because the doors are jammed shut and insulin is having a tough time getting them to open and accept the sugar from your blood (insulin resistance). Using your muscles can help that. You see, because they protect us from danger, muscles have a special ability to drawn those unburned sugars into the cell. Imagine there was a fire and you needed to escape, you would have plenty of energy right? Well you can use this to your advantage and the great thing is there doesn’t have to be a real fire to do it. The next time you feel tired and hungry check your blood sugar level. If it’s 80 or lower, it’s time to eat. But if it’s 180, you have plenty of fuel in the blood. Don’t eat and add more fuel on top of it, burn what’s there by going for a walk or by doing some other form of gentle exercise. When the muscles begin to draw these sugars from the blood you will actually feel better. Talk to your doctor and get the okay; then start slowly with a type of activity that you enjoy and suits your lifestyle.

I tried exercising and found that my blood sugar was actually higher when I got back.

This is true for many people, but don't worry about this type of sugar rise unless it persists long after your exercise is over. Just as breathing increases with exercise, sugars are released from the liver when active muscles call for it. Sugar levels, just like your breathing, will return to normal or lower in a short time. In fact since exercise stimulates your metabolism, your body will continue to burn excess calories long after you’re activity has finished. Right now as you sit and read this your body is burning fuel, and just like a car, how much you burn depends on how fast you’re going. Well, your body is idling right now so you’re only burning a minimum amount of fuel, about one calorie per minute. When you’re out walking, doing yard work or house work, your body is burning about 5 calories of energy every minute. If you walk for 1 hour each day you’ll burn up over 2,000 excess calories of energy each week that would have been stored as fat. In a year’s time that’s over 30 pounds of fat. You can see how this really adds up. Some very fit people can exercise at sustained levels that burn well over 10 calories per minute. Remember Lance Armstrong? His main concern regarding food was “am I getting enough”. Wouldn’t that be a welcome problem to have for a change?

My blood sugar has been rising for the past year and now my doctor says it's time to start taking medication to help. What do they do?

You may recall from the reading above how your pancreas was damaged by overwork in the years leading up to your diagnosis of diabetes. For many years it controlled your blood sugars by producing extra insulin, compensating for the fact that your cells weren’t responding to this chemical key. At some point, if a healthy diet, exercise and weight loss are no longer sufficient to keep blood sugars stable, most people will need the additional help that diabetic medications offer. These medications are designed to work in several different ways. Some stimulate your weakened pancreas to produce a little extra insulin for mealtimes, another works by preventing your liver from inappropriately dumping unneeded sugar into the blood, while others sensitize the cells to respond better to the insulin you are producing. If insulin production gets very low, and oral medications are no longer effective, some people will need supplemental injections of insulin itself.

Can you describe how each drug helps to lower my sugar?

Three classes of oral medications are most commonly used to treat high blood sugars (hyperglycemia). The first class of drugs is called secretagogues because they stimulate the pancreas to produce (secrete) extra insulin. These are best taken about 30 minutes before a meal to give the pancreas time to react and produce the extra insulin needed for the upcoming meal. Tolinase (tolazamide), Glucotrol (glipizide), Micronase (glyburide), Orinase (tolbutamide), Prandin (repaglinide), and Starlix (nateglinide) are examples of these. (Note – Drugs have two names and this may sometimes seem confusing. The capitalized word is the name the company gave it, their registered trademark. The other is the actual generic drug name). Of the medications mentioned in this class, Prandin and Starlix are shorter acting for those who tend to have after-meal blood sugar spikes that drop back into the normal range quickly. This shorter acting formulation lessens the risk of blood sugars being lowered too much in the hours after your meal.

