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PDM Newsletter
KDN No. PP4556/08/2012(31341)
Jan - Dec 2012
WDD 2012
NDC 2012
Persatuan Diabetes Malaysia organised three major events in 2012. The 3rd National Diabetes Conference (NDC) 2012 was held on 22nd – 23rd June 2012 at Crowne Plaza Mutiara, Kuala Lumpur. It
was attended by healthcare professionals, mainly doctors and nurses, responsible for managing
people with diabetes. The Workshop 2012 was held on 21st – 22nd September 2012 at Summit
Hotel, Selangor Darul Ehsan. It was attended mainly by nurses from Hospitals and Health Clinics.
The World Diabetes Day (WDD) 2012 was held on 17th November 2012 at Ipoh, Perak It was jointly
organized by the PDM Perak State Branch, PDM HQ, Ministry of Health and other Government
Departments. The activities organized were 10,000 steps, aerobics, exhibition and health screening. The WDD 2012 was launched by YB Dato’ Dr. Mah Hang Soon, EXCO Kesihatan, Perak State Government. PDM State and District Branches organized the WDD 2012 events in their respective cities
and towns, with such activities, as talks and health screenings with the aim of raising public awareness on prevention and control of diabetes and its complications.
Editor’s Message
President’s Message
NDC 2013 & Workshop 2013
Bagaimana untuk beritahu jika anda ada Diabetes atau Prediabetes
Komplikasi kulit
Diet Diabetes dan Panduan Pemakanan
Bolehkah Pil Diabetes Membantu
How to Tell If You Have Diabetes or Prediabetes
Skin Complication
Diabetes Diet and Food Tips
Can Diabetes Pills Help Me
Editor’s Message
Member of International Diabetes Federation
DYTM Raja Muda Perak Darul Ridzuan
Raja Nazrin Shah
It is the time of the year, I suppose, a time for reflection.
A time to take stock. A time to review what the year has
been or hasn’t been. Call it your annual review or your
personal “watchnight service”, if you will. We are talking
about that “iron-clad” promise at the end or the
beginning of the year. We resolve to forge a new
beginning. We promise ourselves that we will do this
and that, we are (were) unwavering in our
determination but these “irrevocable” resolves may last
a few months or just weeks! Sounds all too familiar ?
You are not alone, I have personally lost track of the
number of little and big resolutions made and broken.
Truth be told, I am pretty sure that those of you reading
this would have done the same too. Very few of us have
the power and fortitude to stay the whole course and
finish the race.
Prof Dato’ Dr. Anuar Zaini B. Md. Zain
Dato’ Dr. Shafie B. Ooyub
Prof Dato’ Dr. Ikram Shah B. Ismail
Vice President
Jong Koi Chong
General Secretary
Dato’ Hajah Rahimah Bt. Dato’ Haji Ahmad
Assistant General Secretary
K.S. Maniam
What does this mean if you have diabetes? It is good to
make resolutions about making renewed resolves to
take care of your diabetes and yourselves. You aim to
cut down on your sugar intake that the next Teh Tarik
with plate of Nasi Lemak with Salted fish dish, comes
alone. You promise your doctor or dietitian that you will
watch your cholesterol until aroma of oily fried noodle
with Sambal belacan or extremely sweet Tomyam soup
weakens your every resolve. The fact is: looking after
your diabetes in a veritable 24/7 food paradise is
difficult, if not near impossible. It is akin to asking a kid in
a toy store for the first time not to get excited.
General Treasurer
Editorial Board
Prof. Dato’ Dr. Ikram Shah B. Ismail – Chief Editor
Jong Koi Chong - Editor
Dato’ Hajah Rahimah Bt. Dato’ Haji Ahmad
Dr Vijay Ananda
Dr. S . Elangovan
Dr. Nizam Malik B. Bali Mohamad
Dr. Noraryana Hassan
Nor Hayati Bt. Mohd Nawi
K.S. Maniam
The rest is always history. Do you give up because you
just about break every promise you made to look after
your diabetes better this year? No! Consider the
statistics. For every 1% reduction in your HbA1c towards
the normal level you will reduce your correspondent risk
of eye and kidney complications by 18% not 1%. The
similar risk reduction is 13% for every 10mm mercury
pressure reduction in your high blood pressure toward
the normal level. So make all those promises to yourself
again. If you fail, you never fail alone!
The views, opinions and recommendations contained in
Berita Kontrol are those of the authors and not
necessarily endorsed by the Persatuan Diabetes
Malaysia and the Editiorial Board. The reader should
consult his own doctor for his personal treatment or
other medical advice. The acceptance of advertisements
in the Berita Kontrol does not imply endorsement by
Persatuan Diabetes Malaysia.
Wishing all our readers a Happy and Healthy 2013 New
Year !
Printed by :
Neptune Press
No. 113, Jalan Sultan Abdul Samad
Off Jalan Tun Sambathan
50470 Kuala Lumpur
Tel : 03- 2273 2707 Fax: 03- 2274 7509
Jong Koi Chong
Editor, Berita Kontrol
President’s Message
As you know, PDM is planning an online consultation
process on introducing food advertising guidelines for
children. I hope to hear from all of you when the
consultation start, as your input will have an impact on
the health of our children in future.
Diabetes is a major non-communicable disease (NCD).
