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Diabetes

Our guest experts in November 2010 were members of the multidisciplinary Tridec diabetes management team from Women’s College Hospital in Toronto.

Tridec was founded in 1971 and includes a multidisciplinary team of nurses, dietitians, a social worker and a physiotherapist.

Tridec offers individual counselling appointments to discuss ongoing diabetes self-management, as well as group diabetes education programs. Topics of discussion may include: healthy eating, physical activity, blood glucose monitoring, and psychosocial issues.

The Tridec team:

Nicola Donovan, Advanced Practice Nurse Specialist
Leah Drazek, Advanced Practice Nurse
Janis Rusen, Registered Dietitian
Joanna Osborne, Registered Dietitian
Shelley Sharma-Thakrar, Physiotherapist
Cheryl Harris-Taylor, Social Worker

Here are the responses to your questions on Diabetes.

Q: What is pre-diabetes? There have been conflicting articles on this subject.

A: Pre-diabetes is a term used to describe blood sugars that are higher than normal but not high enough to be diagnosed as diabetes. Individuals with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) are considered to have prediabetes. Fasting blood glucose values (morning blood sugars before eating) between 6.1-6.9 mmol/L are considered to be impaired and fall within the ‘prediabetes’ range. Normal fasting blood glucose values are between 4.0-6.0 mmol/L. Impaired glucose tolerance is an abnormal blood sugar recorded two hours after drinking a 75 gram glucose drink. IGT values between 7.8 and 11.0 mmol/L are considered to be in the ‘prediabetes’ range. Having prediabetes places individuals at an increased risk of developing diabetes and heart disease. Fortunately, lifestyle and dietary changes can improve blood sugars and often prevent the progression to diabetes. Increasing your daily physical activity and choosing a healthy, lower-fat diet are the first steps toward improving your health. Speak to your doctor or health-care provider to learn what you can do to safely reduce your risk of developing diabetes.

 


Q: My friend has Type 2 diabetes. I’m hosting a holiday party soon and would like to make sure there is something she can eat and drink. What are the dietary restrictions of people with Type 2 diabetes?

A: Thanks for your question. Healthy eating is an important strategy in managing Type 2 diabetes, so it is great that you want to incorporate this into your holiday party. The good news is everyone who attends your party will benefit from these healthy meal ideas as well!

For someone with Type 2 diabetes, diet is one way to keep the blood glucose levels (the amount of sugar in the blood) within a healthy range. This can be done by:

  • limiting sugars and sweets such as regular pop, desserts and candies
  • limiting the amounts of high-fat foods eaten
  • eating more high-fibre foods such as whole grain breads and cereals, lentils, dried beans and peas, brown rice, vegetables and fruits

So now you might be wondering, how does this fit with holiday eating?

Here are some ideas:

  1. First off, no food is off limits but portions are important. For someone with diabetes (and even for those without), they would just need to keep their eye on portion sizes. It is not just what they eat, but how much they eat that can make a difference to blood sugar levels.
  2. Try serving fresh vegetables such as colourful peppers, zucchini or cucumber spears, broccoli florets or carrot sticks with a low-fat dip or spread such as hummus or yogurt. This is a lower-fat and higher-fibre alternative to chips and cream-laden dips.
  3. Go for whole grains. Provide whole wheat breads and rolls; if you have a rice dish, choose wild rice instead of using white rice.
  4. Serve crispy whole wheat pita triangles, flatbread or melba toast as an alternatives to salty, high-fat snack crackers.
  5. Instead of having only pies and cakes for dessert, consider offering fruit-based desserts like fondue, fruit cocktail or yogurt parfaits. Have a fresh fruit platter available including seasonal fruits as well as some more exotic ones. Think of pineapple, kiwi and pomegranate, as well as the more conventional strawberries, melons and grapes. Mandarin oranges are also widely available at this time of year. This will not only reduce the fat and calorie content of your meal, but it can also make for beautiful displays.
  6. Make smart substitutions in your baking to reduce the fat content of your desserts. Try using three tablespoons of unsweetened cocoa powder to replace one ounce of unsweetened chocolate in desserts; crushed graham crackers can be used as a healthier alternative to traditional pie crusts; replace half of the oil in dessert recipes with an equal amount of unsweetened applesauce; use fat-free or reduced-fat milk or sour cream instead of the full-fat version, or non-fat frozen yogurt instead of ice cream. Try the Applesauce Brownie recipe from the Diabetic Gourmet.
  7. For alcoholic beverages, moderation is key. This, of course, is up to your guest to control. In addition to the alcoholic beverages you might otherwise provide, you could consider making a wine spritzer or light beer as an option. Alternatively, consider offering a mixed juice beverage (orange juice and cranberry make a nice combination) diluted with sparkling water.

