Diabetes and Nutrition

By Susanne Pettit-Crossman

Diabetes is a common chronic condition affecting three per cent of Canada’s present population. It is believed that if our entire population were tested, this figure would jump to five per cent. Many people have diabetes and don’t even know it.

We often think of diabetes as a relatively new disability, but it goes back as far as ancient Roman and Greek times. Individuals with diabetes noticed a lot of "spilled" sugar in their urine, which drew flies and other sweet-toothed insects to it.

Perhaps we think diabetes is new because it gained far more awareness once insulin was discovered 73 years ago, in 1921. Before this, having diabetes was basically a death sentence for these people who could not properly metabolize the food they ate due to the lack of the hormone insulin, produced by the pancreas.

The pancreas is a gland weighing two-and-a-half to three ounces that lies just behind the stomach. Within the pancreas, small islands -- the "Islets of Langerhans" -- are made up of beta cells which produce insulin.

Without the presence of insulin, glucose cannot get into your cells. Insulin "opens the door" of the cell so that sugar can pass into it. Normally, when we eat any food that raises the blood sugar level, a message tells the pancreas to produce insulin quickly so that the extra sugar can enter body cells rather than remain in the bloodstream. This keeps blood sugar levels within normal limits.

Our body needs a certain amount of sugar; it uses sugar and fat as energy or fuel. Many of the foods we eat such as fruits, vegetables and starchy foods like bread or pasta are made into simple sugar, or glucose, by the body during digestion. Our blood carries the glucose to the cells, but the glucose must enter these cells before it can be used properly as energy. Insulin binds itself to receptors on the cells to allow this energy conversion, which is vital for its control.

If you are a person with diabetes, your pancreas can no longer produce enough or any insulin to keep blood sugar at the correct level.

YOU’RE NOT MY TYPE
There are two types of diabetes: Type I and Type II. There does not seem to be any single reason why people develop diabetes, but a number of factors can lead to Type I or Type II.

About 10 per cent of all people with diabetes have Type I diabetes, where the body produces little or no insulin at all. This type of diabetes is usually discovered in younger people, but can occur in older adults. Referred to as IDIMS (insulin dependent), those individuals with this type must take insulin injections. Signs and symptoms of Type I diabetes include:
- increased thirst (polydipsia)
- frequent urination (polyuria)
- weight loss
- changes in appetite (e.g. polyphagia, or ravenous hunger)
- blurred vision
- extreme tiredness
- itchy skin
- infections, cuts and wounds that heal slowly

Causes of Type I diabetes include:
- heredity (a history of diabetes in your family)
- stress (physical illness or injury)
- viruses (which may have injured your pancreas)
- autoimmune dysfunction - your body’s defense system may attack your insulin-producing cells

In addition to these causes, diabetes may be brought on by medications -- for example, corticosteroids like prednisone. Diabetes may also be the result of another existing condition, such as cystic fibrosis in my case, which affects the pancreas and may affect the beta cells. (I became insulin dependent by the age of 21.) There is also gestational diabetes, which can occur when a woman is pregnant. Blood glucose levels may be higher than normal in the second half of pregnancy, but return to normal in 95 per cent of the cases after the baby is born.

Unlike Type I diabetes, people with Type II diabetes do produce insulin. However, they are unable to use the insulin properly. This is the most common form of diabetes -- 90 per cent of all people with diabetes have Type II. Usually, the problem here is in the receptors on the cells themselves. They may not work properly or, in the case of an individual who is overweight, there are not enough insulin receptors. In either case, glucose builds up in the blood.

Symptoms are similar to Type I, but the onset is slow (over a period of time) rather than rapid. In addition, a person may experience numbness or tingling in the hands or feet, and impotence. Causes of Type II diabetes include:
- age over 40
- overweight
- poor eating habits
- history of gestational diabetes
- family history of diabetes

Medication is not needed for all people with Type II, but in some cases an oral hypoglycemic agent will be prescribed. This agent "kick-starts" the body’s own insulin into working better. Many people with Type II control it with diet, often combined with a weight loss program. In extreme cases where either diet alone or hypoglycemic agents don’t help, insulin may be necessary. People who have Type II diabetes are referred to as NIDIMS (non-insulin dependent).

