Managing Diabetes

Diabetes Self-Management Education and Support
Weight Watching and Nutrition
Guidelines for a Healthy Diet
The New Food Pyramid
Exercise
Exercising with Diabetes
Diabetic Emergencies
Treating Hypoglycemia
Treating Hyperglycemia

Managing diabetes requires consistent, responsible self-care. Many people with diabetes have lived a long time by taking proper care of themselves—eating right, monitoring their blood glucose faithfully, and exercising consistently. One is Gladys Dull, now in her nineties, who has outlived her four nondiabetic siblings, according to diabetes expert Sheri Colberg. She became friends with Gladys during interviews for her book 50 Secrets for the Longest Living People with Diabetes. Robert and Gerald Cleveland, brothers who are both around age ninety, have also lived longer than their younger brother, says Colberg, and one of them still often goes for 20-mile bike rides (32km). Like Gladys and the Clevelands, many of the other people Colberg interviewed for the book showed her that “attention to health and lifestyle has a positive effect.”¹⁷ In other words, living well with diabetes is all about self-management.

Colberg knows how true that is. She has had type 1 diabetes since she was four. It has complicated her life, but she also has a fulfilling, productive life. At age forty-four she is an author, lecturer, professor, exercise physiologist, and expert on exercise and diabetes. She is also a mother, wife, and enthusiastic exerciser. Even with diabetes, “the world is still open to you,” she says. “But it is work, and you have to be aware and plan

ahead, like taking your blood glucose meter and medications along wherever you go.”¹⁸

Diabetes management has several key components: weight, nutrition, exercise, and adequate sleep. But the first important task is to learn about Diabetes Self-Management Education and Support.

Diabetes Self-Management Education and Support

Once Colberg was old enough to understand her diabetes, she was afraid she would die at a young age from its complications—that is what the medical literature of the 1970s and 1980s told her. Today, those fears are gone. New research has brightened the picture and vastly improved the lives of people with diabetes, yet this diagnosis is still frightening and confusing. Diabetes is a serious, chronic disease that can lead to terrible complications. Therefore, it is important that newly diagnosed people be educated about diabetes self-management. Ideally, this program is presented by their health care teams, and many resources are also available elsewhere from books, the Internet, and support groups.

The main focus of Diabetes Self-Management Education (DSME) is giving people the facts and training needed to maintain physical health. This lifesaving program teaches patients how to check their blood sugar, how to eat and when, how to inject themselves with insulin, how to recognize and treat low and high blood sugar, and where to buy diabetes medications and supplies and how to store them. Often, the family is involved, as was the case with Alyssa Brandenstein and Nick Jonas. This way, they can support their loved one in the crucial task of managing diabetes.

However, once the initial education is done, people with diabetes may find it difficult to continue doing what must be done for their lifetimes. They can get discouraged or tired of having to check their blood sugar or watch what they eat. As Colberg found out in her own life, often “the problem is not so much the physical issues as the emotional ones. Diabetes crosses the physical body, the psyche, everything.”¹⁹

In light of this, an additional program can give ongoing support to people with diabetes. It is called Diabetes Self-Management Support (DSMS). In this approach, people with diabetes work with their health care team and often with a support group of other people with diabetes to become more self-reliant in managing their illness. Rather than feeling overwhelmed by their disease, DSMS can help them feel more empowered to handle it safely and well. They learn together how to solve problems they face with their illness and receive support from others who understand. In addition, they are more likely to eat right more often, create better exercise habits, and set goals for themselves, such as exercising and eating correctly, that keep them feeling better physically and emotionally. Family workshops or camps for kids with diabetes are helpful for this kind of support.

Weight Watching and Nutrition

Fat helps cause diabetes because too much of it interferes with the way insulin operates in the body. This is especially true for “apple-shaped” people who carry most of their weight around the abdomen, but people who are “pear-shaped,” with their weight around their hips, are also at risk. However, once diabetes develops, even a modest weight loss can help to control it.

People with diabetes need a plan that lets them safely choose the right amounts and kinds of food. By using sound guidelines to plan their meals and snacks, based on their own lives and activities, they will better control their blood glucose. In addition to helping them lose pounds or maintain a healthy weight, an eating plan keeps their food balanced with insulin and other medications.

Skipping Insulin for Weight Loss Can Be Deadly

A deadly trend has developed among some girls and youngwomen with type 1 diabetes: They skip insulin to lose weight. However, the results of this foolhardy practice can be life-threatening.

