Conquering Diabetes

By Megan Fendt, RD, CDN, CDE

Megan Fendt, RD, CDN, CDE is a nutritionist at the Gerald J. Friedman Diabetes Institute at Beth Israel Hospital in NYC. Prior to joining the institute staff, she spent three years at New York-Presbyterian Hospital as a clinical dietitian. Megan frequently contributes her nutrition expertise to Eyewitness News, CBS, Fox, AOL Health, and The Daily News. She believes in and practices an active lifestyle, creative consultation, and the power of laughter.

As a diabetes educator, I do my best to sample all the medical equipment my patients might use to get a real life idea of how they work and feel. I’ve poked myself with insulin pens, hooked myself up to continuous glucose monitors, worn insulin pumps, and sampled every glucometer under the sun. I realized the other day that I had neglected to try the simplest insulin delivery tool there is: the good old syringe.

After sitting through what felt like my fortieth lecture on insulin injection technique, I felt well-prepared to take the plunge (take the plunger, more like it). I took my 3/10 cc sterile insulin syringe, loaded it up with saline, and 1-2-3… injection success!

A second later, though, I sat wondering why the heck my injection site in my abdomen hurt so much. Insulin pen needles never felt like this. I checked my site and saw it starting to bruise. Concerned now that I’ve been lying to all my syringe users (“It really doesn’t hurt, I swear!”), I frantically tried to backtrack and figure out what I did wrong. The syringe was new, so no problem with a dull needle… I didn’t have wet alcohol on my site…I was using a mini 5mm needle… WAIT! This was no mini needle! Syringes only come in short (8mm) and original (12.7mm) needles, which meant my needle was too long to inject without the “pinch an inch” technique. I was stabbing saline right into my muscle. No wonder it hurt! After focusing so much on insulin pens (which we can use with the shorter mini [5mm] and nano [4mm] needles), I totally blanked on how to use the longer-needled syringe.

After getting over the feeling that I was the world’s worst CDE “patient-in-training,” I realized that sometimes, no matter how often we hear things, we need to make a few real life mistakes before information really sinks in. Diabetes isn’t about perfection; it’s about doing the best we can. The bruises eventually fade, and tomorrow is another day. Has there ever been a time in your life with diabetes where you felt information only really stuck with you after making a few mistakes? Let me know about it!

By Lynn Polmanteer, MS, RD, CDN, CDE

Lynn Polmanteer, MS, RD, CDN, CDE is a nutritionist at the Gerald J. Friedman Diabetes Institute at Beth Israel Hospital in NYC. Prior to joining the institute staff she spent three years at New York-Presbyterian Hospital as a clinical dietitian. Lynn contributes to CBS, The Daily News, and Sirius XM Radio as a nutrition expert, hosts fresh and healthy-themed cooking classes at FDI, and is an avid runner and biker.

I’ve been a registered dietitian for several years now. I’ve always enjoyed going to dinner parties, summer barbecues, weddings, and restaurants. I love catching up with old friends and making new ones over great food! I’ve noticed that whether I’m meeting someone for the first time, or if I’ve known the group forever, the subject of jobs always tends to come up. As luck would have it, this conversation is typically held towards the end of the meal, right before dessert. If I’m in the mood for something sweet (especially if it’s chocolate) I have some. Immediately I hear, “You’re a dietitian! You can’t be eating that!” My innate response is, “but the key is moderation!” While I don’t have diabetes, I can imagine that people with diabetes hear “You can’t eat that” on a regular basis. Which reminds me of the first time I met my boyfriend’s uncle. I’ll refer to him as Uncle Awesome. For several years now, he has successfully managed and controlled type 2 diabetes. He lives an active lifestyle, diligently takes his medications, and checks his blood sugar on a daily basis.

I met Uncle Awesome for the first time at a family gathering. Lunch consisted of fruit, chips, a few different salads, bagel sandwiches, and, of course, dessert. After the meal, Uncle Awesome reached for the sweets. His daughter yelled, “Dad what are you doing?!? You have diabetes and Lynn’s a dietitian who specializes in diabetes! Don’t eat that!” While I appreciated the concern she had for her father’s health, I thought to myself, “if Uncle Awesome avoids chips, the fruit, or the whole bagel, he can have some dessert.” But how does one explain carbohydrate counting over a casual lunch? I had just met Uncle Awesome and I didn’t think Carbohydrate Counting 101 was appropriate given the circumstances. Uncle Awesome ended up having a taste of the sweets and asked me afterwards some questions about nutrition and diabetes.

