You've asked and we've answered your questions about managing diabetes in the following categories:
Diet and nutrition
I have been trying to eat better to manage my diabetes. Now that I know my risk for cardiovascular disease, I realize I have to eat better for my heart, too. As a person with diabetes, am I supposed to watch my calories, fat or carbohydrates?
Lori Wolf, R.D./L.D., patient education advisor for the American Heart Association in Dallas, Texas, explains:
Diabetes increases the risk for cardiovascular disease (CVD), and dietary intervention has been proven to help lower that risk. Following recommendations from the American Heart Association is heart healthy. Since diabetes is a major risk factor for CVD, you should protect your heart with diet and physical activity (as your healthcare provider allows).
To manage your diabetes, it's important to monitor calories, fat and carbohydrates. On a diabetic meal plan, your caloric intake should remain about the same from day to day. That's because the meal plan is designed around a total caloric level. Your healthcare provider set your level to support optimal blood sugar control and to allow gradual weight loss or weight maintenance, depending on your need. That's why it's imperative that you comply with the recommended calorie levels.
Fat is an important nutrient in the diet, so don't exclude it. To manage your diabetes to protect your heart, it helps to know about saturated, unsaturated and trans fats.
- Saturated fats are usually solid at room temperature and come from animal products such as meats, cheese, eggs, milk products and butter. They are also found in tropical oils such as coconut and palm oils. Saturated fats increase CVD risk by increasing the bad cholesterol (LDL) . To protect against CVD, you should limit these fats to less than 5-6 percent of calories in your diet.
- Unsaturated fats are liquid at room temperature and come from vegetable sources such as canola oil and olive oil. They also can be found in soft tub or liquid margarine. These fats protect your heart's health by lowering the bad cholesterol, so most of your daily fat should come from unsaturated fats. And you should use these oils to substitute for saturated fat choices, not in addition to them.
- Trans fats are created in an industrial process that adds hydrogen to liquid vegetable oils to make them more solid. Another name for trans fats is "partially hydrogenated oils." Look for them on the ingredient list on food packages. Trans fats raise your bad (LDL) cholesterol levels and lower your good (HDL) cholesterol levels. You should limit your diet to less than 1 percent of your total daily calories. To manage diabetes and decrease CVD risk, it's best to increase unsaturated fats and decrease saturated fat and trans fat.
Carbohydrates should be the main focus of your daily efforts to control your blood sugar and thus your diabetes. Carbohydrates are completely digested and put into your bloodstream in the form of sugar within two hours of eating them. (This is one of the reasons it's important to test your blood sugar two hours after a meal to monitor how your body handled the amount of carbohydrates you just ate and to design the perfect plan for your body.) To successfully manage diabetes, consistency is the key with carbohydrates. Typically, eating the same amount of carbohydrates at each meal at the same time every day is a great formula for stabilizing blood sugar levels according to the caloric level of your meal plan. Some people are more sensitive because of medications and/or activity levels. They will need more specific monitoring of their meals and carbohydrate intake with a dietitian's help.
First, there was the South Beach Diet, then the Grapefruit Diet, then the Atkins Diet. Do any of these — and other fad diets — work for someone with diabetes? What's the best way to lose weight?
John Crouse, M.D. explains:
First, I do not like the word "diet" as it is commonly used. Instead, think "lifestyle change," because when you stop using a diet, you go back to where you were before you began the diet.
There's nothing magical about any of these fad diets. They're quick fixes. All of them will help you lose weight as long as you eat fewer calories than you expend. A lot of these diets replace something you eat with something else. So, going on these diets is the wrong approach to take.
If, as a person with diabetes, you want to get your weight under control, make major behavior changes. I recommend you join Weight Watchers because it will put you into a lifestyle change mode. Think of diet in the context of "eat less, move more." You must work on both sides of the equation: how many calories you consume (diet) and how many calories you expend (exercise).
There's a difference between diets that help you lose weight and diets that can help you lower both blood cholesterol and body weight. For example, the diet that lowers blood cholesterol is low in saturated fat and cholesterol and has the right amount of calories for you. A diet that fosters weight loss only, such as some of the fad diets, can cause weight loss temporarily but may not help with glucose control or maintaining weight loss. In fact, a good diet — that is, a healthy lifestyle — causes weight loss and will improve blood sugar control, lower blood pressure and lower blood cholesterol.