I AM WHAT I AM
Diagnosis of diabetes is actually very easy. A simple blood test will determine your blood sugar levels. Two blood tests are routinely used:
- Fasting blood sugar test: Blood is taken in the morning before breakfast. If the blood is in the normal range of 4-6 mmol/L, you do not have diabetes. But if it is over 8 mmol/L, then you do.
- Glucose tolerance test: A fasting blood sample is drawn again, and the person then drinks a liquid containing sugar. Every so often an additional sample of blood is drawn to determine how the body deals with the sugar over a period of time. Again, this will diagnose whether or not you have diabetes.

Many people have diabetes and don’t even know it. I for one went for quite some time before actually having these blood tests (they are not routinely done). I had become irritable and thirsty, and was getting up in the night a lot to go to the bathroom. The most significant clue, though, showed up when I studied for my university exams. I notoriously ate a lot of candy when studying, and since my sugar just skyrocketed, I would pass out on my books. But it wasn’t until we actually studied diabetes in one of my nutrition courses that I realized I had all of the symptoms outlined in this article, and diagnosed myself! If you have any doubts at all, ask your doctor for a fasting blood sugar test.

THE MEAL DEAL
Good blood sugar levels depend on a balance between insulin and/or oral agents and exercise --and the right diet, which is the right amount of food energy based on a person’s age, sex, height, frame and weight control. Usually a "mixed meal" effect is strived for. Carbohydrates are combined with protein and/or fat at meals and snacks so that the time it takes the sugar to be absorbed is delayed.

There are several things you can do to plan meals that will help you eat well, feel good and control the diabetes (there is no "cure").
- Eat well-balanced meals (refer to the new Canada’s Food Guide).
- Eat meals and snacks as scheduled (this keeps insulin and food coordinated so you don’t experience any extreme lows or highs with your blood sugar).
- Eat more fibre (which can help reduce blood glucose).
- Eat less sugar (remember, just because you have diabetes, this does not mean you do not need sugar in your diet, but there are good and bad sugars).
- Eat less animal fat.
- Consume less salt.

Finding out you have diabetes and must adhere to a good meal plan is not as difficult or awful as you might think. The diet is just common sense eating, and even someone without diabetes will benefit by the same diet and exercise program.

The only real difference I’ve noticed is that I can no longer "pig out" on everything and anything I want. My food intake is more measured, and I must substitute or interchange foods in the various food groups. As an example, standard protein foods are each equivalent to 30 grams in cooked food weight. A one-ounce steak equals 1/4 cup of cottage cheese, equals one medium egg.

There are diet guidelines and tables available for people with diabetes, although everyone has an individual program. Even if you don’t have diabetes and are considering a weight control program for yourself, you will find these guidelines extremely helpful.

The food groups in these guidelines are basically identical to those in the Canada Food Guide Program. However, foods are divided into the groups with a little more attention paid to their carbohydrate content:
- protein foods (high and low fat choices; will slow down sugar absorption)
- starchy foods (contain complex sugars)
- fruits and vegetables (including only sweet vegetables like beets, tomatoes or squash; contain simple sugars)
- milk choices (contain lactose, or milk sugar)
- fat and oil choices (slow down sugar absorption; also an energy source)
- extra foods (including all other vegetables, usually containing little or no sugar)

The "meal deal" you develop for yourself with a health professional will incorporate all of these groups to maximize your weight and sugar control.
TRY A LITTLE HELP FROM YOUR FRIEND
If you are insulin dependent, it will be necessary for you to inject insulin one to three times daily for the rest of your life. Not the most pleasant of thoughts! The best way to deal with this is to think of the insulin as a friend. Without it, sugars will rise and all the symptoms and side effects will reappear. I remember trying to get around having to inject myself, but finally the needle was by far the lesser of two evils -- better than feeling really quite unwell.