I outlined the keys to successfully incorporating carbohydrates into your diet; everyone needs them for energy, even those with diabetes. It’s just important to know what they all are and how they differ from each other as it’s a huge group of food! I classify carbohydrates into four categories:

• Starches (for example, pasta, rice, potatoes, corn, cereal, bread)
• Fruit
• Milk and yogurt
• Sweets

It’s okay for people with diabetes to have sweets given proper portion control. I usually tell my patients to limit them to no more than once or twice per week. I told Uncle Awesome that next time he goes to a party and wants to have a small piece of cake, a small cookie, or a ½ cup of ice cream, to have less of the “other” carbohydrates during the meal. I call it swapping. I don’t expect my patients who like sweets to avoid them 365 days per year. I encourage them to practice portion control and to remember that moderation is the key.

By Michael Dansinger, MD

There are many good reasons to keep a food record, as discussed in Food Records Part 1: Why Should I Keep a Food Record? Here I discuss various methods for keeping a food record. Many folks simply use a “pen and notebook” system, which works very well. Alternatively, one can use the more sophisticated advanced technology available on WebMD to keep a food record, or use one of the many downloadable applications available for smart phones.

The “pen and notebook” system is the most basic. I favor this method when meeting face-to-face with patients. Small notebooks often work well because they can be carried in a purse or pocket. A nicely sized notebook allows one day’s worth of eating to fit on a single page. I ask my patients to write both the day and date at the top of each page to help keep me oriented when I view the record. I ask them to list the amounts of each food—for example, “honeydew—1.5 cups” and to record the calories associated with that quantity of food in the right-side margin and provide a total for the day at the bottom of the page. I request a 7-day calorie average each week.

Although some people weigh and measure their food with a food scale and measuring cups, most use the “hand method” to estimate their food amounts. A closed fist is about a cup (or a bit more for larger hands) and a palm (thickness and diameter ignoring the fingers) is typically about 5 ounces for men and 4 ounces for women (give or take an ounce for larger or smaller-than-average hands). There are 3 teaspoons in a tablespoon. Together, careful estimation of cups, ounces, or tablespoons can provide the information required to list the food intake quantities in most cases.

To determine the calories, one can use a calorie-counting book such as CalorieKing or Biggest Loser Calorie Counter. Foods are listed alphabetically in the appendix, which then refers you to the correct page with detailed nutritional information according to portion size. Calories and grams of carbohydrate, protein, and fat are typically provided. Before long, most people have memorized the calorie contents of the foods they eat most often, which is a tremendously helpful skill when trying to take off the last 10 pounds in a calorie-counting weight-loss strategy.

There are many free internet programs available for logging your food intake, and WebMD’s logging program is among the best. It is easy to get started (by clicking here and following the simple instructions). Once you enter the amount of a particular food, the program automatically provides the calories, carbohydrates, protein, fats, and other more detailed nutritional information. A fabulous feature of the WebMD food log is how simple it is to keep a list of commonly eaten foods and just click and drag to enter each time you want to record that food. For example, if you tend to repeat the same breakfast often, it takes just a few seconds to update your food record with such frequently eaten foods.

There are many free and inexpensive apps available for smart phones. Examples include FitDay and My Fitness Pal. Many find this to be the most convenient way to keep a food log, especially because it is so portable. Some apps even allow one to scan the barcode of a product to help speed the process.

I believe that future versions of food logging programs will not only make logging more convenient—it will transform food logging into a game or entertainment. Immediate gratification for food logging would be a tremendous advance in my view. A fun example is the on-line Wok created by the world-famous Joslin Diabetes Center in Boston. This computer program allows you to click and drag various icons of Asian ingredients into a virtual “wok” that sizzles while providing the nutritional information of a prepared dish containing all ingredients entered. For example, it took me about 30 seconds to get the nutritional information of a Chinese stir-fry containing chicken breast, broccoli, scallions, bean sprouts, canola oil, and soy sauce. I could almost smell the finished dish as it “cooked”—and I could quickly see it would be about 300 calories for a good-sized serving loaded with healthy protein, fiber, and not too much saturated fat.

