Don Werkstell’s motto is “check, check, and recheck.” A former Department of Homeland Security inspector, he made sure that cargo flying in and out of terminal A at Dallas–Fort Worth Airport posed no threats. Diagnosed with type 2 diabetes in 2004, he now applies the same “check and check again” philosophy to his own blood sugar.
“I have to know what my numbers are. It’s the only way to keep my blood sugar low and avoid all the complications of diabetes,” says Werk-stell. “I check my blood sugar all the time and guide my exercise and food choices by it. And every few months, I get a long-term test called an A1c. Diabetes runs in my family. I’ve seen what can happen if you don’t take care of yourself.”
Most of the 21 million Americans with type 2 diabetes aren’t as “in control” as Werkstell. Despite government-sponsored health campaigns and newspaper and TV headlines, most of us are still in diabetes denial.
• One-third of all Americans with diabetes don’t know they have it.
• Among those who do, most are still in danger. In mid-2005, a stunning new survey of 157,000 diabetic women and men revealed that while 85 percent think they’re keeping the lid on high blood sugar, two out of three actually have dangerously high levels that can lead to kidney failure, blindness, amputation, deadly heart attacks, and stroke. The survey was commissioned by the American Academy of Clinical Endocrinologists.
• When Harvard Medical School researchers recently checked up on diabetes care at 30 of the nation’s top university medical centers, they uncovered shocking neglect. Half the time, people with diabetes were sent home without the medicines they needed to lower dangerously rising blood sugar—leaving them at unnecessary risk for complications.
What’s gone wrong? People with diabetes—and their doctors—underestimate the urgent need to keep blood sugar tightly controlled via diet, exercise, stress reduction, regular blood sugar checks, and medication if necessary.
In fact, a new University of California, Los Angeles, study underscores the power of diet for people with diabetes. In this small, controlled 3-week study, 6 of 13 overweight or obese men with type 2 diabetes finished diabetes-free, with normal blood sugar levels. How? With meals that were low in fat (12 to 15 percent of calories), moderate in protein (12 to 25 percent), and high in carbs (65 to 70 percent). Participants also walked for 45 to 60 minutes a day. But eating low-fat foods and no refined carbs—absolutely no toaster pastries or brownies—was critical to their success, says researcher Christian Roberts, PhD, the author of the study. He predicts that sticking to the diet long-term may undo heart damage associated with diabetes.
But if you’ve had diabetes for a few years, diet may not be enough.
“Every time you see your doctor about your diabetes, you should discuss how well your treatment plan is working and whether it needs to be changed,” says Kenneth J. Snow, MD, acting chief of the Adult Diabetes Division at the Joslin Diabetes Center in Boston. “You can’t judge your diabetes by the number of pills you take. You should gauge it by your blood sugar—and by how well your treatment plan mix of diet, exercise, and medication is working to keep it low.”
Cutting-edge diabetes treatment calls for aggressive care, particularly for the millions of people whose diabetes developed earlier in life, says Anne Peters, MD, director of the University of Southern California’s clinical diabetes program and author of Conquering Diabetes: A Cutting-Edge, Comprehensive Program for Prevention and Treatment. “If your doctor seems behind the curve, ask what’s going on. This is especially important if you’re in your thirties, forties, fifties, or even your sixties. If your diabetes is diagnosed when you’re younger or if you plan on living a long life, there’s less room for error. High blood sugar is more dangerous when it goes on for years and years.”
If your blood sugar is higher than your target goals, your doctor should be talking about a revised treatment plan, Dr. Peters says. If he or she doesn’t bring it up, you should.
You’ve got type 2 diabetes if your blood sugar is over 125 milligrams of glucose per deciliter of blood (mg/dl) on a fasting blood sugar test, or over 190 mg/dl on an oral glucose tolerance test (in which you fast, then consume a sugary beverage and take a blood test 2 hours later). If your blood sugar has soared to these levels, it means that nearly every aspect of your body’s blood sugar control system has been damaged at a cellular level.
Diabetes is the last stop in a decades-long series of breakdowns in that system. Here’s how the progression from normal blood sugar to diabetes unfolds: Thanks to a powerful combination of genetics, overweight, inactivity, abdominal fat, and stress, cells throughout your body first become insulin resistant—ignoring this vital hormone’s signals to absorb blood sugar. To compensate, beta cells in your pancreas crank out extra insulin. Finally, beta cells wear out. Insulin production drops; blood sugar rises. At first, sugar levels are only slightly higher than normal, a condition called prediabetes. But finally, as more beta cells cease functioning, your blood sugar rises to officially diabetic levels.