The first effects of insulin skipping can be nausea, depression, and exhaustion that become worse over time. One young diabetic patient went blind and another suffered kidney failure as a result of avoiding their insulin. Other complications, including coma and death, can result.

This behavior is common among diabetic teen girls and young women with an eating disorder called bulimia. Usually, people with bulimia repeatedly eat huge amounts of food and then force themselves to vomit. However, diabetic girls who do not take enough insulin can eat anything they want and still lose pounds without throwing up. Doctors have begun calling them “diabulimics” and say that this behavior affects approximately one-third of all diabetic young women.

Sadly, many girls and women who forgo their insulin in order to stay thin will have shorter life spans because of the terrible stress this puts on the body.

A healthy meal plan takes into account the person's likes and dislikes and food allergies. Creating a meal plan is best done with a dietitian's help. Dietitians are experts in nutrition

and healthy eating. They define a healthy diet as one that includes a variety of foods from all the food groups, is high in vitamins and minerals, high in fiber, and low in processed foods. In addition, a healthy diet reduces the risk of illnesses such as diabetes, heart problems, cancer, and stroke. So, a diet that is healthy for people with diabetes is healthy for anyone. With proper planning and attention to portion size, people with diabetes can eat the same healthy and delicious foods their families do.

Guidelines for a Healthy Diet

The 2005 Dietary Guidelines from the U.S. Department of Agriculture, sometimes called the new “food pyramid,” contain the latest scientific understanding of nutrition. People with diabetes can use the food pyramid to create a well-balanced and nutritious eating plan.

These guidelines are based on science, and they recognize that all people have their own food needs according to their age and level of activity. For instance, a grown man who works in an office and does not exercise needs less food than another man who is a marathon runner. A teenage girl needs a different amount of food and nutrients than her younger brother. Women in their thirties have different nutritional needs than women in their seventies. All of these things are true whether or not someone is diabetic, but diabetes requires more attention to the details of eating.

The New Food Pyramid

The new food pyramid at www.mypyramid.gov breaks down foods into six groups: grains, vegetables, fruits, milk, meat and beans, and oils. Each group has foods that are better than others. For instance, whole grain bread is better than highly processed white bread. Oatmeal is better than sugary cereals. Whole fruit is better than juice.

In order of largest to smallest amounts that should be eaten daily, here are the food groups:

• Grains—Half the grains eaten daily should be whole grains. Eat at least three ounces of whole grain bread, cereal, crackers, rice, or pasta every day.
• Vegetables—Eat a variety of veggies in lots of colors for the most benefit, and eat more dried beans and peas.
• Fruits—Eat a variety, whether fresh, frozen, canned, or dried. Keep fruit juice to a minimum.
• Milk—Dairy products are important for calcium, which keeps bones strong, and other nutrients. Choose low-fat or fat-free milk, cheese, and yogurt. Other good sources
  
  of calcium are tofu, some dark green vegetables like broccoli, and calcium-enriched cereals and juices.
• Meat and beans—For lean protein, beans are unsur-passed. Choose lean meats and poultry. The best choice is a variety of fish, beans, peas, nuts, and seeds.
• Oils—Most fat should be from fish, nuts, and vegetable oils. Limit solid fats like butter, stick margarine, shortening, and lard. Avoid trans fats, which are fats manufactured by adding hydrogen to oils to make them solid. Look for the words “hydrogenated” or “partially hydrogenated” on the label. Trans fats are also a big contributor to heart disease.

Eating the right amounts of food is also important. Too many calories mean weight gain. Underestimating the number of calories in food is easy to do, particularly today when portion sizes have grown so large. Learning to closely estimate the correct portion size can be a great help in losing or maintaining weight as well as controlling blood sugar. For instance, the healthy adult portion for a steak is 3 ounces (0.1kg), or about the size of a deck of cards. One cup of salad greens is similar in size to a baseball. A half-cup serving of ice cream is the size of half a baseball.

One of the reasons Gladys Dull has done so well controlling her diabetes for many decades is because her mother helped her learn the correct portion sizes of the foods she ate. This is a skill that can be mastered, and one that is tremendously helpful for anyone wanting to maintain a healthy weight for a lifetime.

For people with diabetes, eating at the right times and coordinating insulin injections with food is also necessary. In general, they should eat the same amounts of food at the same times every day whenever possible. Since blood sugar is usually lowest upon waking up, eating a good breakfast after checking blood sugar levels is important.