For more recipe ideas when it comes to holiday entertaining you could look to the Dietitians of Canada’s cookbook Simply Great Food or the Complete Canadian Diabetes Cookbook from the Canadian Diabetes Association.

Source: Canadian Diabetes Association http://www.diabetes.ca.

 



Q: What is the difference between taking an insulin injection and taking metformin, in terms of its effect on your body (short and long term)?

A: Metformin is an oral anti-diabetic drug. It may be used alone or in combination with other diabetic medications. It is the first drug of choice for the treatment of Type 2 diabetes, particularly in overweight people and those with normal kidney function. Metformin decreases sugar being put into the bloodstream from the liver and increases insulin sensitivity. Decreasing resistance at the cell allows insulin to move sugar into the cell more easily. Metformin does not increase the concentration of insulin in the blood and therefore does not cause excessively low blood glucose levels (hypoglycemia) when used alone.

Insulin is absolutely necessary for individuals with Type 1 diabetes as there are no beta cells in the pancreas to produce insulin. Individuals with Type 2 diabetes may need to go onto insulin as the beta cells in the pancreas are slowly diminishing. Oral medications can help the individual with Type 2 diabetes for a while, but are only effective if the person’s beta cells in their pancreas are still producing some insulin. Unfortunately, insulin is not available in a pill or tablet. There is no oral medication for insulin.

There are many different insulins on the market and each of these insulins would have a different onset/peak/duration in the body. Generally when an individual with Type 2 diabetes is started on insulin, it is most often a basal insulin or a background insulin. This type of insulin can help your blood sugar level when you wake up (fasting blood glucose) and help compensate for the effects of your liver putting out extra sugar (glucose) overnight. Unlike metformin, all insulins can cause a person to have a low blood sugar as the action of the insulin is to lower blood sugar. The person on insulin will have to monitor their blood glucose frequently and eat a consistent diet to prevent their blood glucose from rising or falling too much. 

In summary, the actions of metformin and insulin have been reviewed as to how they help to improve glycemic control. They are both equally important in preventing the long-term complications of diabetes.

 


Q: If I have diabetes, is there anything I can do to help prevent my child from getting diabetes in adulthood?

A: If you have Type 1 diabetes, the chances of your child developing Type 1 if you are a female is  about three per cent; if you are a male about six per cent. Since Type 1diabetes is an autoimmune disease, there is nothing that can be done to prevent Type 1 from developing in your child. There are, however, studies looking at the genetic markers for developing Type 1 diabetes. Screening for such markers involves a simple blood test for the presence of diabetes-related autoantibodies that may appear years before Type 1 diabetes develops.

If you have Type 2 diabetes, there are actions you can take to involve your child in preventing Type 2 diabetes from developing. There are risk factors associated with developing Type 2 diabetes, such as being a member of a high risk group (Aboriginal, Hispanic, Asian, South Asian or African descent), having a parent or sibling with diabetes, being overweight (especially carrying most of the weight around the middle of the body), health conditions that are associated with diabetes (such as schizophrenia and polycystic ovary syndrome), high blood pressure and high cholesterol.

