The stories I've heard and the questions people ask during education sessions are the inspiration for my blog posts. I know for sure that I have learned as much or more than I've taught over the years.
This is probably the most asked question I get from a person with diabetes. Or more likely it comes as the statement “I am going to get off these medicines”.
I get it- nobody wants to be reliant on a medicine for the rest of her life. And if there is something that can be done to avoid it, we all want to know what that is.
The trouble is, the answer to that question depends on a lot of things. Of course, diet and exercise are going to play a part, but there are a few other things that are just as (if not more) important predictors of a person’s need for diabetes medicines. Things like
-how much diabetes is in the family,
-how advanced your diabetes was when it was found
-how long you’ve had diabetes.
A family history of diabetes is the first strike against you. You have this strike the minute you’re born and there isn’t a thing you can do to change it- we don’t get to pick our parents! If you’re born into a family with diabetes, chances are you inherited traits that make it difficult for your body to clear sugar from the blood. And if that’s the case you may need medicine to help you do that. You should know though that having a family history of diabetes doesn’t make it certain you will develop it too.
Type 2 Diabetes is a progressive disease. It starts as pre-diabetes where the beta cells that release the insulin needed to keep sugar cleared from the blood are struggling to keep up with the sugar demand. (See pre-diabetes) These beta cells are in trouble and are wearing themselves out trying to keep sugar in the blood at a healthy level. It’s estimated that by the time most people find out they have diabetes they have already lost half of their ability to make insulin- the beta cells have worn themselves half out! But this didn’t happen overnight. Many people are in the pre-diabetes state for as long as 15 years and don’t have a clue. If your diabetes was caught early- in the pre-diabetes state- and you were able to make changes that lightened the load on your beta cells, chances are you can make it a while without the help of medicine. But if your diabetes was not caught in the pre-diabetes state it’s possible that your beta cells have been damaged to the point that you will need help from medicines to make what insulin you are still making work better.
For the same reason, if you’ve had diabetes for several years (especially if it was uncontrolled) it is more likely that your beta cells have fought all they can fight and you’ll require medicine or maybe even insulin if you’ve progressed to the point of not making much.
I often use the phrase “3 strikes and you’re out” to describe the “why” of diabetes. The first strike is a family history. The second strike is being overweight- carrying around extra weight makes it harder for insulin to do its job of clearing sugar and this adds to the load on the beta cells. And the third strike is not being active enough. Regular activity burns the sugar trying to build up in the blood. If you get to a point in your life where you’re not active enough, the beta cells have to take on the load of burning this sugar. If you have a family history, you are overweight and you aren’t active, chances are very good that you will develop diabetes. We can’t choose our parents but we can choose to strive for a healthy weight and to move as much as possible and that could possibly be enough to avoid medications.
Some people have more room for improvement in the area of lifestyle changes than others. For example, a person who drinks sweet drinks throughout the day, eats a good deal of high calorie/low nutrient foods, and has a sedentary lifestyle can make good progress towards blood sugar control with lifestyle changes and might be able to avoid medications. But someone who already watches her diet decently well and tries to stay active may have to take the next step to medication to get control.
We all want the best control on the least amount of medicines. Medicines come with side effects and cost but I invite you to think about their benefits also. Remember those beta cells struggling to make enough insulin to keep sugar cleared from the blood? Some medicines can make your body respond better to your own insulin (improve insulin resistance), and cut down on the extra sugar your body naturally releases- both issues that start in pre-diabetes. These medicines actually lighten the load on those tired and weary cells and could help prolong their lifespan if taken in time. This could be just the thing a person with a family history of diabetes needs to give his beta cells a fighting chance of living out the remainder of his life and avoid having to take insulin from an outside source.
It’s estimated that less than half of prescriptions for diabetes medicines are filled and taken as they were prescribed. This may be why only about a third of people with diabetes are adequately controlled. Every medicine has pros and cons and it’s important to discuss those with your provider and make an informed decision. The pro just may be worth the con!