Globally, the World Health Organisation estimates that
more than 346 million people worldwide have diabetes.
In Malaysia, more than 3.6 million people have diabetes,
and most of them are above the age of 40. As our
population grows and ages, the number of Malaysian
residents aged above 40 with diabetes is projected to
increase to alarming numbers before 2020.
Screening and prevention of complications
Aside from lifestyle modifications, screening early for
diabetes is also crucial. More than 50% of people with
diabetes are unaware of their condition. I urge PDM
non-diabetics members and their family to undergo
screening early, not just for diabetes, but other chronic
conditions such as high blood pressure and high
cholesterol. Affordable and convenient screening is
available under the Integrated Screening Programme
(ISP), which brings together a bundle of recommended
screening tests.
Diabetes also imposes lifelong demands on people living
with the condition and their families. If left undiagnosed
or poorly treated, diabetes can cause complications such
as blindness, kidney failure, limb amputations, heart
attacks and stroke. Annually, approximately 1 in 700 of
all diabetics develop kidney failure requiring dialysis. In
2010, approximately 1 in 110 diabetics suffered a heart
attack, 1 in 140 diabetics suffered a stroke, and 1 in 400
underwent lower limb amputations.
Managing the condition well
Changing the way we live
Screening must be accompanied by follow-up and
appropriate action, management and treatment to
prevent complications from setting in. Among known
diabetics, the proportion with poor sugar control (HbA1c
≥ 8.0%) was 32.0%. The Chronic Disease Management
Programme (CDMP) has a comprehensive approach to
the care of diabetic patients by general practitioners
(GPs) / family physicians, and follows a standardised
treatment protocol.
The key message of World Diabetes Day 2012 is that
“the way we live is putting our health at risk”. This is a
harsh but true fact. The increasing prevalence in type 2
diabetes has, for most countries, has developed
alongside rapid cultural and social changes, aging
populations, increasing urbanisation, and unhealthy
behaviours such as poor dietary habits and reduced
physical activity. Malaysia has not been spared.
PDM will continue working closely with Ministry of
Health Malaysia to improve our healthcare system,
including ensuring that a healthy lifestyle is accessible
and affordable. The public too, must play their part by
leading healthy lifestyles and encouraging others to do
so. Together, we can promote healthy communities and
families and protect our future. To all PDM branches
throughout the country I wish you all the best in your
unswerving fight against diabetes in coming 2013.
A major risk factor for developing diabetes is obesity.
Though our rates of obesity are relatively low compared
to other countries like the USA or UK, this is no time for
complacency. The rates of obesity in Malaysia residents
increased drastically since 2006. We are therefore
stepping up efforts to promote physical activity in the
population. A common barrier to exercising which has
been cited is “a lack of time”. However, physical activity
need not happen only in the gym, but anytime,
anywhere, and can be accumulated through small
changes in daily lifestyle habits, such as taking the
staircases or walking to nearby hawker centres for lunch
rather than driving.
Thank you.
Encouraging good habits is a lifelong process which
should start from young. Getting our youth to adopt a
healthy lifestyle sets the stage for them to continue
maintaining healthier habits into adulthood and old age.
Therefore, PDM activities will leverage a peer-to-peer
approach for health promotion. Another strategy we will
be exploring is how to minimise the exposure of
advertising of foods high in salt, sugar and fat content to
Prof. Dato’ Dr. Ikram Shah Ismail
President, PDM
HOW TO TELL IF YOU HAVE DIABETES OR PREDIABETES What to Do If You Have Prediabetes While diabetes and prediabetes occur in people of all ages and races, some groups have a higher risk for developing the disease than others. Diabetes is more common in African Americans, Latinos, Native Americans, and Asian Americans/Pacific Islanders, as well as the aged population. This means they are also at increased risk for developing prediabetes. Prediabetes is a serious medical condition that can be treated. The good news is that the recently completed Diabetes Prevention Program (DPP) study conclusively showed that people with prediabetes can prevent the development of type 2 diabetes by making changes in their diet and increasing their level of physical activity. They may even be able to return their blood glucose levels to the normal range. There are three different tests your doctor can use to determine whether you have prediabetes: •
While the DPP also showed that some medications may delay the development of diabetes, diet and exercise worked better. Just 30 minutes a day of moderate physical activity, coupled with about a 7% reduction in body weight, produced a 58% reduction in diabetes. The A1C test (HbAIC) The fasting plasma glucose test (FPG) or the oral glucose tolerance test (OGTT). The blood glucose levels measured after these tests determine whether you have a normal metabolism, or whether you have prediabetes or diabetes. The American Diabetes Association is developing materials that will help people understand their risks for pre-­‐diabetes and what they can do to halt the progression to diabetes and even to, "turn back the clock" In the meantime, we have a wealth of resources for people with diabetes or at risk for diabetes that can be of use to people interested in prediabetes. If your blood glucose level is abnormal following the FPG, you have impaired fasting glucose (IFG); if your blood glucose level is abnormal following the OGTT, you have impaired glucose tolerance (IGT). Both are also known as prediabetes. Weight Loss Being overweight or obese increases your risk for type 2 diabetes. Losing just a few pounds through exercise and eating well can help with your prediabetes and can reduce your overall risk. Q: What is prediabetes? A: Prediabetes is when a person's blood glucose levels are higher than normal but not high enough to be type 2 diabetes. People with prediabetes are more likely to develop type 2 diabetes and may have some problems from diabetes already. mg/dl
