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Diabetes

In September 2007, our guest experts in Le Club's Ask the Expert segment were part of a multidisciplinary team at the Tri-Hospital Diabetes Education Centre (TRIDEC) at Women’s College Hospital.

TRIDEC has been at the forefront of innovative diabetes care and management for over thirty years.  It was the first centre to put into practice the principles of patient empowerment and client-centered care, which are key elements of diabetes management.

Since its inception, TRIDEC has provided evidence-based assessment and education programs, to encourage clients to take ownership of their diabetes. 

Its multidisciplinary expertise in diabetes has been shared with thousands of clients annually and health-care professionals worldwide. The TRIDEC team addresses the complex medical, emotional and social needs of people living with diabetes. Members of the team include:

  • Nurses
  • Dietitians
  • Diabetes educators
  • Endocrinologists
  • Social workers
  • Psychiatrists

Here are the TRIDEC team’s answers to your questions on Diabetes:

Q: How can I make the holiday season fun again? I have type 2 diabetes. I try to avoid eating sweets but everywhere I turn, there is temptation.


A:  If you have diabetes, that doesn’t mean you can’t eat sweets. In fact, the Canadian Diabetes Association states that sugar (sucrose) can account for 10 percent of total daily calories. This means you can eat foods with sugar as long as you work them into your meal plan as you would any other carbohydrate-containing food.  Most sweets and desserts are lacking the important vitamins and minerals found in more healthful foods, so you need to ensure you are maintaining a balance.  Many treats can also be high in fat and calories.

The key to keeping your blood glucose on target while including sweets in your meal, is to cut back on other carbohydrate containing food. For example, have less mashed potatoes or skip the bread roll and have a small slice of pumpkin pie. Cookies such as shortbread, plain oatmeal, or ginger usually have less carbohydrates then chocolate chip or an iced sugar cookie.

One great idea is for you to bring the dessert to the party. Many dessert recipes can be modified by decreasing the sugar content by one-third to one-half without compromising taste.

Another trick is to share dessert with a friend, or scrape off the sugary icing or high fat whipped-cream. Keep in mind that the holidays are not a good time to take a break from you daily exercise routine. Exercise such a walking, is a great way to manage your blood glucose (sugar). Try parking far away from the mall, or power walking while shopping.  The holidays can be stressful, so make sure you take time for yourself and enjoy a tea and biscuit.

 


Q: I am a diabetic, have high cholesterol (on Crestor at present), and am also on Coumadin. I control the diabetes by watching my diet, but that is becoming increasingly more difficult as I have to watch diet restrictions for the cholesterol, Vitamin K for the Coumadin as well as the proper diet for diabetes.  How does one get proper guidelines that will balance these needs?

A: Multiple medical issues can make healthy eating a challenge.  One way to live well is to focus on similarities rather than differences. For the majority of your medical conditions, general healthy eating strategies apply. This means eating lots of vegetables, whole grain products, and lean meats.

Adding fibre to your diet is also important so try a psyllium based cereal, oatmeal or beans.  Coumadin is affected by the vitamin K in foods. This does not mean you can’t eat kale, Swiss chard, spinach, or broccoli but you need to keep your intake of these foods consistent. 

How to keep these foods consistent is dependent on your preferences and the categorization of vitamin K containing foods.

To get proper guidelines you need to contact a registered dietitian who specializes in diabetes. If you live in the Toronto area you can contact us here.

 



Q: I have had diabetes since I was two years old and now I am 22. I'm approximately 30 lbs overweight and have tried many different diet meal plans and find it very difficult to lose weight. I have asked my diabetes educator and endocrinologist for help but nobody has the answer. I'm on a pump it that helps. I have only received very general vague answers.


A: Managing your weight with diabetes can definitely be a challenge. I’m assuming that you’ve had a full medical work-up to rule out any other possible explanations for the difficulties that you’ve had in losing weight.