Food logging is here to stay. We can’t seem to conquer diabetes and obesity without monitoring our food intake. I’m counting on technology to make it easier and than ever and even sort of fun to keep track of what we eat, while simultaneously taking comfort in knowing the “old-fashioned” low-tech methods also remain quite effective and relevant today.

By Michael Dansinger, MD

Have you ever kept a food record? Why would someone do that? I ask all my patients to keep food records. For years I tried to help patients meet their health goals without requiring a food record, because food records require time and effort. However, I was never able to achieve the kind of results I wanted as a lifestyle coach until I started insisting on food records. My patients started losing excess weight much more reliably and had much better chance of reversing their type 2 diabetes or prediabetes once I embraced this fundamental principle.

Every patient I see who has achieved success has kept a food record and taken it seriously, while just about every patient who has declined to keep a food record has failed to achieve satisfactory results. In my view recording food intake is practically a prerequisite to success. I know there are individuals out there who are exceptions, but for the most part this holds true.

What is it about keeping a food record that makes such a difference? There are several reasons.

Reason 1: Keeping a food record raises self-awareness. The act of keeping the record forces one to think consciously about WHAT food is being eaten and HOW MUCH of that food is being eaten. Did you drink 1 cup of orange juice or 3 cups? That would go into the food record.

Reason 2: Another reason is because the food record can be used for counting. Whether you’re counting calories, carbohydrate grams, fat grams, or something else, the process of counting takes the entire process to the next level of awareness. How many calories were in those 3 cups of orange juice? That would go into the food record. If you’re trying to lose weight or maintain a weight loss, the process of counting and then comparing your 7-day calorie average (or average carb grams, or fat grams, or other) to your weekly weight change, is a powerful technique for linking your food intake to your weight. Put another way, if you are counting something then you can “budget” what you’re counting. If you know your calorie intake, then you can budget your calories (or carbs or fat grams, etc.), allowing you to adjust your rate of food intake or total daily intake according to your weight loss or other health goal.

Reason 3: The next reasons have to do with coaching. Working with a nutrition and lifestyle coach can provide accountability, information, and encouragement. However, without keeping a food record, the coach can’t really know what the patient/client/participant is eating. The coach must know what the patient is eating, and even if the patient can remember in perfect detail what was eaten and how much, it is impossible to verbalize it efficiently. A coach needs to be able to visualize it and see the amounts and patterns. The food record is like the coach’s eyes, and without the food record the coach is blinded. Advice becomes general rather than specific without a food record. To me, as a coach, this is the most important reason to keep a food record and why I can’t do a good job without one.

Reason 4: When a patient knows a coach will be looking at the food record, and if there is a particular eating plan the patient is aiming to follow, then the food record helps “keep you honest”. Imagine you are tempted to eat a cookie (or 5 cookies). If you are keeping a food record and working with a coach, then you have 3 choices. Eat the cookies and write it down, eat the cookies and lie to your coach (and yourself), or skip the cookies and make a healthier choice. The combination of food record and coaching together force the situation of full disclosure because a patient quickly sees it is pointless to work with a coach without fully disclosing the food intake. When you know someone else is going to know about the cookies, it makes you think twice about eating them. This dynamic is extremely helpful because it provides accountability and promotes increased dietary adherence. Together the coach and patient can gage the dietary adherence level and compare that to the target adherence level.

Together, these reasons explain why a food record combined with coaching creates a driving force for better health. Without a coach, one generally doesn’t keep a food record, and without a food record, one often doesn’t get lasting results. The food intake is the main driver of success or failure to meet health goals. Unfortunately it is not human nature to police one’s own food intake, at least not to the extent of actually keeping a food record, unless someone else is going to be viewing that record. A coach can help keep you honest, help you explicitly connect your food intake to your progress, and provide specific feedback and suggestions based on your specific food intake patterns. Without a food record, none of this is possible.

In part 2, I will discuss methods for keeping a food record.

By Michael Dansinger, MD

It’s holiday party time! Many of my patients find this time of year to be particularly challenging for maintaining glucose, waist size and body weight. So many treats, so many parties, so many mixed feelings about this time of year. For some the right balance is to remain strict, while for others the right balance is to loosen up a bit and enjoy a little more dietary freedom. In either case they’re looking to January for renewed commitment and resolve, or at least a “clean slate”.