People with type 1 diabetes should not skip meals because they always have insulin, which they have injected, in their bloodstream. Along with meals at regular times, a snack in

Native Americans Returning to Traditional Diet to Combat Diabetes

Native Americans have the highest rates of diabetes in the United States. To become healthy again, many tribes are returning to eating their traditional diets instead of the highly processed foods many of their people eat.

The Oneida Nation, near Green Bay, Wisconsin, has created an organic farm, orchards with thirty-seven varieties of apples, and a cannery. They began raising a herd of buffalo for their meat, which is leaner and healthier than beef.

The Oneida Indian Nation Health Department also began the “Three Sisters Nutrition Project” to improve the health of all Native Americans living in central New York. The Three Sisters are squash, beans, and corn—traditional foods in this region that the Native Americans there consider life-sustaining gifts. When planted together, these three crops also help improve and renew the soil they are grown in, which is another advantage of raising them.

midmorning and midafternoon is a good idea. A bedtime snack can also help regulate glucose levels through the night. Weight control might be more of an issue for people with type 2 diabetes, since most of them are overweight. Even a small weight loss of 10 percent of body weight can play a large role in reducing heart disease.

Exercise

Exercise is important for everyone. But for people with diabetes, it is one of the best ways to manage their illness, even for thin diabetics who tend to be less active. Humans have muscles for a reason—they were meant to use them in active ways. Regular exercise improves glucose tolerance (so blood sugar can be controlled better with less medication) and lowers cholesterol and blood pressure. It reduces the risk of life-threatening complications of diabetes. It reduces stress. It strengthens muscles, bones, and the heart, and it keeps joints flexible. It can also help people feel happier and more energetic because it causes the brain to produce natural “feel good” chemicals called endorphins.

However, people do not have to run marathons or ride a bike for hours to get enough exercise. Lots of little activities can add up to big benefits as well. For example, take the stairs or choose a parking space farther from the door to the mall or school. Vacuum the house, garden or mow the lawn, wash the car, walk the dog—they all count as physical activity, especially if done vigorously. All it takes is a minimum of thirty minutes daily, all at once or in two or three parts.

People who have been inactive for a long time should see a doctor first and get an OK to exercise. They should explain what kinds of exercise or activities they want to try. Some might be off-limits because of diabetes. For instance, for people with diabetes who have numbness or less sensation in their feet, swimming or biking might be better than walking or running. For a person with abnormal growth of blood vessels in the retina, called diabetic retinopathy, strenuous activity might cause bleeding in the eye or cause the retina to detach, which is a very dangerous condition. A softer kind of exercise would be better.

Both aerobic exercise and strength training are beneficial to people with diabetes (and to everyone else). Aerobic means “with oxygen,” so aerobic exercises such as walking, swimming, or biking at a faster than normal pace get the heart pumping and oxygen flowing through the body to burn calories. Strength training with weights—even small ones—builds muscles, and bigger muscles burn more fat faster.

In any case, people are more likely to continue exercising if they enjoy it. They should also seek out a qualified exercise specialist for learning how to lift weights, use exercise equipment, or do other unfamiliar activities.

Also important is to check with a doctor about the best times to exercise. People who take insulin might need to adjust their doses or wait a while after injecting their insulin before exercising.

Exercising with Diabetes

In general, the best time to exercise is when glucose peaks, about sixty to ninety minutes after eating. This timing provides enough energy, allows calories to be burned, and avoids high blood sugar after eating. Also important is to learn how to determine the right insulin dosages before, during, and after exercise. Why? Too much insulin before a workout can lead to too-low blood sugar, or hypoglycemia, while not enough insulin can cause too-high blood sugar, or hyperglycemia. Stress and heat can affect the blood glucose/insulin balance, so these factors must also be taken into account.

A good idea is to have some carbohydrates available during exercise in case blood sugar needs to be raised quickly. Eating carbohydrates helps to prevent hypoglycemia. And exercising with a partner who knows what to do in case of a diabetic emergency can add a safety factor as well as make exercise more fun.

Diabetic Emergencies

Emergencies related to diabetes will happen to all people with the illness. People who have a hard time controlling their diabetes will have them more frequently than those whose diabetes

is under better control, but even those people will have one from time to time. These medical emergencies are impossible to predict, and they can be deadly. A diabetic emergency occurs when glucose levels are either too low (hypoglycemia) or too high (hyperglycemia). The best way to prevent or minimize these situations is to know what a diabetic emergency is, know how to handle it, and do everything possible to avoid it.