divided by 18
= mmol/l
times 18
= mg/dl
Q: If I have prediabetes, will I definitely develop type 2 diabetes? A: No. Research shows that you can lower your risk for type 2 diabetes by 58% by: 6 •
Losing 7% of your body weight (or 6.8kg if you weight 91kg) •
Exercising moderately (such as brisk walking) 30 minutes a day, five days a week •
An A1C 5.6% or below is normal. In prediabetes, A1C levels range between 5.7%-­‐6.4%. If the A1C is 6.5% or above, a person has diabetes. Q: Who should get tested for prediabetes? A:People in these groups should be tested: Don't worry if you can't get to your ideal body weight. Losing just 10 pounds (4.5kg) to 15 pounds (6.8kg) can make a huge difference. For some people with prediabetes, early treatment can actually return blood glucose levels to the normal range. •
Q: How do I know if I have prediabetes? A: Doctors can use a fasting plasma glucose test (FPG), oral glucose tolerance test (OGTT), or an A1C test to detect prediabetes: •
If you are overweight and age 45 or older, you should be checked for prediabetes during your next routine medical office visit. If your weight is normal and you're over age 45, you should ask your doctor during a routine office visit if testing is appropriate. For adults younger than 45 and overweight, your doctor may recommend testing if you have any other risk factors for diabetes or prediabetes, including: FPG •
Requires a person to fast overnight. The blood glucose is measured first thing in the morning before eating. Normal FPG is below 6 mmol/l. A person with prediabetes has a fasting blood glucose level between 5.5 mmol/l and 6.9 mmol/l. If the blood glucose level rises to 7 mmol/l or above, a person has diabetes. o
Q: How often should I be tested? A: If your blood glucose levels are in the normal range, get checked every three years, or more often if your doctor recommends it. If you have prediabetes, you should be checked for type 2 diabetes every one or two years after you are told you have prediabetes. OGTT •
Also requires a person to fast overnight. The person's blood glucose is checked after fasting and again 2 hours after drinking a glucose-­‐rich drink. Normal blood glucose is below 7.8 mmol/l, 2 hours after the drink. In prediabetes, the 2-­‐
hour blood glucose is 7.8 to 11.0 mmol/l. If the 2-­‐hour blood glucose rises to 200 mg/dl or above, a person has diabetes. Q: What is the treatment for prediabetes? A: Treatment consists of losing a modest amount of weight (7% of total body weight) through healthy eating and moderate exercise, such as walking, 30 minutes a day, five days a week. A1C •
A blood test that gives the average amount of glucose in the blood over the past 3-­‐4 months. Don't worry if you can't get to your ideal body weight. Losing just 4.5kg to 6.8kg can make a big difference. 7 high blood pressure low HDL cholesterol and high triglycerides a family history of diabetes a history of gestational diabetes or giving birth to a baby weighing more than 9 pounds belonging to an ethnic or minority group at high risk for diabetes If you have prediabetes, you are at a 50% increased risk for heart disease or stroke, so your doctor may wish to treat or counsel you about cardiovascular risk factors, such as tobacco use, high blood pressure, and high cholesterol. • SKIN COMPLICATION Q: Will my insurance cover testing and treatment? A: All insurance plans are different. However, Medicare and most insurance plans cover diabetes testing for people suspected of having diabetes. People at risk for diabetes are also at risk for prediabetes. Since the test is the same and the risk factors are the same for both conditions, a prediabetes test may be covered. Talk to your doctor and health insurance company to be sure. Diabetes can affect every part of the body, including the skin. As many as 33 percent of people with diabetes will have a skin disorder caused or affected by diabetes at some time in their lives. In fact, such problems are sometimes the first sign that a person has diabetes. Luckily, most skin conditions can be prevented or easily treated if caught early. Some of these problems are skin conditions anyone can have, but people with diabetes get more easily. These include bacterial infections, fungal infections, and itching. Other skin problems happen mostly or only to people with diabetes. These include diabetic dermopathy, necrobiosis lipoidica diabeticorum, diabetic blisters, and eruptive xanthomatosis. Q: Is prediabetes the same as Impaired Glucose Tolerance or Impaired Fasting Glucose? A: Yes. Doctors sometimes refer to high blood glucose levels as Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG), depending on what test was used to detect it. General Skin Conditions Q: How many people with prediabetes go on to develop type 2 diabetes? A: One major study, the Diabetes Prevention Program, showed about 11% of people with prediabetes developed type 2 diabetes each year during the average three years of follow-­‐up. Other studies show that many people with prediabetes develop type 2 diabetes in 10 years. Bacterial Infections Several kinds of bacterial infections occur in people with diabetes: •
Q: Could I have prediabetes and not know it? A: Absolutely. People with prediabetes don't often have symptoms. In fact, millions of people have diabetes and don't know it because symptoms develop so gradually, people often don't recognize them. Some people have no symptoms at all. Symptoms of diabetes include: •