In my view, this time of year is part of a natural order that compels us to simultaneously celebrate our present situation and to think about our future. It is in our nature to work hard and then celebrate a job well done. We need to recharge, rejuvenate, celebrate and prepare for the work to come.

It is natural to reflect at this time on the gifts life brings. Many of us are fortunate to have family members and friends who care a great deal about us. We are fortunate to have others in our lives we care about. Many of us are grateful for the opportunity to do meaningful work that provides a service or product that people need or want. I am particularly grateful for the opportunities I have had to engage in a variety of intellectually stimulating and/or challenging projects that hopefully make the world a better place, at least for some. Many of us are grateful for the health we have (even if it is not as good as it once was), recognizing it could be very much worse. I am particularly grateful to have a healthy body and the freedom and opportunity to substantially influence my state of health. Many of us are grateful to live in a place that affords the freedom to have a good amount of control over our destinies, as well as the experience, knowledge, and wisdom to take advantage of opportunities to better ourselves.

When it comes to health and wellness during this natural time of celebration, my philosophy is that what matters most is how you live MOST of the time, not SOME of the time. Are you “celebrating” 70% of the time or 10% of the time? This is the most important time of the year to think about how you want to conduct yourself during the next year. Are you living in “balance”? Are you living like its December all year long? In my view, the most important thing right now isn’t putting the cookie down but taking stock of what a great gift your life is and preparing mentally for the work required to take full advantage of life’s opportunities. In other words, let’s get ready to eat right and exercise all year long, so we can celebrate once in a while without guilt and without going overboard.

I, for one, pledge to do a better job with eating and exercise in 2012 than I did in 2011. Not that I did a bad job this year, but there’s always room for improvement no matter who you are or what your circumstances are. So join me in celebrating all we have to live for, and all the opportunities we’re going to seek to better ourselves in the year to come!

Best wishes for a healthy, happy, peaceful holiday season and New Year.

Photo: Ryan McVay

This WebMD article highlights the latest scientific findings on the favorable effects of exercise for diabetes patients. The article reports what we would all expect: cardiovascular (aerobic) exercise and resistance training are both beneficial for diabetes and lower the hemoglobin A1c levels.

Structured exercise programs (I like to think of these as formal exercise programs with some degree of hands-on supervision) typically produce better results than “exercise advice”, simply because the structured exercise programs achieve greater intensity and duration and greater compliance, than when patients are left to their own devices to get the recommended exercise. (more…)

Photo: Pixland

Chocolate is one of the world’s most prized flavor sensations, and most people who are interested in healthy eating have a vague notion that chocolate might have health benefits. For example, this WebMD article published a few weeks ago reports on the combined results of 21 studies with 2,575 participants showing that cocoa consumption is associated with decreased blood pressure, improved blood vessel health, improvement in cholesterol levels, and improvements in diabetes risk factors such as insulin resistance.

Unfortunately, the role of chocolate in disease prevention has proven to be complicated and controversial from both medical and ethical standpoints. (more…)

One in three American adults has prediabetes, and to make matters worse, only a small fraction of these people know it!

I consider this to be a national emergency. If we fail to detect and reverse prediabetes, then how are we going to stand any chance at reducing the growing epidemic of type 2 diabetes? (more…)

Four years ago, in a WebMD/Medscape video editorial, I called for a national ban on partially hydrogenated trans fat, an artificially manufactured, harmful fat that promotes heart disease and diabetes.  At that time it was commonly added to commercially prepared fried and baked foods, and average intake was estimated to be 5 to 6 grams per day with an associated 25% increase in heart disease risk in the US. (more…)

One of my greatest pleasures in life is to help patients achieve remission of their type 2 diabetes. This means their blood sugar levels have become normal in the absence of any diabetes medication.

Many clinicians and patients are interested in learning my views about how to go about decreasing and discontinuing diabetes medications. The main role for medications is to help reduce or delay the risk of nasty complications of diabetes, particularly the damage to the retina, kidney, nerves, and circulation. The higher the average blood sugar level, as indicated by the hemoglobin A1c level, the greater the complication risk (which increases exponentially with increasing A1c). We know from clinical trials that using medication to keep the A1c at or below 7% can help reduce the risk of these complications. There is broad agreement that clinicians should recommend starting or increasing diabetes medications to patients who cannot get their A1c level to 7% or less via lifestyle change.