So remember, it's not about diet — it's about behavior change.
I have heard that drinking a glass of wine a day is good for the heart. Is this true if you have diabetes? Are the benefits of alcohol limited to wine, or can I drink other types of alcohol? Can alcohol have an adverse effect on my blood sugar levels?
Prakash Deedwania, chief of the cardiology division and professor of medicine at the University of California School of Medicine in San Francisco, Calif., explains:
Drinking a glass of wine is good for the heart in the sense that the main mechanism by which alcohol protects the heart is increasing good cholesterol (HDL). The grape skin provides flavonoids and other antioxidant substances that protect the heart and vessels from the damaging effects of free oxygen radicals produced by our body. This is particularly true for diabetics because they have been shown to have a high production of free oxygen radicals. But we don't have any evidence specifically related to diabetes patients.
A glass of wine can also help individuals relax. The strongest evidence is in favor of wine, but some evidence recently showed beer and other types of alcohol may provide the same benefits related to increasing good cholesterol (HDL).
In general, alcohol does not seem to have an adverse effect, unless excessive amount is used — and it increases calories, among other things. For example, excessive amounts of alcohol consumption could be harmful by increasing the risk of high blood pressure, for which diabetic patients are already at high risk.
Weight management and physical activity
My healthcare provider told me that if I lose some weight, my diabetes will be better controlled. I have been incorporating physical activity into my everyday life and have lost a little weight. But the last couple of weeks, I feel like I have hit a plateau — nothing's happening anymore and I still have some weight to go! What's going on?
First, congratulations on your weight loss! Losing even 10 pounds will improve your blood sugar readings and HbA1c. It also will help lower your blood pressure and LDL ("bad") cholesterol and raise your HDL ("good") cholesterol.
It's hard for most people to get enough physical activity to substantially reduce their weight. Regular physical activity must be combined with sensible eating — and, most importantly, portion control.
Even when physical activity and reducing calories are used together, people often reach a plateau. The number of calories that your body needs depends on your body weight. The heavier you are, the more calories you can eat to maintain your body weight. As you lose weight, though, you may need to adjust your calorie intake downward to keep losing weight.
Sometimes if people have been severely restricting their calorie intake, they may lower their metabolic rate. Then they may need to add 100 to 200 calories per day of healthy foods to rev up their metabolism.
When people have been working at weight loss for a long time and feel that they've hit a plateau, it's often a good idea to take a break from actively trying to lose more and spend some time maintaining this new weight. Also, varying the type of physical activity can be helpful. By doing this you will not only use different muscle groups, but you will be less likely to become bored. In addition, you may want to assess how much and what types of food you are eating. It is easy to believe you are eating less when in fact you are taking in more calories than is necessary. Remember to drink enough water, too — it helps your metabolism and cellular function.
Losing weight is hard work. The people who are most successful in the long-term are those who have lost weight slowly and steadily and who have learned to incorporate sound eating habits and moderate levels of physical activity into their everyday life.
I've started working some physical activity into my daily routine. But my blood sugar seems a little more out of control. How does my becoming more active affect my blood sugar?
Alain Bertoni, M.D., M.P.H., assistant professor in Public Health Sciences and Internal Medicine at Wake Forest University School of Medicine in Winston-Salem, N.C., explains:
Becoming more physically active is a great way to help control your diabetes. When you walk or do other moderate-intensity physical activities such as biking, swimming or dancing, you burn more calories than when you're sitting still. Your now-active muscles take up sugar from the blood to use as energy. This tends to lower your blood sugar levels, which is generally good.
Many people with diabetes can exercise safely. Before beginning any exercise program, consult with your healthcare provider to help choose the safest activities for you, given your age and medical history. Once your healthcare provider has given you the green light, increase your physical activity. By doing regular physical activity, you will probably lower your blood sugar levels (as measured by the HbA1c test) and may make it easier to reach your diabetes treatment goals.
However, be aware that the change in blood sugar levels during a particular exercise session may cause blood sugar to drop so low that it could cause hypoglycemia (extremely low blood sugar levels). This may be more likely to happen if you use insulin or oral drugs in the sulfonylurea family. To guard against this, you should know your usual symptoms of hypoglycemia and carry a source of sugar with you such as tablets, hard candy or juice (with real sugar, not artificial sweetener). If you experience hypoglycemic symptoms, stop exercising and eat or drink the source of sugar. Other general precautions include:
- don't take your medications just before exercise, and
- don't skip meals.