Styes (infections of the glands of the eyelid) Boils Folliculitis (infections of the hair follicles) Carbuncles (deep infections of the skin and the tissue underneath) Infections around the nails Inflamed tissues are usually hot, swollen, red, and painful. Several different organisms can cause infections, the most common being Staphylococcus bacteria, also called staph. unusual thirst frequent urination blurred vision extreme fatigue frequent infections cuts/bruises that are slow to heal tingling/numbness in the hands/feet Once, bacterial infections were life threatening, especially for people with diabetes. Today, death is rare, thanks to antibiotics and better methods of blood sugar control. But even today, people with diabetes have more bacterial infections than other people do. Doctors 8 recurring skin, gum, or bladder infections Dermopathy often looks like light brown, scaly patches. These patches may be oval or circular. Some people mistake them for age spots. This disorder most often occurs on the front of both legs. But the legs may not be affected to the same degree. The patches do not hurt, open up, or itch. believe people with diabetes can reduce their chances of these infections by practicing good skin care. If you think you have a bacterial infection, see your doctor. Fungal Infections Dermopathy is harmless and doesn't need to be treated. The culprit in fungal infections of people with diabetes is often Candida albicans. This yeast-­‐like fungus can create itchy rashes of moist, red areas surrounded by tiny blisters and scales. These infections often occur in warm, moist folds of the skin. Problem areas are under the breasts, around the nails, between fingers and toes, in the corners of the mouth, under the foreskin (in uncircumcised men), and in the armpits and groin. Necrobiosis Lipoidica Diabeticorum Another disease that may be caused by changes in the blood vessels is necrobiosis lipoidica diabeticorum (NLD). NLD causes spots similar to diabetic dermopathy, but they are fewer, larger, and deeper. NLD often starts as a dull, red, raised area. After a while, it looks like a shiny scar with a violet border. The blood vessels under the skin may become easier to see. Sometimes NLD is itchy and painful. Sometimes the spots crack open. Common fungal infections include jock itch, athlete's foot, ringworm (a ring-­‐shaped itchy patch), and vaginal infection that causes itching. If you think you have a yeast or fungal infection, call your doctor. You will need a prescription medicine to cure it. NLD is a rare condition. Adult women are the most likely to get it. As long as the sores do not break open, you do not need to have it treated. But if you get open sores, see your doctor for treatment. Itching Localized itching is often caused by diabetes. It can be caused by a yeast infection, dry skin, or poor circulation. When poor circulation is the cause of itching, the itchiest areas may be the lower parts of the legs. Atherosclerosis Atherosclerosis is a thickening of the arteries that can affect the skin on the legs. People with diabetes tend to get atherosclerosis at younger ages than other people do. You may be able to treat itching yourself. Limit how often you bathe, particularly when the humidity is low. Use mild soap with moisturizer and apply skin cream after bathing. As atherosclerosis narrows the blood vessels, the skin changes. It becomes hairless, thin, cool, and shiny. The toes become cold. Toenails thicken and discolor. And exercise causes pain in the calf muscles because the muscles are not getting enough oxygen. Diabetes-­‐Related Skin Conditions Diabetic Dermopathy Because blood carries the infection-­‐fighting white cells, affected legs heal slowly when the skin in injured. Even minor scrapes can result in open sores that heal slowly. Diabetes can cause changes in the small blood vessels. These changes can cause skin problems called diabetic dermopathy. 9 People with neuropathy are more likely to suffer foot injuries. These occur because the person does not feel pain, heat, cold, or pressure as well. The person can have an injured foot and not know about it. The wound goes uncared for, and so infections develop easily. Atherosclerosis can make things worse. The reduced blood flow can cause the infection to become severe. Digital Sclerosis Allergic Reactions This condition happens to about one third of people who have type 1 diabetes. The only treatment is to bring blood sugar levels under control. Sometimes, people with diabetes develop tight, thick, waxy skin on the backs of their hands. Sometimes skin on the toes and forehead also becomes thick. The finger joints become stiff and can no longer move the way they should. Rarely, knees, ankles, or elbows also get stiff. Allergic skin reactions can occur in response to medicines, such as insulin or diabetes pills. You should see your doctor if you think you are having a reaction to a medicine. Be on the lookout for rashes, depressions, or bumps at the sites where you inject insulin. Disseminated Granuloma Annulare In disseminated granuloma annulare, the person has sharply defined ring-­‐ or arc-­‐shaped raised areas on the skin. These rashes occur most often on parts of the body far from the trunk (for example, the fingers or ears). But sometimes the raised areas occur on the trunk. They can be red, red-­‐brown, or skin-­‐colored. Diabetic Blisters (Bullosis Diabeticorum) Rarely, people with diabetes erupt in blisters. Diabetic blisters can occur on the backs of fingers, hands, toes, feet, and sometimes, on legs or forearms. These sores look like burn blisters and often occur in people who have diabetic neuropathy. They are sometimes large, but they are painless and have no redness around them. They heal by themselves, usually without scars, in about three weeks. The only treatment is to bring blood sugar levels under control. See your doctor if you get rashes like this. There are drugs that can help clear up this condition. Acanthosis Nigricans Acanthosis nigricans is a condition in which tan or brown raised areas appear on the sides of the neck, armpits, and groin. Sometimes they also occur on the hands, elbows, and knees. Eruptive Xanthomatosis Eruptive xanthomatosis is another condition caused by diabetes that's out of control. It consists of firm, yellow, pea-­‐like enlargements in the skin. Each bump has a red halo and may itch. This condition occurs most often on the backs of hands, feet, arms, legs, and buttocks. Acanthosis nigricans usually strikes people who are very overweight. The best treatment is to lose weight. Some creams can help the spots look better. The disorder usually occurs in young men with type 1 diabetes. The person often has high levels of cholesterol and fat in the blood. Like diabetic blisters, these bumps disappear when diabetes control is restored. 