Many patients come to me because the A1c is already over 7% and their primary care provider proposes increasing their diabetes medication, unless the patient can get to 7% or less with improved eating and/or exercise habits. Some of these patients are already on many pills, and insulin shots are the frequently the next appropriate treatment. Many patients would rather make the lifestyle changes than take more medication, so when the doctor frames the issue in this way, then a patient might become inspired to renew or increase the lifestyle efforts. The clinician might say “lets recheck the A1c in 3 months, and start the new medication if it is still above 7.0%”.

My goal with patients is to use the lifestyle strategies I’ve discussed previously in this blog to drive the A1c as low as possible. I want to push the A1c very far below 7.0%. If possible I would prefer to push the A1c into the normal range of 5.7% or less, and I’ve helped many patients push it close to 5.0%. There can be little doubt that using lifestyle changes to normalize the glucose levels and A1c is a good thing. In contrast, the strategy of driving the A1c well below 7.0% with multiple medications has little to offer most patients in terms of quality of life or reduced risk of complications.

Most patients I see are already taking metformin, which is the preferred second line treatment after lifestyle change. Opinions differ about when to start this drug. Some experts advocate starting it in patients who have pre-diabetes because clinical trial evidence demonstrates that it can delay the progression to type 2 diabetes, while other experts could argue that there is little evidence that it reduces diabetes complications when the A1c is below 7.0%, so no point in starting it until 7.0% It is important to discuss these issues with patients.

I typically recommend initiating it in patients with A1c’s of 6.5% who cannot push it any lower via lifestyle change. For patients who are already on metformin, I do not decrease the dose unless the A1c is 6.0% or less. I might reduce the dose by half every 3 months, as long as the A1c stays at 6.0% or less. I stop the final 500 mg of metformin when the A1c is 6.0% or less for at least 3 months. Once a patient has discontinued it, I would then recommend restarting it if the A1c reaches 6.5%. Other alternative approaches would also be reasonable, and patient and physician preferences should be taken into account when making such decisions about starting and stopping metformin.

Some drugs can lower the blood sugar levels below the normal range, causing symptoms of hypoglycemia. These drugs, which include insulin and those in the sulfonylurea family (which are common in patients on more than one kind of diabetes pill) need to be reduced or discontinued by the clinician as required to avoid hypoglycemia, so these are typically the first drugs to be discontinued. It is important that patients who take these medications check their blood sugar levels regularly, particularly while making lifestyle changes. Doing so lets us know the risk of future hypoglycemia and guides the decision about when to decrease or discontinue such medications.

For patients on insulin, this type of monitoring is mandatory. Initially, insulin dose reduction typically mirrors dietary carbohydrate reduction, and many patients are quickly using half as much insulin, particularly the short-acting insulin boluses used to prevent hyperglycemia during and after meals. Weight loss often brings additional reductions and sometimes discontinuations of insulin, however the glucose and A1c levels are the key to managing insulin dosing over time. The majority of my patients have not been able to discontinue insulin altogether, although nearly all of them have been able to significantly reduce their dose as well as their A1c levels. The chances of discontinuing insulin are best when the lifestyle adherence levels are high, the weight loss is large, the initial insulin requirement is relatively low, and the duration of diabetes is short, almost always less than 10 years.

In the absence of insulin or sulfonylureas, then other drugs (such as pioglitizone) come off next. I typically wait until the A1c is 6.5% or less to propose stopping such drugs, and would not initiate or re-initiate any diabetes drugs (other than metformin as noted above) unless the A1c is above 7.0%.

So, in summary, ambitious eating and exercise goals are important in all stages of diabetes, and drugs are crucially important in patients who cannot otherwise keep the A1c below 7.0%. Metformin is the first drug of choice whenever possible, and the last drug to be discontinued in patient who normalize glucose levels via lifestyle changes. The A1c levels to start and stop metformin are up for debate, and may be individualized according to patient and clinician preferences. It is clear that medications can be avoided, delayed, or discontinued when lifestyle efforts are intensified and sustained. For many (if not most) patients, lifestyle coaching by a clinician, dietitian, personal trainer, peer group, etc. can dramatically increase the odds of success.

- Michael Dansinger, MD