Lifestyle changes are key as this can help prevent or delay the onset of Type 2 diabetes.  A healthy meal plan, weight control and physical activity are important prevention steps.

 


Q: What’s the connection between diabetes and peripheral neuropathy? Moreover, how is peripheral neuropathy diagnosed, and what are the treatment options?

A: Diabetic neuropathy (nerve damage) is the most common complication of diabetes. Over time, high levels of sugar (glucose) circulating in the bloodstream can cause damage to the tiny blood vessels which supply the nerves in body parts such as your feet. This damage results in decreased nerve impulses and diminished sensation.

Peripheral neuropathy usually occurs in the feet or lower legs but rarely can also affect the hands and/or arms or something to that effect. Early symptoms of peripheral neuropathy include numbness and tingling in the affected area which is often described as a ‘pins and needles’ sensation. More advanced symptoms include a hot or cold burning sensation and/or a stabbing or shooting pain which may be worse at night. However, 50 per cent of people with diabetic peripheral neuropathy do not have symptoms. Factors which increase an individual’s risk of developing neuropathy include longer duration of diabete, chronically elevated blood sugars (hyperglycemia), being overweight; being a smoker and/or having elevated triglycerides (a type of blood fat).

People with Type 1 or Type 2 diabetes should be screened for peripheral neuropathy every year. Two of the most common tools health-care professionals use to screen for peripheral neuropathy are the 10 gram Semmes-Weinstein monofilament, which is placed on different points on the foot; and the 128 Hz tuning fork, which is placed on top of the big toe. During a 10 gram Semmes-Weinstein monofilament exam, the individual is asked to close their eyes and the examiner will place the monofilament on different points on the person’s foot. The individual says ‘yes’ when they feel the monofilament. The examiner counts the number of times the person felt the monofilament to calculate a score. A score of seven or eight out of eight means the person likely does not have peripheral neuropathy.

To prevent or delay the progression of peripheral neuropathy work with your health-care professional(s) to achieve blood sugar levels at or near the blood glucose target range; do not walk barefoot; wear proper-fitting shoes; inspect your feet daily for signs of redness, dry skin, calluses, blisters, cracks, ingrown toe nails or signs of infection. Treatment options for peripheral neuropathy include medications from the anti-convulsant and antidepressant drug classes, as well as certain pain medications. If you have peripheral neuropathy, speak to your health-care professional about what treatment options might work best for you.

 



Q: What are the effects of alcohol on diabetes?

A: Alcohol has the potential to cause a high or a low blood sugar. If a person with diabetes consumed an alcoholic beverage containing sugar (for example, a vodka cooler) their blood sugar would increase for a short time.

However it is possible for individuals who are treating their diabetes with insulin or insulin secretagogue pills (glyburide) to have a low blood sugar (hypoglycemia) up to 24 hours after drinking alcohol.

When a person consumes alcohol, their liver enzymes are busy breaking down the alcohol. Therefore during this time the liver is not able to create new glucose (a process called gluconeogenesis).

Therefore when the liver depletes its existing glycogen (stored glucose) supply, the person can have low blood sugar.

Thus it is recommended to limit alcohol intake to one drink per day if you are a woman and two drinks per day if you are a man.

If you are taking the diabetes pill metformin, speak to your pharmacist or other health-care professional about alcohol use with this medication.

If/when you drink alcohol ensure you eat carbohydrate-rich foods with the alcohol; carry your glucose meter and treatment for low blood sugar with you (such as six LifeSavers); tell a responsible person you have been drinking and always wear your MedicAlert bracelet.

It is also important to know that glucagon, a treatment for a severe low blood sugar, will not work when there is alcohol in the body.

 


Q: How do I know if I have diabetes? What are some symptoms?

A: There are a number of symptoms that people living with diabetes can experience, such as:

  • increased thirst (polydipsia)
  • increased hunger (polyphagia)
  • frequent need to urinate
  • drowsiness or fatigue
  • frequent skin infections or slow healing wounds
  • dry mouth
  • blurred vision
  • weight change (gain or loss)

Generally, people with high blood sugars are more likely to experience these symptoms.