The second drug commonly used is Glucophage (metformin). This medication slows the release of sugars that are stored in the liver. One of the many jobs of the liver is to store extra sugars and release them during emergencies (fight or flight reaction) and when blood sugars drop during the night. Many of you may experience this “Dawn Effect” and find that your morning sugar readings are higher then when you went to bed. Glucophage will help lessen this effect. Take this medication with food and start slowly to avoid the possibility of stomach distress. Most patients start with a single 500 mg (milligram) tablet once a day (dinner). If your doctor prescribes more than that, wait until your body gets used to the lower dose before adding more. Usually add the second pill after one week (breakfast). If there is a third pill to take, wait until the third week then add it to your lunchtime/diner meal as your doctor directs. Glucophage also helps lower insulin resistance and sensitize the cells so they use insulin more efficiently by opening the “doors” that have been stuck shut. This sensitizing effect makes this drug an effective option for people with “metabolic syndrome” because of added abdominal body fat. It can also be used in combination with any of the medications from the first group of drugs mentioned above (e.g. glipizide) to help lower blood sugars even more effectively than using one class alone.

The third most commonly prescribed class of medications includes Actos (pioglitazone) and Avandia (rosiglitazone). These medications work as insulin sensitizers to reduce insulin resistance and make your insulin work better. These drugs tend to cause water retention, so they must be used with care in patients with congestive heart failure. Also make sure to have periodic liver function tests to monitor any negative reaction to your diabetic medications. For patients struggling to maintain stable blood sugars, this class can also be added to the others to make a triple combination therapy, though most often a patient will begin adding insulin injections at this point.

I know that stress isn't good for your health, but will it affect my blood sugar?

Yes It will. Unrelieved stress is one of the things that will not only have an effect on your emotions and overall health; it will have a direct effect on your blood sugars.

The body views stress as an attack or challenge, and responds by preparing our bodies to fight or flee. Adrenalin and the stress hormone cortisol are pumped into the blood from glands just above the kidneys; your heart begins to beat faster and blood pressure goes up; and blood sugars rise, all to help you escape the danger at hand. In a more natural situation, real danger would pass and our bodies would return to a normal state. But in today’s world many "dangers" do not pass, so instead of the action found in fight or flight, our response is to freeze, leaving ourselves in a state of constant anxiety. These modern day "dangers" in fact, don’t even have to be a real or immediate threat. If we perceive it as threatening in any sense of the word; fear, anger, even frustration or uncertainty; in any case, we’re left with the continuing feeling of anxiety, and fear. This lack of resolution of distress leaves us literally “stewing in our own juices”. This type of unrelieved stress is one of the most insidious factors negatively affecting our health and well-being. Cortisol, also known as the stress hormone, may be responsible for the increase in belly fat seen in many type-2 diabetics. Studies show that when a person is overly stressed, the body reacts by storing away extra fat in anticipation of the coming danger.

I want to be sure you understand what I mean by unrelieved stress. Stress is not a single thing. It’s really a continuum that starts low and continues to high. Some stress is necessary in our lives. In fact stressors are what give our lives richness and meaning. If we had no stress in our lives, we would have no reason to get out of bed in the morning; no reason to live. A research study was done in Florida to determine how stress affected the health of retirees in an “old folk's home”. I use the term purposely because it implies the conditions they found; an old, run down facility where people simply sat out their last years with very limited stimulation. When the researchers changed the environment by opening windows to let in more light, playing music, taking the patients out into the garden, bringing in a box of puppies and letting them play, things began to change. Patients’ depression lessened and moods became brighter, they had more energy and began to get themselves up and take better care of their hygiene, they slept better and laughed more and most importantly they lived longer. All of us need some stimulation in life, some reason to live. This level of stress is termed eustress, which means normal or good stress. It gives our lives meaning. When we fill our lives with activities and things that are meaningful, we increase our stress, but in a healthy way.