10 Sourse : American Diabetes Association is gained, constant monitoring and exercising will help prevent complications. Methods to Adapt When Overindulgence Is Unavoidable Alcohol contains toxins triggering an active process of detoxification in the body. However, there is a limit to which diabetics will be able to resist building calories. The system can be adversely affected, if calorie buildup exceeds dangerous limits due to overindulgence in alcohol. A drink or two may not cause as much damage as consuming half a bottle of the choicest drink. Losing consciousness or balance may occur much earlier in diabetics than normal people. Individual capacity has to be taken into consideration. People often buy Diabeta from canada pharmacies to control blood sugar levels. The prescription medication can be easily combined with proper diet and exercise to stimulate release of natural insulin from the body. Properly following a medical plan prescribed by the doctor will help overcome overindulgence to some extent. Prediabetes is a condition that normally occurs before full-­‐blown diabetes is diagnosed. It also means people have excess blood glucose levels, and insulin produced in the body may not be sufficient enough to keep it under control. Such people have to focus more on keeping body weight under control by exercising regularly and generating enough strength to withstand sudden changes in diet and lifestyle habits. In such cases, pre-­‐festive preparation may help much more in terms of reducing damage caused by overindulgence during the holidays. Canada pharmacies recommend that people develop the habit of disciplined living once diabetes sets in. HOW DIABETES CAN BE MANAGED IN FESTIVE SEASON People tend to rejoice and celebrate during the festival season, which may not always be a good move for those suffering from diabetics. It is a challenge to maintain optimum blood sugar levels throughout the year but is especially difficult during the holidays. Canada pharmacies point out it is a time when family members meet each other. Euphoria is in the air. People suffering from diabetes are often forced to overindulge in fatty foods. It is therefore not uncommon for them to gain disproportionate weight within a short period of time. Losing it becomes a major problem once normalcy returns after the holidays. There are, however, some basic precautions diabetics can take in preparation for such events. One of the most common reasons for overindulgence is abstinence from eating food in anticipation of a sumptuous meal at get-­‐togethers, family reunions, or parties in general. People resort to instant diets in order to reduce weight and then “let go” when the festive season arrives. Ideally, diabetics should never starve or overindulge in food at one go. It is always better to have a small snack consisting of fresh fruits or vegetables. The habit provides ample scope to avoid overstuffing at any event. Choice of foods can always be manipulated depending on the season. Chocolate cakes, consumption of alcohol, and a wide variety of food items served at bouquets can be especially damaging and difficult to overcome during the festive season. Exercise is one of the best ways to enable the body recover from such events. If weight 11 sugar rapidly, while low GI foods have the least effect. DIABETES DIET AND FOOD TIPS Diabetes And Diet Tip 1: Choose High-­‐Fiber, Slow-­‐
Release Carbs You can find glycemic index and glycemic load tables online, but you don’t have to rely on food charts in order to make smart choices. Australian chef Michael Moore has come up with an easier way to regulate the carbs you eat. He classifies foods into three broad categories: fire, water, and coal. The harder your body needs to work to break food down, the better. Carbohydrates have a big impact on your blood sugar levels—more so than fats and proteins—but you don’t have to avoid them. You just need to be smart about what types of carbs you eat. In general, it’s best to limit highly refined carbohydrates like white bread, pasta, and rice, as well as soda, candy, and snack foods. Focus instead on high-­‐fiber complex carbohydrates—also known as slow-­‐release carbs. Slow-­‐release carbs help keep blood sugar levels even because they are digested more slowly, thus preventing your body from producing too much insulin. They also provide lasting energy and help you stay full longer. •
Choosing carbs that are packed with fiber (and don’t spike your blood sugar) Instead of… Try these high-­‐fiber options… White rice Brown rice or wild rice White potatoes Sweet potatoes, yams, (including fries and winter squash, mashed potatoes) cauliflower mash Regular pasta Whole-­‐wheat pasta White bread Whole-­‐wheat or whole-­‐
grain bread Sugary breakfast cereal High-­‐fiber breakfast cereal (Raisin Bran, etc.) Instant oatmeal Steel-­‐cut oats or rolled oats Croissant or pastry Bran muffin •
8 principles of low-­‐glycemic eating 1. Eat a lot of non-­‐starchy vegetables, beans, and fruits such as apples, pears, peaches, and berries. Even tropical fruits like bananas, mangoes, and papayas tend to have a lower glycemic index than typical desserts. 2. Eat grains in the least-­‐processed state possible: “unbroken,” such as whole-­‐kernel bread, brown rice, and whole barley, millet, and wheat berries; or traditionally processed, such as stone-­‐ground bread, steel-­‐cut oats, and natural granola or muesli breakfast cereals. Making the glycemic index easy What foods are slow-­‐release? Several tools have been designed to help answer this question. The glycemic index (GI) tells you how quickly a food turns into sugar in your system. Glycemic load, a newer term, looks at both the glycemic index and the amount of carbohydrate in a food, giving you a more accurate idea of how a food may affect your blood sugar level. High GI foods spike your blood 12 Fire foods have a high GI, and are low in fiber and protein. They include “white foods” (white rice, white pasta, white bread, potatoes, most baked goods), sweets, chips, and many processed foods. They should be limited in your diet. Water foods are free foods—meaning you can eat as many as you like. They include all vegetables and most types of fruit (fruit juice, dried fruit, and canned fruit packed in syrup spike blood sugar quickly and are not considered water foods). Coal foods have a low GI and are high in fiber and protein. They include nuts and seeds, lean meats, seafood, whole grains, and beans. They also include “white food” replacements such as brown rice, whole-­‐