If you have these symptoms and/or have risk factors for developing diabetes, talk to your doctor.  The risk factors to be aware of are:

  • sedentary lifestyle
  • overweight
  • abdominal obesity (increased fat around the waist)
  • age 40 or over
  • history of gestational diabetes (diabetes during pregnancy)
  • high blood pressure
  • high cholesterol
  • schizophrenia
  • polycystic ovary syndrome
  • member of high-risk populations (Aboriginal, Hispanic, South Asian, Asian or African descent)

Your doctor can do a blood test to confirm a diagnosis of diabetes.

 


Q: Can someone develop diabetes even if there is no family history?

A: Although family history, particularly having a first-degree relative with diabetes, can put an individual at greater risk for developing diabetes, it is possible to get Type 2 diabetes with no family history.

There are many risk factors which can put an individual at risk for developing Type 2 diabetes, such as:

  • sedentary lifestyle
  • overweight
  • abdominal obesity (increased fat around the waist)
  • age 40 or over
  • history of gestational diabetes (diabetes during pregnancy)
  • high blood pressure
  • high cholesterol
  • schizophrenia
  • polycystic ovary syndrome
  • member of high-risk populations (Aboriginal, Hispanic, South Asian, Asian or African descent)

The cause for developing Type 1 diabetes is unknown. There may be a genetic link and/or an environmental trigger. People are usually diagnosed with Type 1 diabetes before the age of 30, most often during childhood or in the teenage years.

 


Q: What role does stress play in diabetes?

A: Chronic stress created from our busy lifestyle can increase the risk of developing diabetes and can worsen the diabetic conditions of people with diabetes. Our fast-pasted lifestyles – from our daily commute, continuous commitment to the computer and cell phones to other daily work, family and social responsibilities – can easily take over our time and our physical and emotional resources. These stressors therefore drain our resources which then contribute to increasing our blood sugar levels. 

When we are facing a stressful situation beyond our control, the brain releases two hormones: cortisol and adrenalin. These hormones raise blood sugar levels to help increase energy so we are able to react to danger or to a life-threatening challenge. This allows us to engage in our fight-or-flight response. If our blood sugar levels remained low we would not have the energy to react to the danger. When the brain is constantly bombarded with a daily onslaught of overwhelming stressful situations, it begins to pump out these hormones in excess, throwing off the body’s other systems and causing an increased risk for illness.

It has been shown through research that high levels of cortisol and adrenalin change the way the body stores fat, leading to higher rates of obesity, which is linked to increased in insulin resistance and increased blood sugar levels, which results in diabetes.

To curb the increase in blood sugar levels, individuals needs to know their early signs of too much stress and learn how to cope with their stressors. Early signs of too much stress can be felt physically, psychologically and behaviourally. Physically, people may experience fatigue, muscle tension, headaches and/or insomnia. Psychological signs are short temper, feeling worried and/or making poor decisions.

Behaviourally, signs of too much stress include compulsive eating, drinking to excess, smoking, blaming others and/or being argumentative.

Learning how to cope with stressors is a key component to lowering blood sugar levels. There are several strategies, including listening to your body and acknowledging the stressful triggers. By acknowledging them, one can then either avoid a stressful situation and/or learn how to relax, and breathe through the tension. This process is part of a program referred to as Mindfulness Based Stress Reduction. Exercise, participating in yoga, tai chi and pilates classes, as well as positive affirmations can also be helpful. Talking to a supportive friend and/or attending therapeutic sessions with a trained mental-health therapist or the social worker at Tridec are other methods of coping with stressors. Finally, one key stress-reduction tool is to take care of oneself. Self care is very important.

Stress can continue to play a role after being diagnosed with diabetes, and can negatively affect individuals with diabetes. By coping with one’s stressors the person better able to control over blood sugars and improve her way of life.

 

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