Like the meal plan, insulin is very individualized. There is a variety of insulin available. Depending on your needs, a person will be placed on short-, medium- or long-acting insulin, usually a combination of two. The goal is to blend an insulin with your food and activity that will best match nature’s own insulin pattern.

TOO MUCH OF A GOOD THING
Managing to balance your injected insulin/oral agent, food intake and exercise can be difficult at times. And if one or another of these three variables is changed, you can run into problems. There are two extreme blood sugar states that can be potentially dangerous: hypoglycemia and hyperglycemia.

The term hypoglycemia simply means "too low." Hypoglycemia is caused by too much insulin/oral agent, too little food, too long a period of time between eating, or too much exercise. If someone is hypoglycemic they will quickly experience the following:
- cold, clammy sweat
- pale skin
- shakiness
- weakness
- blurred vision
- headache
- mood change
- hunger
- staggering gait
- dizziness
- slurred speech
- drowsiness

In this situation, a quick boost of sugar is essential -- foods like juice, pop, cubes of sugar, honey or candies. Usually in 5 to 10 minutes this fast sugar will begin to work and the symptoms will disappear. If you have diabetes, these hypoglycemic states are usually referred to as "insulin reactions." They must be dealt with immediately as they can lead to seizures, unconsciousness and coma.

People always tease me because I carry a purse that is bigger than I am, but hypoglycemia is one of the reasons why. I keep candies, fruit juice and a milkshake-type drink with me at all times just in case my blood sugar drops too low. You can never predict this and if you are in your car or walking on a nature trail, a sudden low blood sugar without any backup could kill you. I also tend to buy clothes with pockets in them so I can carry candies or fruit with me.

Hyperglycemia is just the opposite state -- your sugars are too high. This can occur after too much food, not enough exercise or too little medication or insulin. Stress and illness can also affect your sugars. The symptoms are:
- extreme thirst
- frequent urination
- sleepiness
- irritability
- lots of infections or slow healing

Hyperglycemia can be an occasional problem, but if high blood sugars are left out of control on an ongoing basis and over a period of time, someone with diabetes can run into some very serious long-term complications, which is why diabetes can be a dangerous disability.

TO COMPLICATE MATTERS...
Diabetes left out of control and unmanaged can lead to ketoacidosis. If you do not have enough insulin to move glucose into your cells for energy, then the body will start to break down fat, which is a secondary energy source. Over the long term, cells can become severely damaged and a person may have extreme weight loss, making him or her more susceptible to illness and even death.

Other long-term complications leading to disabilities and problems (I would call this adding insult to injury!) include:
- blindness
- dental problems
- kidney failure
- increased infections
- heart attacks and strokes
- impotence
- nerve damage
- problems with pregnancy
- foot problems

MANAGING THE PROCESS
In this article I have discussed a lot of "whats" and "wherefores" to controlling diabetes. But it is most important to understand why.

Good management can help someone with diabetes live longer and avoid some of the problems that are associated with diabetes. These complications can occur with the aging process alone, so why fuel the fire?

Good management can help you improve your quality of life, allowing you to live a much more active and productive life. Other goals of diabetes management include controlling the symptoms, achieving a desirable body weight, maintaining a healthy level of physical activity, and maintaining near-normal blood glucose levels and, ultimately, long-term blood glucose levels.

Most importantly, if you can learn to achieve a sense of well-being with this disability, you can learn to take charge of your diabetes and your life -- instead of the other way around.

(Contributing columnist Susanne Pettit-Crossman is the host of CBC’s Disability Network. Susanne has a nutrition degree from Ryerson Polytechnic University and is a dietitian. She did her internship at Sunnybrook Medical Centre. Susanne manages special dietary needs for both diabetes and cystic fibrosis. She is also an avid gourmet cook and has appeared in T.V. Guide’s Celebrity Chef feature.)