One common reason for diabetic emergencies is that even with the best glucose monitoring, the same dosage of insulin can have varying effects at different times. The effect depends on the kinds and amounts of food eaten, the amount of exercise and stress, and how healthy the person is.

People with type 1 more often have swings in blood glucose than people with type 2, and so may experience more emergency situations. Hypoglycemia is the most common

emergency condition for people with type 1, who take insulin or medications that lower blood glucose. In people who do not have diabetes, the body naturally stops releasing insulin before blood glucose falls too low. But once insulin is injected, its action cannot be stopped. If hypoglycemia continues too long, the person could have seizures, lose consciousness, or die.

Treating Hypoglycemia

Having help available when needed is important. The person's family members, coworkers, or other trusted people should learn to recognize the symptoms of hypoglycemia and know how to treat it if necessary. Symptoms of hypoglycemia are dizziness, sweating, feeling shaky or faint, clamminess, rapid heartbeat, clumsiness, moodiness, and extreme hunger. However, each person should know his or her own particular symptoms since everyone reacts differently.

Some people eventually lose their ability to realize they are hypoglycemic. If they miss the early signs, fuzzy thinking may be the first symptom, which means they will not know how to help themselves. It is recommended that these people test blood glucose more frequently and test it before driving, wear a diabetes ID bracelet, and keep a prescription for glucagon nearby. Glucagon is a hormone that, when injected, causes the liver to release glucose, and it also slows insulin release. People with type 1 must know how to inject it and also should train someone, such as a family member or coworker, to inject it in case they are unable to do so.

In a case of severe hypoglycemia, the person must immediately eat or drink a small amount of a carbohydrate that the digestive system can quickly pick up from the bloodstream. Glucose tablets or gel from the pharmacy work well, as do raisins, regular soda, orange juice, honey, or jelly beans. These sugars should be kept at home, school, and work, in a purse or pocket, and in the car. About fifteen minutes after taking one, blood sugar should be checked. If it is still too low, another small dose of carbohydrate should be taken or a meal eaten.

Treating Hyperglycemia

The other diabetic emergency is hyperglycemia, or too much blood sugar. It is unpredictable, possibly deadly, and happens from time to time to all people with diabetes. This is more rare than hypoglycemia but still very dangerous. People with types 1 and 2 can suffer from it but react differently.

In type 1, diabetic ketoacidosis (DKA) occurs when people do not get enough insulin. The body believes it is starving and breaks down fat to get energy. This causes ketones to form in the blood, and if the body cannot release them through urine, they build up and poison the body. The body also becomes dehydrated because of frequent urination, which only increases the concentration of ketones. As ketones build up to dangerous levels, coma, shock, difficulty breathing, and death can result.

Symptoms usually come on slowly. The major DKA symptoms are dry mouth, terrible thirst, and frequent urination. Others include little appetite, blurry vision, vomiting or feeling sick to the stomach, fever, weakness, sleepiness, and fruity odor on the breath.

Someone who is hyperglycemic must have an injection of quick-acting insulin and drink lots of sugar-free liquids. If the condition does not improve rapidly, the person must seek emergency medical help. Sometimes, people who do not yet know they have type 2 diabetes can develop hyperglycemia. They and people already diagnosed with type 2 who experience this condition can have it for a long time without realizing it. Their glucose level can zoom to extremely high levels, which can lead to coma and death.

Hyperglycemia leads to a condition called HHS. It can happen to people who do not use insulin but take oral medicines. HHS symptoms are sleepiness or mental confusion, extreme thirst, no sweating, and warm skin. Also, the person will have high blood glucose levels. Seeking medical help is important when blood sugar levels are extremely high. The best way to avoid HHS is to check glucose levels at least once a day.

Managing diabetes is complicated and time-consuming, but it is necessary in order to avoid the terrible complications that

an happen as a result of having this illness. Careful management includes blood glucose monitoring, insulin and sometimes other drugs, regular exercise, and a healthy diet. In addition, studies have shown that laughter and a positive attitude are good medicine for diabetes. Laughter has been found to lower glucose levels after eating. It also produces chemicals in the body that make people feel better in general, which helps make daily life easier and more pleasant.