My first suggestion for you would be to review your current level of physical activity.  Any increase in your activity level can help tremendously with your weight and also help to reduce your insulin requirements. Choose something that you enjoy and build it into your regular routine as often as you can. Whether it’s swimming, biking, yoga, tennis or even walking, being more active is the first step in helping you to lose weight.

When you are on the pump, there are several different techniques to use to adjust your insulin doses when you increase your level of activity. You can try a temporary basal rate reduction or adjusting your pre-exercise meal bolus. Generally the more fit you are, the less adjustment you need to make when you exercise. It’s a good idea to work with someone experienced in working with people on insulin pumps who are active. Here at TRIDEC, we work with all types of athletes ranging from those just starting a walking program or weekly aerobics class to competitive athletes and former Olympians!

Another benefit of being on the pump is that you should have more flexibility with your food choices. It’s easier to eat less and adjust your insulin doses on the pump than when using injections. If you are having difficulty losing weight, sometimes it could be because you need to eat to “chase your insulin” or to treat frequent low blood glucose (hypoglycemia). If this sounds familiar, you may need an adjustment to your basal rates and/or insulin to carbohydrate ratio.  If the rates are set right and you are eating a healthy, well-balanced diet, adding physical activity to your life may go a long way in helping you to achieve your goals.  Start small, be realistic and congratulate yourself each time you make a positive change.

 


Q:  I find it very hard to stick to my diet plan, partly because I like one-dish meals (pasta or grains + meat + veggies) and partly because I binge under stress and having Type II diabetes stresses me out!

A: First of all, I’d like to know what type of a “diet plan” you’ve been given.  Nowadays, we tend to shy away from meal plans and teach our clients how to make healthy food choices.  Healthy eating with diabetes is no different than healthy eating for everyone else.  If it’s been a while since you’ve had diabetes education, I might suggest that you book an appointment with your dietitian who can help you identify the foods in your diet which impact your blood glucose and how to balance these foods throughout the day.

Most one-pot meals can be very healthy and nutritious.  Include whole grains (for example, whole wheat pasta, brown rice, barley, couscous or quinoa), lean meats or legumes and plenty of vegetables.  When it comes to portion size, use your blood glucose as a guide.

In terms of your stress level, try to RELAX. Being stressed out can raise your blood glucose and make managing diabetes more challenging. Check out your local community centre to see if there is, for example, a yoga class or tai chi session that you can join.  Ask your health care team about support groups or stress management programs for people with diabetes in your area.  Keep your chin up – you’re doing a great job!

 


Q: Hello. I have recently been diagnosed with PCOS and have read that it is related to insulin resistance. Does that mean PCOS is related to diabetes? Do I have a greater chance of developing diabetes because of this? Anything you can suggest to lower my risk? Thanks.

A: The exact cause of polycystic ovary syndrome (PCOS) is unknown. Genetics most likely play a role as most women with PCOS have a mother or sister with the condition as well.  New research is also pointing to a connection with insulin.  Insulin is a hormone produced by the pancreas that controls the uptake of glucose (glucose) into our cells.  This is how we get “energy” from the food we eat. Women with PCOS develop insulin resistance and higher levels of insulin in their body.  Excess insulin stimulates the production of androgen, a hormone produced by fat cells, the ovaries, and the adrenal gland.  High androgen levels may lead to weight gain, hair growth, acne and other symptoms common to PCOS.

Women with PCOS are at greater risk of developing diabetes or pre-diabetes before the age of 40. Maintaining a healthy weight and exercising are great ways to manage your PCOS and lower your risk. If you are overweight, try to eat fewer processed foods (like TV dinners, canned foods) and foods with added sugar (granola bars, some cereals, desserts). Increasing your intake of fresh fruits and vegetables is another great strategy.  Try to have at least 3 pieces of fruit per day and make vegetables the focal point of meals.

For example, make a pasta sauce with onions, garlic, zucchini, broccoli, and kidney beans. Also try having a garden salad with low calorie dressing as an appetizer before dinner. The salad should help fill you up so you will need less to eat.  We know that a modest weight loss of 10 percent can improve insulin sensitivity and help restore a normal more regular menstrual cycle.