wheat bread, and whole-­‐wheat pasta. 3. Limit white potatoes and refined grain products such as white breads and white pasta to small side dishes. 4. Limit concentrated sweets—including high-­‐
calorie foods with a low glycemic index, such as ice cream— to occasional treats. Reduce fruit juice to no more than one cup a day. Completely eliminate sugar-­‐sweetened drinks. 5. Eat a healthful type of protein at most meals, such as beans, fish, or skinless chicken. 6. Choose foods with healthful fats, such as olive oil, nuts (almonds, walnuts, pecans), and avocados. Limit saturated fats from dairy and other animal products. Completely eliminate partially hydrogenated fats (trans fats), which are in fast food and many packaged foods. 7. Have three meals and one or two snacks each day, and don’t skip breakfast. 8. Eat slowly and stop when full. •
Adapted from Ending the Food Fight, by David Ludwig with Suzanne Rostler (Houghton Mifflin, 2008). Diabetes and Diet Tip 2: Be Smart About Sweets Tricks for cutting down on sugar Eating for diabetes doesn’t mean eliminating sugar. If you have diabetes, you can still enjoy a small serving of your favorite dessert now and then. The key is moderation. •
But maybe you have a sweet tooth and the thought of cutting back on sweets sounds almost as bad as cutting them out altogether. The good news is that cravings do go away and preferences change. As your eating habits become healthier, foods that you used to love may seem too rich or too sweet, and you may find yourself craving healthier options. •
How to include sweets in a diabetes-­‐friendly diet •
Hold the bread (or rice or pasta) if you want dessert. Eating sweets at a meal adds extra carbohydrates. Because of this it is best to •
13 cut back on the other carb-­‐containing foods at the same meal. Add some healthy fat to your dessert. It may seem counterintuitive to pass over the low-­‐fat or fat-­‐free desserts in favor of their higher-­‐fat counterparts. But fat slows down the digestive process, meaning blood sugar levels don’t spike as quickly. That doesn’t mean, however, that you should reach for the donuts. Think healthy fats, such as peanut butter, ricotta cheese, yogurt, or some nuts. Eat sweets with a meal, rather than as a stand-­‐alone snack. When eaten on their own, sweets and desserts cause your blood sugar to spike. But if you eat them along with other healthy foods as part of your meal, your blood sugar won’t rise as rapidly. When you eat dessert, truly savor each bite. How many times have you mindlessly eaten your way through a bag of cookies or a huge piece of cake. Can you really say that you enjoyed each bite? Make your indulgence count by eating slowly and paying attention to the flavors and textures. You’ll enjoy it more, plus you’re less likely to overeat. Reduce how much soda and juice you drink. If you miss your carbonation kick, try sparkling water either plain or with a little juice mixed in. Reduce the amount of sugar in recipes by ¼ to ⅓. If a recipe calls for 1 cup of sugar, for example, use ⅔ or ¾ cup instead. You can also boost sweetness with cinnamon, nutmeg, or vanilla extract. Find healthy ways to satisfy your sweet tooth. Instead of ice cream, blend up frozen bananas for a creamy, frozen treat. Or enjoy a small chunk of dark chocolate, rather than your usual milk chocolate bar. Start with half of the dessert you normally eat, and replace the other half with fruit. Proceed with caution when it comes to alcohol Ways to reduce unhealthy fats and add healthy fats: It’s easy to underestimate the amount of calories and carbs in alcoholic drinks, including beer and wine. And cocktails mixed with soda and juice can be loaded with sugar. If you’re going to drink, do so in moderation (no more than 1 drink per day for women; 2 for men), choose calorie-­‐free drink mixers, and drink only with food. If you’re diabetic, always monitor your blood glucose, as alcohol can interfere with diabetes medication and insulin. •
Diabetes and Your Diet Tip 3: Choose Fats Wisely •
Fats can be either helpful or harmful in your diet. People with diabetes are at higher risk for heart disease, so it is even more important to be smart about fats. Some fats are unhealthy and others have enormous health benefits. But all fats are high in calories, so you should always watch your portion sizes. •
Unhealthy fats – The two most damaging fats are saturated fats and trans fats. Saturated fats are found mainly in animal products such as red meat, whole milk dairy products, and eggs. Trans fats, also called partially hydrogenated oils, are created by adding hydrogen to liquid vegetable oils to make them more solid and less likely to spoil—which is very good for food manufacturers, and very bad for you. •
Diabetes and Diet Tip 4: Eat Regularly and Keep A Food Diary If you’re overweight, you may be encouraged to note that you only have to lose 7% of your body weight to cut your risk of diabetes in half. And you don’t have to obsessively count calories or starve yourself to do it. •