When I was working on my dietetics degree in the mid 90s, the Diabetes Exchange List was the recommended meal planning program for people with diabetes. I remember sitting through a day long class on how to use and teach the Diabetes Exchange Lists for Meal Planning and thinking “no wonder diabetes nutrition is such a thorn in everyone’s side”.
If you’re not familiar with it, the American Diabetes Association's Exchange Lists for Meal Planning groups together foods according to their common nutritional content based on calories, carbohydrate, protein, and fat (food groups). Patients are given a certain number of exchanges from each of the groups for each meal or snack based on their needs. Sounds good right? In a perfect world yes. But in a world of busy schedules, food preferences, food availability issues, and grocery budgets it is very difficult to implement. I’ve come across a few people in my career who have used it well- but very few. The “why” of the Exchange Lists is good- proper nutrition spread out throughout the day. But the idea that you must include something from each food group in EVERY meal is unrealistic, and I think unnecessarily burdensome. Who has time for that?
While I was still in school, I shadowed a hospital dietitian to get experience in the field. One day there was a patient in the hospital with diabetes and the provider ordered education. My mentoring dietitian handed me a copy of the Exchange Lists and sent me in to do the education. I’m not sure how the patient felt about the experience, but it felt like a disaster to me. Number one- inpatient hospital settings are THE WORST place to do education. Patients are sick- that’s why they’re there- not a good state to be in for learning. I think in-depth education is best saved for the outpatient setting and education in the hospital should cover only the basics. The patient I attempted to educate that day was a middle-aged male with lots of health issues. And using the Exchange Lists required brain power neither of us had at the time. I’m pretty sure my visit was a waste of this man's time. But it was very valuable to me! I came away thinking “there has to be a better way- I will never educate that way again”.
I did find a better way and 25 years later my approach includes “proper nutrition spread out throughout the day”- the “why” of the Diabetes Exchange Lists- in a simplified “how”. The people with diabetes I’ve worked with over the years have taught me the best eating plan is one that makes sense, includes foods they like, and is easy to implement. And the goal of a diabetes nutrition plan is threefold it (1) Contributes to good blood sugar control (2) Provides adequate nutrients for energy, disease prevention, and healing and (3) Is appropriate in quantity to maintain a healthy weight. These are lofty goals!
Carbohydrate foods have the biggest impact on blood sugars after meals. That doesn’t mean carbohydrates are bad as some popular diets would have us believe. Carbohydrates are our bodies’ most efficient fuel source, some of our most nutritious foods are carbohydrate foods, and some of our most loved foods are carbohydrate foods. Energy, nutrients, and love are all very good! For this reason, I like the recommendation that ½ of a person’s calories should come from carbohydrates but those carbohydrates should be of the highest quality possible (most of the time) and spread out throughout the day. So, I recommend a budget for carbohydrates at meals and snacks based on the person’s needs.
Adequate nutrients come from eating a variety of foods. Our bodies use hundreds of nutrients to get us through a typical day. Not to mention the nutrients needed to ward off heart disease and heal wounds- very important for people with diabetes! These nutrients are provided by a variety of foods- foods from all the food groups- and are stored in our bodies. Typical dieting restricts too many foods that help fill our nutrient stores. For this reason, I teach eating a variety of foods from all the food groups but realize that it won’t come perfectly from all the food groups every meal as the Exchange Lists recommend. Our bodies are amazing at adapting- storing, and using nutrients according to supply. Often if we’re craving a particular food it’s because our stores are running low of the nutrients that food provides. So, if we lack a few servings from one group at one meal, hopefully we’ll make up for it in the next meal or next day. The average nutrient intake over a few weeks is really the best indicator of healthy nutrient stores. If we’re focusing on most of our intake coming from healthy food choices, there’s no need to stress over each meal being a perfect representation of each group.