We would recommend that you talk to your doctor about getting tested for diabetes regularly.  Eating well, exercising, and not smoking will help reduce your chances of developing other health-related problems.

 



Q: I had gestational diabetes and was injecting insulin twice per day during my pregnancy six years ago. Since then, my doctor checks my fasting blood sugar once per year. What are my chances of getting type 2 diabetes and is there really very much I can do to prevent this from happening?

A: Women like yourself, who have had a pregnancy with gestational diabetes (GDM), have a 50 percent chance of developing type 2 diabetes and a 75 percent chance of developing pre-diabetes 15-20 yrs after delivery.  Your risk tends to be higher if you were older when pregnant, had an earlier onset of GDM and are overweight (BMI>25).

There are quite a few lifestyle strategies you can try in order to prevent type 2 diabetes.  Evidence from the 2002 Diabetes Prevention Program demonstrated that choosing a diet lower in saturated and trans fats, a diet with fibre-rich foods such as whole grains, fruits and vegetables and being physically active 20 minutes a day with activities such as walking were lifestyle changes that made a significant difference.   Getting back to your pre-pregnancy weight can help and if you were overweight, losing 7 percent of body weight prevented diabetes in 58 percent of people with pre-diabetes (people at risk for developing diabetes). Example: if your weight was 180 lb before pregnancy you would need to reduce your weight by 12 lbs.  Women, with gestational diabetes, can further reduce risk and also the baby’s risk of developing diabetes by breastfeeding.

If you had GDM in a previous pregnancy and are planning another pregnancy, it is recommended that your doctor or specialist (such as fertility specialist) check that your blood glucose is in normal range before you conceive.  Even if you are not planning another pregnancy, it is recommended that your physician check your fasting blood glucose at least once a year.

 


Q:  I have MS, type 1 diabetes and interstitial cystitis-all autoimmune diseases. Do you think that there is a connection between these conditions?


A: The purpose of the immune system is to defend the body from bacteria, viruses and foreign bodies. Autoimmune diseases are conditions in which a defect in a person's immune system causes an attack on other cells in the body by mistake, resulting in tissue destruction. Reasons for a dysfunction in autoimmunity, are thought to be caused by a combination of genetic, environmental and hormonal factors.

Type 1 diabetes is considered an autoimmune condition as the beta cells in the pancreas are gradually destroyed through this autoimmune process. People who have type 1 (or their relatives) are at increased risk for other autoimmune conditions. There are different patterns within autoimmunity and the one in which type 1 diabetes is most often associated is thyroid dysfunction, but not typically MS.

The causes for interstitial cystitis remain unclear. Unfortunately, you are dealing with several autoimmune disorders although it is not common to see this pattern in the same person. We wish you the best in dealing with these conditions.

 



Q:
Have there ever been cases of Type 2 diabetes patients recovering (i.e. no longer diabetic) without special intervention?


A: Diabetes cannot be reversed but it can be successfully managed. Some people find they are able to manage type 2 diabetes with: healthy meals, weight loss and activity. Others may find that they need medications to help manage their blood glucose levels.  By keeping blood glucose within the target range, it is possible to lead a long, healthy life and slow down the progression of diabetes. To manage diabetes effectively, lifestyle changes are important.

Here are some steps you can take to help manage diabetes:

  • Monitor your blood glucose regularly
    (target range; Before meals: 4-7 mmol/L, 2 hours after a meal: 5-10mmol/L)
  • Eat healthy and well-balanced meals
  • Try to be physically active everyday.  If you are not currently active, start slowly (10-15 minutes) and gradually build up the duration of your activity.  Ask your medical doctor before you start an activity program.
  • Maintain a healthy weight
  • Take medications as prescribed by your doctor
  • Make sure you visit your healthcare team regularly (including eye specialist and dentist).