Each of us has the ability to deal with stress in life, but everyone has limits. When we meet our limits we move into another zone of stress termed distress. This term is more common to us and we all know that distress is a bad thing. Most of us, however, don’t appreciate just how damaging it is on our health. To further complicate things, none of us enters this zone of distress at the same time. Some people are able to perform quite challenging, even frightening activities with no apparent distress. Take a racecar driver for example, or a mountain climber, or bungee jumper. Most of us would not be having fun if we were hanging from a cliff by a single thin rope. How do others do it? Well, we simply don’t know, and for our purposes, it’s really not important. What's important is that we acknowledge that we do have limits, and honor and them. What each of us must do to avoid distress is know when we enter the distress zone. There will likely be signs if we pay attention. When we have too much on our plates, and become overwhelmed, sleep patterns might be affected. One person might sleep too much, another, not at all. You might lose your appetite or eat compulsively. Bowel movements may change from constipation to diarrhea and back again. Some people might have headaches or difficulty concentrating. Accidents are common from not paying attention to the moment, or from moving too fast before we look. Depression, anger, and resentment are often present when a person exceeds their emotional or physical limitations and falls into a state of distress.

Our bodies are built for action, so fight or flee as appropriate, just don't freeze. Take Action. Go for a walk, read, listen to soothing music, meditate or pray, there is no best way. The best way is your way. Find healthy ways to relieve your distress, and do it often.

When I’m feeling low and overwhelmed I like to re-read the wise and comforting advice found in Max Ehrmann’s famous poem Desiderata. "But do not distress yourself with dark imaginings. Many fears are born of fatigue and loneliness. Beyond a wholesome discipline, be gentle with yourself."

I know that motivation is important, but that's the one I'm having trouble with. I sometimes get really discouraged. Besides your diabetes DVD can you recommend any books or websites that will help me stay on track?

Your condition, diabetes, is considered chronic, it's not yet curable. This means that you'll probably live with diabetes the rest of your life (remember, your sugar cruise control is broken). Proper management is the secret to living well with diabetes, and to do that you need to have knowledge about your condition, support from your doctors; your friends and loved ones; and the motivation to carry on even when you are weary. Remember that what you do to maintain good health when you leave the clinic is just as important as anything the doctor can do. In fact, you are the most important part of the process of staying well.

Here are some other helpful books and websites that will help you stay motivated and on track.

Diabetes Burnout by William H. Polonsky, is a supportive guide to keeping you on track during tough times.

For healthy eating tips I think the Mayo Clinic Healthy Weight Pyramid is a good guide to follow, but remember you will have to limit your intake of fruit.

The South Beach Diet is a lower carbohydrate diet that encourages eating lean protein, healthy fats, and high fiber natural "good carbs".

Check out Toma Grubb's website and new book Toma's Diabetic Diet - A Layman's Guide to Controlling Blood Glucose with Diet.

He includes a trial version of CyberSoft's Nutribase-7 Personal Plus Nutrition and Fitness Software that helps you make healthy eating choices and track the results.

One of the early pioneers of diabetes information online is David Mendosa. His website is an excellent source of information on all things related to diabetes. Toma and David are both living well with diabetes and are an inspiration to others wanting to control their blood sugars and avoid health problems by adopting a healthy lifestyle.

A good book and resource for understanding glycemic index and healthy eating is The New Glucose Revolution. by Jennie Brand-Miller.

I also think you should get a calorie-counting guide and begin to learn about the foods you eat. I recommend Allan Borushek’s The CalorieKing Calorie, Fat & Carb Counter. This book is full of great ideas and explanations about how to make healthy food choices.

For those of you who like to chat online, two wonderful websites where you can network with other people with diabetes, ask questions and get ideas and support are TuDiabetes and Diabetic Connect.

Finally, if you would like to get involved with community-based programs that increase awareness about diabetes, the American Diabetes Association website can help get you connected and active locally.

I hope my explanations have been helpful. I encourage you to get my complete Diabetes Basics-Take Control DVD presentation and learn even more about your condition. Be your own advocate, your own best friend, and most importantly, don’t beat yourself up over small setbacks. Believe in yourself and in your ability to take control of your life and control your diabetes; then take the first step toward living a healthy life. Remember, knowledge is powerful only if it leads to positive change. Please leave a comment on my Bio page if this site was helpful or if you have suggestions to improve it. Live well.

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