Take control of diabetes!

January 29, 2009

Hundreds of tools fill the crowded workshop where Bob Bryant makes specialty parts. But the most important tool the maintenance mechanic uses each day is his blood glucose meter.

Two to three times daily, Bryant sticks his finger and checks glucose (sugar) levels in the blood sample. If his sugar is low, he’ll take glucose tablets or consume a fast-acting carbohydrate, like juice. If it’s high, he’ll try to determine what caused the rise, increase his fluids and take a walk. Bryant, 55, has Type 2 diabetes, the most common of the three main types. He found out in 1996, after extreme thirst, frequent urination and fatigue brought him to his primary care physician. He was referred to the Joslin Diabetes Center Affiliate at The Hospital of Central Connecticut for testing and the official diagnosis. “I wasn’t too concerned at first. My symptoms weren’t that bad,”the Plainville man says.In fact, for the first few years, Bryant didn’t check his blood sugar regularly, change his diet or exercise. When he began experiencing more serious problems, like dizziness and fainting, Bryant realized he needed to take care of himself. “I decided I want to be around see my grandchildren graduate and get married.”

Avoiding complications
The American Diabetes Association (ADA) estimates that 23.6 million Americans — 7.8 percent — have diabetes. About 17.9 million have been diagnosed; the other 5.7 million don’t know they have it. This lack of awareness can be dangerous. An immediate effect of diabetes is excess glucose in the blood and insufficient fuel for cells, which can increase thirst and urination and cause fatigue, blurred vision and non-healing cuts. Sometimes, though, symptoms are mild and can go unnoticed. Over time, untreated or poorly managed diabetes can lead to cardiovascular disease (heart disease, stroke), kidney damage, blindness, and/or nerve damage, particularly in the feet. But these complications aren’t inevitable, says Latha Dulipsingh, M.D., medical director of the Joslin Affiliate at The Hospital of Central Connecticut (HCC). She says many people with diabetes can avoid or delay complications indefinitely by:

• Adopting a healthy lifestyle – choosing nutritious foods, exercising regularly
• Taking medications as directed
• Checking blood sugar regularly
• Seeing healthcare providers regularly

To help, Joslin offers individual counseling and classes to teach patients how to manage the disease and support groups to help people deal with the diagnosis. The Affiliate treats people 18 and older with Type 1, Type 2 and gestational diabetes. Opened 11 years ago, it’s one of just two Connecticut hospital affiliates of the international Joslin Diabetes Center. Joslin specialists include endocrinologists (physicians specializing in gland and hormone disorders), certified diabetes educators, registered dietitians, nurse specialists and others. They collaborate on each patient’s care, and work closely with patients’physicians and other specialists,including podiatrists, ophthalmologists and nephrologists (kidney specialists). “We show patients how, with help from their caregivers, they can manage this disease effectively and efficiently,”Dulipsingh says.“We help people understand it’s not the end of the world because they’ve been diagnosed with diabetes.”

Meal by meal

When it comes to managing diabetes, changing eating habits is key. For many, it’s also the hardest part. Bryant says he does well with eating and exercise during the day, but evenings are tough. He’s always loved evening meals and snacks, particularly pasta and bread. “I feel like I’m trying to erase 55 years of bad habits,”Bryant says. “For me, it’s not a day-to-day struggle, it’s a meal-to-meal struggle.” White bread, pasta and potatoes are the types of calorie-dense, nutrient-poor carbohydrates that can cause blood sugar spikes, worsen insulin resistance and promote weight gain, says Patricia O’Connell,M.S., R.D., C.D.E., C.D.-N., one of Joslin’s registered dietitians and certified diabetes educators. That doesn’t mean all carbs are “bad.”After all, fruits and vegetables contain carbohydrates.During a pre-diabetes class at Joslin, Michele Roy, R.D., C.D.E., discusses how to choose carbohydrates that are higher in fiber, vitamins and minerals. Substitute brown rice for white and whole wheat pasta for regular, and eat these in moderation, she advises. Everyone is different, so there’s no single “diabetes diet.” But the Joslin Center offers some general guidelines:

Carbohydrates: About 40 percent of daily calories should come from carbs, including at least 20-35 grams of fiber. Fresh vegetables, fruits, beans and whole-grain foods are best.

Protein: 20-30 percent of daily calories should come from protein (unless you have kidney disease). Best sources: fish, skinless chicken or turkey,nonfat or low-fat dairy products, tofu and legumes (beans and peas).

Fat: 30-35 percent of daily calories. Mono- and polyunsaturated fats are best, from sources like olive or canola oil, nuts, seeds and fatty fish like salmon.