For further information, go to www.diabetes.ca. Always be skeptical about any product that claims to be a cure for diabetes and consult a healthcare professional before trying such a treatment.

 



Q: I have had type 1 diabetes for around 44 years (I am 49 now). I never complain and I have never said "Why Me?', but I am getting very tired of it.  I've got just about every complication that you can get. I'm just really tired.

My question is:  Do you have any words of advice, inspiration or books I might read to help me get a better attitude? It seems like now matter what I do, another complication comes up. Can you give me some hope to help me get through this hard time that I am having right now?


A: You sound like you may be suffering from “burnout.” Burnout was a phrase coined in the 1970’s to describe the extinction of motivation or incentive when your hard work fails to produce the desired results. We end up feeling physically drained and emotionally exhausted as well as increasingly pessimistic. Why bother?  It starts to get more and more difficult to put out the energy needed to work so hard and, on top of all that, we begin to feel guilty because we think we ‘should’ be doing better. These are the classical symptoms of ‘burnout’, most often applied to job burnout however, a psychologist, William Polonsky, who specializes in diabetes wrote a book called Diabetes Burnout  - What to do When You Can’t Take It Anymore.

When you are suffering from ‘diabetes burnout,’ the ‘job’ of daily self-care needed to manage diabetes feels too burdensome and the results so frustrating that the effort just doesn’t seem to be worth it anymore. Sometimes people feel that diabetes controls their whole life and they feel like partially or fully “quitting” their diabetes care. These sorts of feelings about diabetes are more common than you think. When people with diabetes were surveyed, 95 percent said that they had diabetes-related stress.

Polonsky, in his book says, that “ there are three important things you need to know:

  1. You are not alone (diabetes burnout is quite common).
  2. You are not a bad person (given the pressures and the disappointments associated with living with diabetes, burnout is understandable).
  3. Your situation is far from hopeless (burnout can be conquered).

I would start by picking up a copy of Polonsky’s book. It is an inspiring self-help book which is very easy to read and filled with practical examples and uplifting humour and encouragement.  Each chapter in the book focuses on one aspect of self-care that may be challenging and practical solutions are outlined in detailed easy-to-follow steps.

For example, “Ten Good Reasons to Hate blood Glucose Monitoring and What to Do About Them.”  He also covers strategies on how to handle “The Diabetes Police” in your life and how stress and depression impact on diabetes and diabetes management.

Polonsky also has a website that can be accessed at www.behavioraldiabetes.org. Other books that may be of interest to you are:

Living and Loving with Diabetes: Three Experts Answer Questions You Always Wanted To Ask. Janis Roszler, William Polonsky, Steve Edelman. Surrey Books, 2005.

When you or a loved one has diabetes, it can bring stress, tension, and worry into your relationships. Using current medical information, skill-building exercises, questionnaires, personal anecdotes, and humor, three noted diabetes experts’ help you gain control of your diabetes and reach a new level of confidence in your relationships. Learn how to:

  • Take control of your diabetes
  • Deal with your fears, feelings, and emotions
  • Enlist support from family, friends, and internet resources
  • Have diabetes and a fulfilling sex life
  • Distinguish diabetes emergencies from simple urgencies...and more

The Mind-Body Diabetes Revolution.  Richard Surwit, PhD.  Marlowe, 2004.

“Dr. Surwit shows that diabetes has a mind of its own – in other words, stress can raise the blood glucose higher than all the dietary indiscretions and indulgence that most humans allow themselves.  With Dr. Surwit’s easy-to-follow program for managing stress and depression, people with diabetes can conquer their demons and take charge of their health.”  Excellent resources with specific practices and techniques for handling and reducing stress.

Full Catastrophe Living: Using the Wisdom of your Body and Mind to Face Stress, Pain, and Illness.  Jon Kabat-Zinn, PhD. Delta Trade Paperbacks, New York, 1990.

Dr. Kabat-Zinn pioneered the use of mindfulness in a medical setting.This self-help book has a wealth of information on the positive effects of using daily meditation to recover from the negative effects of too much stress. He has tapes and CD’s to guide you in the practice of mindful meditation.  His course is being taught at the University Health Network, the Y’s and many other places in the city. 