Healthy fats – The best fats are unsaturated fats, which come from plant and fish sources and are liquid at room temperature. Primary sources include olive oil, canola oil, nuts, and avocados. Also focus on omega-­‐3 fatty acids, which fight inflammation and support brain and heart health. Good sources include salmon, tuna, and flaxseeds. When it comes to successful weight loss, research shows that the two most helpful strategies involve following a regular eating schedule and recording what you eat. Eat at regularly set times Your body is better able to regulate blood sugar levels—and your weight—when you maintain a regular meal schedule. Aim for moderate and consistent portion sizes for each meal or snack. 14 Cook with olive oil instead of butter or vegetable oil. Trim any visible fat off of meat before cooking and remove the skin before cooking chicken and turkey. Instead of chips or crackers, try snacking on nuts or seeds. Add them to your morning cereal or have a little handful for a filling snack. Nut butters are also very satisfying and full of healthy fats. Instead of frying, choose to grill, broil, bake, or stir-­‐fry. Serve fish 2 or 3 times week instead of red meat. Add avocado to your sandwiches instead of cheese. This will keep the creamy texture, but improve the health factor. When baking, use canola oil or applesauce instead of shortening or butter. Rather than using heavy cream, make your soups creamy by adding low-­‐fat milk thickened with flour, pureed potatoes, or reduced-­‐fat sour cream. •
other moderate-­‐intensity activities—meaning you work up a light sweat and start to breathe harder. Even house and yard work counts. Don’t skip breakfast. Start your day off with a good breakfast. Eating breakfast every day will help you have energy as well as steady blood sugar levels. Eat regular small meals—up to 6 per day. People tend to eat larger portions when they are overly hungry, so eating regularly will help you keep your portions in check. Keep calorie intake the same. Regulating the amount of calories you eat on a day-­‐to-­‐
day basis has an impact on the regularity of your blood sugar levels. Try to eat roughly the same amount of calories every day, rather than overeating one day or at one meal, and then skimping on the next. CAN DIABETES PILLS HELP ME? Only people with Type 2 Diabetes can use pills to manage their diabetes. These pills work best when used with meal planning and exercise. This way you have three therapies working together to lower your blood glucose levels. Diabetes pills don’t work for everyone. Although most people finda that their blood glucose level go down when they begin taking pills, their blood glucose levels may not go near the normal range. What are the chances that diabetes pills will work for you? Your chances are low if you have had diabetes for more than 10 years or already take more than 20 units of insulin each day. On the other hand, your chances are good if you developed diabetes recently or have needed little or no insulin to keep your blood glucose level near normal. Keep a food diary Research shows that people who keep a food diary are more likely to lose weight and keep it off. In fact, a recent study found that people who kept a food diary lost twice as much weight as those who didn’t. Why does writing down what you eat and drink help you drop pounds? For one, it helps you identify problem areas—such as your afternoon snack or your morning latte—where you’re getting a lot more calories than you realized. It also increases your awareness of what, why, and how much you’re eating, which helps you cut back on mindless snacking and emotional eating. Diabetes pills sometimes stop working after a few months or years. The cause is often unknown. This doesn’t mean your diabetes is worse. When this happens, oral combination therapy can help. Even if diabetes pills do bring your blood glucose level near the normal range, you may still need to take insulin if you have a severe infection or need surgery. Pills may not be able to control blood glucose levels during these stressful times when blood glucose levels shoot up. What about exercise? When it comes to preventing, controlling, or reversing diabetes, you can’t afford to overlook exercise. Exercise can help your weight loss efforts, and is especially important in maintaining weight loss. There is also evidence that regular exercise can improve your insulin sensitivity even if you don’t lose weight. Also, if you plan o become pregnant, you will need to control your diabetes with diet and and exercise or with insulin. It is not safe for pregnant women to take oral diabetes medications. There is no “best” pill or treatment for Type 2 diabetes. You may need to try more than one type of pill, combination pills or pills plus insulin. You don’t have to become a gym rat or adopt a grueling fitness regimen. One of the easiest ways is to start walking for 30 minutes five or more times a week. You can also try swimming, biking, or any 15 How Do They Work? Meglitinides In people with diabetes, blood glucose levels are too high. These high levels occur because glucose remains in the blood rather than entering cells, where it belongs. But for glucose to pass into a cell, insulin must be present and the cell must be “hungry” for glucose. People with Type 1 diabetes don’t make insulin. For them, insulin shots are the only way to keep blood glucose levels down. People with Type 2 diabetes tend to have two problems: they don’t make quite enough insulin and the cells of their bodies don’t seem to take in glucose as eagerly as they should. Meglitinides are drugs that also stimulate the beta cells to release insulin. Repaglinide (Prandin) and Nateglinide (Starlix) are Meglitinides. They are taken before each of three meals. Because sulfonylureas and meglitinides stimulate the release of insulin, it is possible to have hypoglycemia (low blood glucose levels). You should know that alcohol and some diabetes pills may not mix. Occasionally, chlorpropamide, and other sulfonylureas , can interact with alcohol to cause vomiting, flushing or sickness. Ask your doctor if you are concerned about any of these side effects. What Are My Options? Biguanides All diabetes pills sold today are members of six classes drugs that work in different ways to lower blood glucose levels: Metformin (Glucophage) is a biguanide. Biguanides lower blood glucose levels primarily by decreaing the amount of glucose produced by the liver. Metformin also helps to lower blood glucose levelsby making muscle tissue more sensitive to insulin so glucose can be absorbed. It is usually taken two times a day. A side effect of metformin may be diarrhea, but this is improved when the drug is taken with food. •