Step by step
At a Know Diabetes, Know Yourself class at the hospital’s Bradley Memorial campus, Joslin diabetes educator Debbie Venditto, R.N., B.S.N., C.D.E., distributes a “behavioral goals” sheet. Participants list goals for eating, taking medication, exercising and other behaviors. They complete statements like: “I will exercise by doing ______for _____ minutes, ____times a week and increase as tolerated.” “I don’t want you to put, ‘I will walk 30 minutes a day, three times a week,’” Venditto says.“If you haven’t been exercising, that’s probably not a reasonable goal to start with. Try 10 minutes a day, once or twice a week.” The 10-hour Know Diabetes class is offered afternoons or evenings and can be spread over two days to four weeks to accommodate different schedules. The class also covers medication, monitoring, meal planning, foot care and other topics. Like all Joslin programs, it stresses the importance of making lifestyle changes gradually.

Physical activity can lower blood glucose levels and help you lose weight. With exercise, choose activities you enjoy and that fit your lifestyle, Venditto says. Can’t run? Walking is very effective. Joint problems? Do pool or even chair exercises. Hospital of Central Connecticut exercise physiologists can design customized exercise programs for people with various health concerns, including diabetes.The ADA and Joslin Center offer these general tips for people with diabetes:

• Before starting a program, consult your doctor.
• Wear comfortable shoes. Diabetes can lead to poor circulation and diabetic neuropathy (nerve damage),particularly in the feet. Properly fitting shoes, and socks without seams or tight elastic are musts. People with diabetes should check their feet at least once daily for cuts, redness/irritation from shoes, ingrown toenails and other injuries that can turn into major infections.
• Wear a diabetes medic alert bracelet.
• Check your blood sugar before and after exercise to see how it responds. Hypoglycemia (low blood sugar) can occur during or long after exercise, so keep handy a snack or glucose pill to quickly raise too-low sugar.
• Be careful if your blood glucose is high before exercise (above 300) — some physical activity can raise it. Those with type 1 diabetes should avoid physical activity if their glucose is above 250 and their urine contains ketones (produced when the body breaks down fat for energy).

Monitoring and management
Many people with Type 2 diabetes take medications that help the pancreas produce more insulin; help cells use insulin better; cause the liver to release less glucose; or work in other ways. But even with lifestyle changes and medication, some type 2 patients must take insulin. People with type 1 diabetes must always take insulin because their bodies don’t produce it. Type 1 occurs when, for unknown reasons, the body’s immune system attacks the pancreas’insulin-producing islet cells. It’s usually diagnosed before age 40, most often in children or teen-agers. Debbie Hogan of Southington was 21 when she first experienced symptoms. “I was out shopping the day after Thanksgiving and I was very thirsty and had to go to the bathroom all the time,” she says. Ironically, when she came home, her sister was watching a telethon for a diabetes charity. “They were talking about the symptoms of diabetes — extreme thirst and frequent urination. I said, ‘that’s what I have.’” She felt better by Monday, but when she mentioned her suspicions at work, her employer sent her to a doctor. She was tested and put on insulin that day. Back then, diabetes education wasn’t as common, says Hogan, now 41. The new regimen was challenging for the busy 20-something; in addition to frequent blood glucose checks, she had to eat and take insulin at specific times. Insulin management got a little easier last fall,when Hogan got a pump. About the size of a card deck, the battery-operated insulin pump attaches to her waistband. A thin tube runs from the pump to a flexible, plastic catheter under the skin in her abdomen. Users can set the pump to give a set,“basal” amount of insulin continuously for 24 hours. At meals, or when blood sugar spikes, the user can deliver an extra dose. Even with the pump, Hogan must check her blood glucose — four to six times daily — eat healthy and exercise. Despite 20 years of diabetes management experience, she works every day to keep her sugar in normal ranges. “I like to say I’m a work in progress,” Hogan says. A Joslin patient for 11 years, she gets encouragement from Pat O’Connell and other Joslin staff. Her husband, Ben, and mother, Maryann Beckius, are her “rocks,”she says.

Hogan’s diabetes has caused some complications, including scar tissue in the retina of her eyes, but after several laser surgeries, her vision is 20/20. She takes these and other challenges in stride, noting that she’s able to work full-time, travel and live a normal life. “I don’t ever feel sorry for myself,” she says. “Diabetes is part of my life. I accept it.” Her advice to others diagnosed with diabetes: “There is so much information out there! Learn as much as you can and explore your options. You don’t need to limit yourself or your life because you have diabetes.” Diabetes has also taught Bryant an important lesson. “Life doesn’t wait. If you don’t take care of your diabetes now, there may not be a tomorrow.”