Appropriate quantity is the tricky part because that is different for everyone every day. Larger, more active people generally need a higher quantity of food than smaller, less active people- but that varies too. The good news is, our bodies are made to know exactly how much we need if we’ll listen. So many are caught up in using a list of arbitrary rules (diets) and have drowned out their body’s hunger cues to what and how much it needs. I teach eat before you get too hungry because it’s hard to watch your portions if you’re too hungry and being too hungry all the time is almost guaranteed to cause you to binge. But also stop eating before you get too full because that uncomfortable feeling means you’ve gone past the amount needed to maintain a healthy weight. In other words, listen and trust your body not some piece of paper telling you what and how much you should eat today!
The ADA no longer lists the Exchange Lists under nutrition recommendations and instead now recommends an individualized approach to meal planning for patients with diabetes under the care of a Registered Dietitian 2019 ADA Consensus Report on Nutrition. We don’t want to throw the baby out with the bath water so the approach I take implements the good parts of the Diabetes Exchange Lists for Meal Planning in a simpler way.
I think back to that patient I tried to educate in the hospital some 25 years ago and wish I could have a do-over. I wonder how things turned out for him and hope and pray that he found someone who could explain it better for him than I did. I thank him for the lesson he taught me that day. I think it’s helped many people over the years!
For more information about Nutrition classes I offer, click on services.
I have a friend who approached me with this question. Her husband Jack had been for a yearly physical. He came home and reported that everything was good but his blood sugar was “slightly high.” When my friend inquired how high, Jack responded “the Dr said it was no big deal.” Jack was definitely trying to downplay the problem.
My response to her question was a definite YES! It is a huge deal! Blood sugar high enough to be considered pre-diabetes is a warning sign, a cry for help from the beta cells that make insulin. If we catch problems in the pre-diabetes state and take care of them, we can eradicate Type 2 diabetes. It’s the closest thing we have to a cure!
Type 2 Diabetes is a progressive disease. It starts with the body being resistant to insulin (the hormone that clears sugar from the blood). Insulin resistance correlates with a variety of things like being overweight, not being active enough, smoking, genetics, aging, ethnicity, some medications, and sleep problems. If any of these issues cause the body not to use insulin well, it causes an overworking of the beta cells that produce insulin and can lead them to fail. If the beta cells fail completely, insulin from an outside source (injections) will be needed to keep blood sugar at a healthy level. The progression is a gradual death of the beta cells. If we find Pre-Diabetes we might be able to “Save the Beta Cells”!
The CDC says one out of three people have pre-diabetes and 90% of them don’t have a clue! Sometimes there are red flags that the body is struggling to clear sugar like high blood pressure, high triglycerides, and weight gain around the waist. But usually there aren’t obvious symptoms. For that reason, the American Diabetes Association (ADA) recommends testing everyone over 45 years old for pre-diabetes. They also recommend testing anyone under 45 who is overweight with an additional risk factor like family history, cardiovascular or polycystic ovary disease, or Latino, Native American, Asian, or African ethnicity.
So many times, when I have a group diabetes education class, there will be a patient who says “I’m just pre-diabetic”. I quickly tell them they are the most important person in the room. They are at a point in the diabetes progression where they have the most control over how things turn out. So many times, the issues are missed at this stage and the beta cell failure progresses to a point where it takes more than diet and exercise to gain control of the blood sugars. I have so many others in my classes who tell me they were diagnosed with pre-diabetes years back but nothing was ever done about it and now they are on insulin. This makes me sad and a little angry!
I met with Jack and told him about the progression of diabetes. We talked about his family history, his usual day’s food intake and activity, and the medications he takes. It turned out Jack had many of the causes of insulin resistance previously stated. He had a family history, he had a sedentary job and got little exercise, and he was on a mood- altering medication that was causing weight gain. This medicine was greatly improving his quality of life and he had no intention of stopping it. So, we talked about the lifestyle changes that could help lighten the load on his beta cells. We discussed ideas for increasing his activity and spreading his carbohydrate intake out throughout the day. And we talked about testing his blood glucose periodically to make sure it was remaining in goal.