Sulfonylureas Meglitinides Biguanides Thiazolidinediones Alpha-­‐glucosidase inhibitors DPP-­‐4inhibitors Thiazolidinediones Sulfonylureas Rosiglitazone (Avandia) and pioglitazone (ACTOS) are in a group of drugs called thiazolidinediones. These drugs help insulin work better in the muscle and fat and also reduce glucose production in the liver. The first drug in this group, troglitazone (Rezulin), was removed from the market because it caused serious liver problems in a small number of people. So far rosiglitazone and pioglitazone have not shown the same problems, but users ares still monitored closely for liver problems as a precaution. Both drugs appear to increase the risk for heart failure in some individuals, and there is debate about whether rosiglitazone may contribute to an increased risk for heart attacks. Both drugs are effective at reducing A1C and generally have few side effects. Sulfonylureas stimulate the beta cells of the pancreas to release more insulin. Sulfonylurea drugs have been in use since the 1950s. Chlorpropamide (Diabinese) is the only first-­‐
generation sulfonylurea still in use today. The second generation sulfonylureas are used in smaller doses than the first-­‐generation drugs. There are three second-­‐generation: glipizide (Glucotrol and Glucotrol XL), and glimepiride (Amaryl). These drugs are generally taken one to two times a day, before meals. All sulfonylurea drugs have similar effects on blood glucose levels, but they differ in side effects, how often they are taken, and interactions with other drugs. 16 Alpha-­‐glucosidase inhibitors Is There A Danger of Interactions? Acarbose (Glycobay) are alpha-­‐glucosidase inhibitors. These drugs help the body to lower blood glucose levels by blocking the breakdown of starches, such as bread, potatoes, and pasta in the intestine. They also slow the breakdown of some sugars, such as table sugar. Their action slows the rise in blood glucose levels after a meal. They should be taken with the first bite of a meal. These drugs may have side effects, including gas and diarrhea. In general, diabetes pills are safe and work well. But like any other drug, they must be used with care. All diabetes pills can interact with other medicines. Because of the chance of medication interactions, you need to tell your doctor about all medicines you are taking. While you’re taking diabetes pills, you should check with your doctor before starting anything new – even over-­‐the-­‐counter items. Any sulfonylurea or meglitinide can cause blood glucose levels to drop too low (hypoglycemia). Metformin or the glitazones rarely cause hypoglycemia unless taken with insulin stimulators (sulfonylureas or repaglinide) or insulin injections. Acarbose or meglitol, taken as prescribed, does not cause hypoglycemia. However, hypoglycemia can occur when acarbose or meglitol is taken in combination with other oral diabetes medications. DPP-­‐4 Inhibitors A new class called DPP-­‐4 inhibitors help improve A1C without using hypoglycemia. They work by preventing the breakdown of a naturally occurring compound in the body, GLP-­‐1. GLP-­‐1 reduces blood glucose levels in the body, but is broken down very quickly so it does not work well when injected as a drug itself. By interfering in the process that breaks down GLP-­‐1, DPP-­‐4 inhibitors allow it to remain active in the body longer, lowering blood glucose levels only when they are elevated. DPP-­‐4 inhibitors do not tend to cause weight gain and tend to have a neutral or positive effect on cholesterol levels. Sitagliptin (Januvia) and saxagliptin (Onglyza) are the two DPP-­‐4 inhibitors currently on the market. How Much Does It Cost? Costs vary widely among the different medications. Even the same medication can vary in price from store to store. Call around to find the best price for the one you take. Generic versions of some sulfonylureas are available. These cost less than brand-­‐name and in general are reliable. There is now a generic Metformin (Glucophage). To save you more money, ask your doctor to prescribe the largest tablet strength suitable for the dose you need. One 500-­‐mg tablet, for example, often costs much less than two 250-­‐mg tablets. You can then use a pill splitter (available at any pharmacy) to cut the larger tablet into halves or quarters to get the appropriate dose, if necessary. (Caution: some extended-­‐release drugs will not work properly if they cut into pieces; check with your pharmacist or doctor before using a pill spliter). Diabetes pills aren’t perfect, but they can help to lower glucose levels for many people with Type 2 diabetes. Keeping your blood glucose levels close to normal will help to reduce risks for the long-­‐term complications in the future and help you feel your best today. Oral Combination Therapy Because the drugs listed above act in different ways to lower blood glucose levels, they may be used together. For example, a biguanide and a sulfonylurea may be used together. Many combinations can be used. Though taking more than one drug can be more costly and can increase the risk of side effects, combining oral medications can improve blood glucose control when taking onlya single pill does not have the desired effects. Switching from one single pill to another is not as effective as adding another type of diabetes medicine. 17 What About Insulin? Although it is a common practice to try pills before insulin, you may start on insulin based on several factors, including the following: •
How long you have had diabetes How high your blood glucose level is What other medicines you take Your overall health Because diabetes pill seem to help the body use insulin better, some people take them along with insulin shots. The idea behind “combination” therapy is to try to help insulin work better. Source : American Diabetes Association. 18