Many people discover their diabetes only after years of undetected high blood sugar has led to outward symptoms. Fatigue, thirst, getting up frequently at night to use the bathroom, frequent infections and slow-healing wounds, sexual difficulties (such as vaginal dryness and erection problems), and digestion trouble (diarrhea, vomiting, and slow digestion, all due to nerve damage) are all warning signs of type 2 diabetes. (If you have any of these problems, call your doctor and schedule a blood sugar test!)
Once diagnosed, you’re in a whole new world. Suddenly, you must learn to operate a blood sugar meter—and find room for it in your purse and in your busy schedule. Meals morph into arithmetic problems if you’re trying to control blood sugar by counting carbohydrate grams or exchanges. And the pills! You might take one, two, or even 10 to 15 medications to lower your blood sugar and protect against diabetes-related heart risks such as high blood pressure and high cholesterol. You need to worry about your feet (even the smallest bump or cut could lead to a major infection), your eyes (high blood sugar can lead to vision problems), your kidneys (excess blood sugar can lead to kidney failure), and more. Small wonder, then, that people with diabetes report feeling more stressed and depressed.
The Sugar Solution’s glucose-lowering strategy can help you feel in control again. Here’s what to do.
Luscious fruits, fresh veggies, whole grains, good fats, lean meats, and a minimum of refined carbohydrates: The foundations of the Sugar Solution eating plan can help you tame high blood sugar quickly, effectively, and deliciously. The meals suggested in this book even contain exchange-list information for people with diabetes who use that type of system to stay on track with healthy eating.
“Start with the fundamentals,” says endocrinologist Richard Hellman, MD, a clinical professor of medicine at the University of Missouri/ Kansas City School of Medicine and medical director of the Heart of America Diabetes Research Foundation. “The foundation of good diabetes care is always a healthy diet and regular exercise. Often, if you see your blood sugar levels slipping on daily checks, it’s because of that. Even if you need more medication, your diet still helps because it can help prevent weight gain, supplies important nutrients, and will still have an impact on your blood sugar. Exercise helps muscle cells become more insulin-sensitive.”
Here’s how to tailor the plan to fit your needs:
Talk with a registered dietitian or certified diabetes educator. Many insurance plans, including Medicare, cover at least one visit. These food specialists can help you customize the carbohydrate levels and portion sizes to meet your body size and unique blood sugar processing “style.” They can also help you make the plan fit your lifestyle.
Fit exercise into your day, your way. In Chapter 14, you’ll find several walking programs, plus lots of ways to identify activities that match your personality. We urge you to include 10 to 15 minutes of strengthening exercises each day (or two or three longer sessions each week) to build muscle mass that burns more blood sugar, around the clock. Why not keep dumbbells and/or resistance bands near the TV, so you can fit in your strengthening routine while you watch your favorite shows?
Take advantage of the spa effect. Cutting stress reduced blood sugar significantly in one Duke University study of 108 people with type 2 diabetes. Those who took a stress-reduction class lowered their A1c levels by as much as 1 point. Learning to say ahhh not only gives you a blood sugar advantage but also makes you feel great. Lead researcher Richard Surwit, PhD, suggests these stress-less techniques: yoga, mindfulness-based stress reduction, a relaxing hobby, and progressive relaxation. Cutting back on caffeine can also help; the jolt in coffee and even tea can raise stress hormones and blood sugar levels.
To stay healthy and avoid complications, you need tight blood sugar control. How do you know if your diet, exercise, and medication plan is really working? By testing your blood sugar every day with your blood sugar meter—and seeing your doctor several times a year for an A1c test, which reveals your average blood sugar for the past 2 to 3 months.
“Daily checks and A1c tests look at blood sugar in two very different ways,” says Francine Kaufman, MD, former president of the American Diabetes Association, head of the Center for Diabetes and Endocrinology at Childrens Hospital Los Angeles, and author of Diabesity: The Obesity-Diabetes Epidemic That Threatens America—And What We Must Do to Stop It. “A daily test is a snapshot. Taken with a blood sugar meter, it tells you what your level is at one moment. It’s very useful for finding out how high your blood sugar is at key times of day—first thing in the morning before you eat, before a meal, after exercise—or to see how well your body handles the natural rise in blood sugar after you eat.”
In contrast, Dr. Kaufman says, the A1c is like a full-length movie. It tells you what’s happened, on average, to your blood sugar over the past 2 to 3 months.