The Relaxation Response. Herbert Benson.  Harpertorch. 1975. and
 The Wellness Book:  The Comprehensive Guide to Maintaining Health and Treating Stress-Related Illness.  Herbert Benson M.D. & Eileen Stuart. Fireside, New York,1993.

Herbert Benson, M.D. coined the phrase, ‘the relaxation response’ after studying the effect of meditation on stress.  Benson  encourages people to incorporate a relaxation technique into their everyday lives in order to overcome the negative effects of stress.

 



Q: Please discuss the issue of chronic yeast infections and type 1 diabetes - the science behind this problem and possible approaches to address it. Also, how does the TRIDEC team encourage teens/young adults with Type 1 to maintain healthy blood glucose levels?


A: Up to 75 percent of all women will experience a yeast infection within their lifetime. A yeast infection occurs when there is an overgrowth of yeast cells in the vagina. Normally, different types of bacteria which live in the vagina (such as Lactobacillus acidophilus) help prevent overgrowth of yeast and other organisms by creating an acidic environment. When the vagina becomes less acidic, there can be a resultant increase in yeast growth leading to a vaginal infection. The acidic balance of the vagina can be altered by: menstruation, spermicides, some antibiotics, birth control pills, steroids, hormonal changes (such as with pregnancy) and medical conditions such as HIV infection or diabetes.

Women with diabetes are at a greater risk of having recurrent yeast infections, which is defined as four or more vaginal yeast infections per year. This is especially true for individuals who may be having difficulty maintaining their target blood glucose levels. When blood glucose levels are high, two things happen which contribute to more frequent yeast infections: The yeast feeds on the extra sugar or glucose, enabling the yeast cells to multiply, and the excess glucose suppresses the growth of the good bacteria which helps our body fight off infections.

To determine that you do in fact have a yeast infection, your doctor should take a vaginal swab and get a culture for yeast. Based on your culture result, your doctor can treat you accordingly. Yeast infections are typically treated with antifungal medication which can come in the form of pills, vaginal suppositories, or cream. There are a variety of effective treatment doses available ranging from single-dose treatment to treatment courses of 3-7 days. Typically the longer course of treatment is recommended for individuals with diabetes (i.e. 7 days) and some physicians also recommend maintenance therapy for a number of months to control the yeast symptoms.

Other therapies such as yogurt tablets have not been proven to be overly effective. Some simple ways of decreasing your risk of developing vaginal infections are wearing cotton underwear; avoiding tight fitting pants; wiping from front to back after using the toilet; changing out of wet bathing suits or damp clothing as soon as possible; avoiding douches or the use of feminine hygiene sprays, deodorant sanitary pads or bubble bath. One of the most important ways in which you can decrease your risk of developing chronic yeast infections is by working with your health care team to reach and maintain your target blood glucose levels.

Type 1 diabetes is a heavy burden for anyone and especially for young adults. With this in mind, we offer programs that are more accepted by younger people. One focus of the diabetes program at The New Women’s College Hospital is type 1 diabetes. We have an interactive educational program that includes Choices!, a series of two-hour weekly sessions for five weeks. This program covers many topics dealing with type 1 diabetes and discussions focus on how the participants manage their diabetes in many different situations. The goal of our education program is to enable people with type 1 diabetes to learn how to count carbohydrates and then to adjust insulin doses accordingly. In discussing these different issues together, the participants often help each other.

As well as the Choices! program, there is opportunity for participants to meet on an individual basis with members of our team which includes nurse practitioners, dietitians, a social worker and referral to endocrinologists and our mental health program. The advanced pump program at Women’s College Hospital initiates insulin pump therapy and offers advanced support for ongoing pump problems. We have annual programs open to the public as well as meetings for insulin pumpers and other support groups. We also plan to create programs specific to the needs of women across the lifespan.

 

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