If you have experienced hypoglycemia during exercise, especially if severe passing out or if milder cases have occurred several times, consult with your healthcare provider or diabetes educator before continuing your exercise program. You may need to coordinate your eating, exercise and medication times, test your blood sugar levels before exercising, or eat a heart-healthy snack (like a piece of fruit) just before exercising.
Finally, pay close attention to your eyes, feet and joints. Wearing shoes that don't fit properly or doing more demanding exercises (like jogging) may cause injuries. Lower-impact sports and good socks/athletic shoes may help guard against this. Report blisters or ulcers to your healthcare provider immediately. Certain strenuous activities (like racket sports) may cause problems with your eyes if you already have significant retinopathy.
I am eating right, and increasing my activity, but my waist size is still big. Is this okay, or am I still at risk?
Dr. Lori Mosca, an American Heart Association volunteer and director of preventive cardiology at New York-Presbyterian Hospital explains:
Waist size is a very important predictor of having unhealthy levels of blood cholesterol, high blood pressure, and prediabetes. For men, if the number is over 40, or for women if the number is over 35, risk increases. The research is beginning to tell us that it's not IF you're fat that matters, but WHERE you're fat. It seems the belly is not just a simple storage depot for fat but is a pretty active place in the body that leads to a lot of metabolic abnormalities that increase the risk for cardiovascular disease, such as heart attack or stroke. At this point we can't fully explain why, but we do know that an oversized waist is a red flag.
Cardiovascular disease risk
I have heard that if I have type 2 diabetes, my risk for heart attack is the same as that of someone who has already had a heart attack. Is this true? Can you help me understand the relationship between type 2 diabetes and heart disease?
Dr. Lori Mosca, an American Heart Association volunteer and director of preventive cardiology at New York-Presbyterian Hospital explains:
Type 2 diabetes is the type that often develops in adulthood, though more and more children and adolescents are also developing it. It's often associated with being overweight and leading a not-so-healthy lifestyle.
We've learned in our research that people with diabetes have almost the same risk of having a future heart attack as people who already have heart disease or other vascular disease. So diabetes is really one of the strongest risk factors we have.
Some of us feel so strongly about diabetes that we call it a risk equivalent, which means it's equivalent to having heart disease already. We are extremely aggressive with this risk factor, because we know that if you have diabetes, you are at substantially higher risk for future heart disease.
We also know that diabetes is associated with unhealthy levels of different types of blood cholesterol. So, people with diabetes tend to have an increased level of the bad cholesterol (LDL) and of triglycerides, and they tend to have reduced levels of the good cholesterol (HDL). This may be one of the explanations for why people with diabetes are at such high risk for heart attacks.
My healthcare provider told me I have type 2 diabetes. He also told me that my risk for cardiovascular disease, such as heart attack or stroke, is very high. Why is the risk so much higher for me?
Wahida Karmally, Dr.Ph., R.D., associate research scientist and director of nutrition of the Irving Center for Clinical Research in the Columbia University Medical Center in New York, explains:
Even when blood sugar levels are under control, diabetes increases the risk of heart disease and stroke. The risks are even greater if blood sugar is not well controlled. This occurs because diabetes causes damage to the blood vessels and arteries throughout the body including the ones that supply blood to your heart and brain. As this damage occurs, it becomes easier for plaque to form in the arteries. This buildup (atherosclerosis) is what can increase your blood pressure.
When high blood pressure exists with obesity, smoking, high blood cholesterol or diabetes, the risk of heart attack or stroke increases several times. It's very important to control your weight and blood cholesterol with a low-saturated-fat, low-cholesterol, plant-based diet and regular exercise. It's also important to lower high blood pressure and not to smoke.
Diabetes is a coronary heart disease risk equivalent. This means the risk for major coronary events is equal to that in established coronary heart disease. The risk for cardiovascular disease, such as heart attack and stroke, is higher because most people with diabetes have other health problems such as high blood pressure and blood cholesterol.