“With results of both tests, you can see if there’s a disconnect between your diabetes management plan and your real blood sugar levels,” Dr. Kaufman explains. “What if your daily checks look good, but your A1c is high? You may discover that the meter you use for daily checks isn’t working right or that there’s a time of day when your sugar’s much higher than you ever realized. You may need to alter your medication dosage, adjust the size of your meals or your food choices, work on lowering stress, or resolve to exercise more. If you weren’t getting A1c checks every few months, you’d never know there was a problem.”
An A1c test measures the amount of sugar attached to hemoglobin in your bloodstream. Found inside red blood cells, hemoglobin carries oxygen from your lungs to cells throughout your body. But it also links up with sugars such as blood glucose along the way. Like Christmas cookies rolled in sweet sprinkles, hemoglobin picks up more and more sugar if there’s an excess in your blood. Research confirms that every one-point rise in your A1c level significantly raises your risk for heart attack; stroke; and damage to eyes, kidneys, and nerves. An A1c above 7 percent raises heart attack risk 25 percent, ups stroke risk 30 percent, triples your chances of nerve damage in legs and feet, and raises odds for nerve damage in the eyes by up to 50 percent. Every one-point drop in your A1c cuts your risk for complications by up to 41 percent.
But daily tests are important, too. “The A1c cannot give you the quick results you need to see if a new sugar control strategy is working,” Dr. Kaufman says. “You need to know right away if your medication is effective, whether a new food raises your levels too high, or how physical activity impacts your blood sugar. Everyone’s body is different. Daily tests let you see just how your body is reacting, so that you can fine-tune your plan.” Here’s how to get the most from this testing strategy.
If blood sugar checks hurt, these strategies could help.
• Adjust your blood sugar meter so that the lancet penetrates as little skin as possible.
• Use a fresh lancet for each test. Reused lancets grow dull and hurt. (Medicare and private insurance usually cover the cost of lancets, so there’s no need to save money by reusing them again and again.)
• Try taking your blood sample from your palm or the side of your finger instead of your finger pads. Some meters can also test on your thigh or upper arm.
• Be patient. Checking your blood sugar may soon be as simple as slicing an onion. A new study from India reveals that tears may be just as effective as blood samples at tracking blood sugar levels. The discovery will allow researchers to develop a new kind of test strip that could measure blood sugar levels simply by being placed near the corner of the eye.
When to check: Work with your doctor. If you’ve just been diagnosed or are starting a new medication, you may need to test three to six times a day. If your treatment is working well, you may need fewer checks. Smart tip: If you test just once or twice a day, check at different times on different days. That will give you a more complete idea of how your sugar levels rise and fall.
Shoot for these numbers: For a fasting test (such as first thing in the morning) or before a meal: 90–130 mg/dl; 2 hours after a meal: less than 180 mg/dl.
Best test equipment: A glucose monitor that’s less than 2 or 3 years old or an older meter that’s been calibrated with your doctor’s help. “After a while, meters wear out,” says Karmeen Kulkarni, MS, RD, CDE, president of the ADA’s health care and education program and a certified diabetes educator at St. Mark’s Hospital in Salt Lake City. “New meters have some great features—you can store your previous readings, then download them into your computer, for example.”
Cost: Meters may cost as little as $10 for a very basic model to more than $300 for a sleek version that doubles as a personal digital assistant (PDA). Supplies, such as lancets for drawing blood and test strips, cost extra. Money-saving tip: Check with your insurance company to see which meters they cover or how much they’ll kick in. Some insurers also cover the cost of test strips.
Smart test tip: Write your results down. If you don’t use a meter that automatically records your readings, keep a blood sugar log of the date, time of day, and whether it’s a fasting reading or after a meal. Add comments about factors that could have influenced your reading, such as a stressful experience, a just-completed exercise routine, or a new food (or a splurge). Take your records to every diabetes checkup so your doctor can review them with you.
A growing stack of research confirms that keeping your A1c level in a healthy range (experts recommend a reading of 6.5 to 7 percent for people with diabetes, lower if possible) is a powerful, effective strategy for sidestepping a host of serious, scary complications. This test measures average blood sugar for the last 2 to 3 months. Here’s how a high A1c threatens your health.
Heart trouble. In a recent British study of 10,232 women and men with type 2 diabetes, University of Cambridge researchers found that every one-point increase in HBA1c levels raised heart disease risk 24 percent for men and 28 percent for women. Other research shows that it doubles heart failure risk.
Brain attacks. The same study found that stroke risk rose 30 percent when HBA1c levels rose above 7 and tripled at levels above 10.