Last I heard Jack is still trucking along with no diagnosis of diabetes. I’m sure his provider is keeping a close eye on his blood sugar. If you have been told you have pre-diabetes, “borderline diabetes”, or the sugars are running “slightly high”, take it seriously. There is no guarantee you can prevent Type 2 Diabetes but at least you can give it your best shot-wait and see should never be the plan. Small changes now could prevent big changes in the future. It is a very big deal! pre-diabetes.docx
I remember vividly my first encounter with diabetes. I was walking through the kitchen of the busy home I grew up in in small town Arkansas. And out of the corner of my eye I see my Aunt Jo, who was visiting from up north, fiddling with something strange. I stopped to see and was intrigued as I watched her pull out a syringe, and a bottle of clear liquid and inject herself.
My mom’s sister Aunt Jo was a special person. She was loud and boisterous- unlike myself- and she was fun. Things always seemed a little more exciting when she and uncle Bugs were around. They had three children of their own who are a bit older than me and my six siblings and they would make the trip down south usually once or twice a year to visit us and Grandma- mom and Aunt Jo’s mother.
I knew nothing about diabetes and later asked my mom about the strange “shot” Aunt Jo had given herself. My mom then told me that Aunt Jo had diabetes and had to take insulin. She went on to say that Aunt Jo wouldn’t have to do that “if she would just eat right”. As a child of probably ten, this statement did not sit well with me. I remember thinking “What does “eat right” mean?...there has to be more to it than that…Aunt Jo ate the same thing we all ate for breakfast- the family favorite strawberries and pancakes…is she not supposed to eat that?…what can she eat?...how does she know?...is there someone who teaches her how to eat?” This would later be the motivation for my career as a Registered Dietitian.
After spending half of my life as a Registered Dietitian and Certified Diabetes Educator the statement “if she/he would just eat right” still doesn’t sit well with me. I hear it sometimes from loving family members of someone with diabetes. Sometimes I hear it from well-meaning doctors and nurses, and I often hear it from the patients themselves. I definitely now know there is so much more to diabetes control than “just eating right”. Food plays a big part- don’t get me wrong- but there is oh so much more...
Like… at diagnosis with Type 2 diabetes most people are only making about half of the insulin (the hormone responsible for clearing sugar from the blood) that a person without diabetes makes. And a person with Type 1 diabetes is usually making close to none. So even if that person ate perfectly (whatever that is) they most likely would still need help from meds or insulins to clear sugar that our bodies just naturally produce.
Like… “eating right” is different for everybody. For some it is eating the family favorites (pancakes and strawberries) especially on special occasions because that makes them feel love. For some it is not going back for seconds at supper. For another it might be sharing in a special celebratory event with a piece of cake (birthday, wedding). All of these things are right. What is not right are the feelings of deprivation, guilt, and excruciating hunger so many think are necessary for blood sugar control. And it is not right to leave out foods or food groups that help heal and protect our bodies from the complications that often accompany diabetes.
In my mind “eating right” means you are nourishing your body and your soul with a variety of nutrients, in the right amount, at the right time. It does not mean leaving out all the foods you love or choking down foods you hate. I believe there is room for every food in the life of a person with diabetes- there is no one food that is so bad that you can never have another bite of it again.
Having said that, many of us could benefit from putting a little more thought into our food choices and portion sizes. And I encourage anyone dealing with diabetes to get education from a Registered Dietitian who is a Certified Diabetes Educator to learn how to do just that. With proper education you can be the judge of what “eating right” means to you. I hope and pray it means changes that you can make while continuing to enjoy your life. Good blood sugar control is a balance of activity, good nutrition, and usually medications. There are no extra points for doing it all with diet. Especially if being overly restrictive with food is interfering with quality of life. If a person has diabetes, being in control is the thing that matters most, how they get there is not.
It turns out that Aunt Jo had developed Gestational Diabetes during her last pregnancy which left her at double risk for developing Type 2 diabetes, and she eventually did. She went on to live her joy filled boisterous life more than 50 years after being diagnosed and I have many fond memories with her. I think she figured out what “eating right” meant to her.