If you have diabetes, you can reduce your risk for cardiovascular disease and stroke by controlling your
- Blood sugar — Aim for hemoglobin (HbA1c) below 7.
- Blood pressure — Keep it below 130/80 mmHg.
- Blood cholesterol — Get your cholesterol checked and talk to your doctor about your numbers and how they impact your overall risk.
Managing your weight, eating a plant-based healthy diet, engaging in regular physical activity and taking medications (if prescribed by your healthcare provider) can also help you reach your treatment goals.
I was recently diagnosed with type 2 diabetes and I am concerned about my children's risk for diabetes. What steps can I take to help them lead a healthy lifestyle and avoid diabetes?
Many parents who are diabetic worry about their child’s risk for diabetes. It is true that having a family member with diabetes measurably increases the risk that a child may develop diabetes. Fortunately, with some knowledge and with help from your health care providers, there are things you can do to keep your children healthy.
Type 2 Diabetes Mellitus
Having a parent with type 2 diabetes increases a child’s risk for developing diabetes. This is related in part to genetics and in part to learned habits around exercise and eating. One way of thinking about it is that genes lay the groundwork, and the lifestyle allows for or protects against a diabetic predisposition. So, having a healthy lifestyle is extremely important.
The risk that your child will develop type 2 diabetes depends on the parent’s gender and how old they were when they were diagnosed; children of mothers diagnosed before the age of 50 years have significant risk, 1 in 7.
No medication has yet been shown to slow the progression to type 2 diabetes in children, although some medications may be useful in adults, and research is ongoing. Fortunately, lifestyle change can prevent diabetes in adults, and this is likely to be true in children as well.
Weight loss, regular moderate-intensity, aerobic physical exercise such as 30 minutes of brisk walking 5 times per week and healthy eating habits, decrease the risk of diabetes in adults. Research in children shows that having a healthy lifestyle can improve factors associated with diabetes, including weight, cholesterol and blood pressure. Some specific things you can do to improve your child’s health are:
- Limit screen time: Keeping screen time to 2 hours or less per day may reduce rates of obesity, an important risk factor for diabetes type 2
- Encourage a healthy diet: Serve lots of fruits and vegetables, unsalted nuts, low-fat (1%) or fat free dairy, fiber-rich, whole grain foods, fish twice per week, and limit intake of saturated fat, trans fat, and cholesterol. Choose healthy, monounsaturated and polyunsaturated fats and avoid highly processed foods that can be high in sodium. Limit added sugars in beverages and foods such as sodas, fruit drinks, sucrose, fructose, maltose, honey, high-fructose corn syrup, concentrated fruit juice, corn syrup, cane juice, sweets (examples: candy, cookies, cake, etc.).
- Aim for a healthy weight: helping your child work towards a healthy weight is an important way to reduce your child’s risk of diabetes. Children and adolescents should do 60 minutes or more of physical activity per day.
- Model good habits: Positive role modeling is important. Show your children that physical activity is important and can be fun by spending time playing actively. Keep in mind that if you don’t take care of yourself, it will be hard for your children to follow a healthy lifestyle.
Type 1 Diabetes Mellitus
For parents with the more rare type of diabetes mellitus, Type 1, the risk that your child will develop the disease depends in part on your gender and also the age you were diagnosed. Children of male type 1 diabetics have a 1 in 17 risk of contracting diabetes, while children of very early onset diabetics, those with two affected parents, and with multiple endocrine problems are at much greater risk (1 in 2-10). Breastfeeding may offer some protection from Type 1 diabetes. Some research has evaluated blood tests that may be available for siblings of children with type 1 diabetes; speak to your child’s doctor about this. So far, no medication has been shown to prevent type 1 diabetes in children, although research studies are ongoing.
Testing for Diabetes
You and your doctor can better understand your child’s individual risk for diabetes using blood testing. A fasting glucose test should be done in overweight children with 2 of the following risk factors: family history of Type 2 diabetes including gestational diabetes in the child’s mother, at risk racial/ethnic background, high risk medical conditions such as insulin resistance, PCOS or metabolic syndrome. Screening should be done at least every 3 years using either a fasting glucose or a glycosylated hemoglobin (hemoglobin A1C). A more specialized test (oral glucose tolerance test) can tell how the body responds to glucose and can help your provider evaluate your child more closely. Talk to your child’s doctor about these tests.