Amputation. Tulane University scientists found in a recent study of 4,526 women and men that an HBA1c over 7 triples the risk for peripheral vascular disease—the nerve damage responsible for foot and leg amputations among people with diabetes.
Blindness. In a study of 11,247 women and men, researchers from the International Diabetes Institute in Australia found that the odds for retinopathy—damage to the tiny blood vessels inside the retina—rose 25 percent when A1c levels were over 7.5 percent for up to 4 years, and 50 percent when A1c remained high more than 8 years.
Kidney damage and failure. The higher your A1c, the greater the odds for kidney failure, say Israeli researchers who found that high blood sugar, high blood pressure, and high cholesterol levels all raise kidney risk for people with diabetes.
The bright side. You’re in control. University of Oxford scientists say that reducing your A1c (by tightening your blood sugar control) cuts all of these risks dramatically. A one-point drop in your A1c level will reduce heart attack risk 14 percent, lower heart failure risk 16 percent, cut stroke risk 21 percent, cut risk for amputation due to peripheral vascular disease by 41 percent, and reduce risk for blindness or kidney failure by 35 percent.
When to check: Every 2 to 3 months if your blood sugar is high. If it’s been under tight control for a long time (at least a year), your doctor may OK twice-yearly A1c checks.
Shoot for this number: An A1c reading of 6.5 to 7. “Normal A1c levels for people without diabetes are 6 percent or lower,” says diabetes specialist Jaime A. Davidson, MD, of the Dallas-based Endocrine and Diabetes Associates of Texas. “The closer to normal, the better, but be reasonable. If your A1c is high and you bring it down even somewhat, you’ve reduced your risk for complications.”
Best test equipment: The kind at your doctor’s office or a commercial lab. Home A1c tests are available for about $25, but experts recommend lab tests. You get more consistent results, your doctor reads the report, and she can help chart your progress.
Cost: Forty dollars at a private lab. Insurance may cover most or all of the cost.
Smart test tip: Many doctors test A1c levels just once a year. Ask about more frequent checks, Davidson suggests, especially if you’ve started a new medicine or have difficulty keeping your daily blood sugar under control.
“Most people with type 2 diabetes will need more medications as time goes by—and it’s not their fault,” says Kenneth J. Snow, MD, acting chief of the Adult Diabetes Division at Boston’s Joslin Diabetes Center. “It’s just the natural progression of diabetes. But doctors don’t always explain this, and people are very surprised and troubled when it happens.”
It’s important to understand that diabetes does progress. With type 2 diabetes, insulin-producing cells in your pancreas dwindle; as insulin levels fall, blood sugar continues to rise. When British scientists tracked this process in a group of 4,075 women and men with newly diagnosed type 2 diabetes, they found that 75 percent needed several drugs to control blood sugar after 9 years. Just 9 percent kept their blood sugar within a safe range with diet and exercise alone. The researchers concluded that in less than 10 years after diagnosis, most people with type 2 will need insulin shots to keep blood sugar low.
Diet, exercise, and stress reduction are fundamentals of good diabetes care. But when you need more help, ask for it. “Every time you see your doctor about your diabetes, you should discuss how well your treatment plan is working and whether it needs to be changed,” Dr. Snow says. Don’t wait for your doctor to suggest an adjustment. In a 12-year study of 570 diabetics, researchers at Kaiser Permanente Northwest found that doctors often delayed for months or years before upgrading the treatment plans of diabetes patients with high blood sugar.
Maggie Lopez of Port Orange, Florida, had symptoms of type 2 diabetes—and, with her Hispanic heritage and ample waistline, a host of risk factors. “I was tired and thirsty all the time, and I always seemed to have to visit the bathroom,” says the operations supervisor of a call center.
Because she was still in her thirties, Lopez, now 42, never suspected diabetes. But her doctor did and ordered a blood test. The diagnosis: type 2. The treatment: weight loss and healthy eating.
Lopez received a crash course in healthy living. She cut down on bread, rice, and other starches and chose healthy meals when she ate at restaurants. She also began walking 30 minutes each day after work.
That was 5 years ago. Today, Lopez is 32 pounds lighter and feels better than she has since high school. She takes an oral diabetes medication, rosiglitazone maleate (Avandia), and monitors her blood sugar at least twice a day.
Motivated by his wife, Lopez’s 5-foot-7-inch, 270-pound husband, Salvador, had his blood sugar tested and was also diagnosed with type 2. “He’s lost about 50 pounds since he was diagnosed and feels great,” says Lopez. And her daughter, 19-year-old Elizabeth, is also more careful about what she eats. Says Lopez, “Being diagnosed has been a blessing in disguise.”