When Memphis resident Theresa Okwumabua was first diagnosed with diabetes a year and a half ago, she tried to ignore it. She didn't want to change her lifestyle.
But her doctor kept urging her to get her blood-glucose levels under control, so she began to change her habits. Okwumabua, a clinical psychologist and coordinator of community outreach at the University of Memphis, exercised more consistently, gave up her beloved Coca-Colas and ate smaller portions. She took the medication her doctor prescribed, and along the way lost a few pounds. Now, most days her blood glucose levels are within the normal range.
Being diagnosed with diabetes used to feel like a lifelong prison sentence, complete with boring food and never eating anything sweet again. Doctors would hand newly diagnosed patients a "diabetic diet" plan with strong recommendations to follow it exactly and to learn to live without some of the foods they loved.
Fortunately, health providers today know so much more about diabetes and how to control it, including helping people learn to fit in some of their favorite foods without sacrificing blood glucose control.
It's a good thing, too, because more and more people are developing the disease. The latest statistics, reported by the American Diabetes Association on its website (diabetes.org), show that more than 20 million Americans have diabetes. The Centers for Disease Control and Prevention has identified a diabetes "belt," a swath of counties across mainly Southern states where at least 11 percent of residents are diagnosed with diabetes. Almost every county in Tennessee and Mississippi is included.
One thought that has changed about diabetes is how to manage intake of sugar and other carbohydrates. Except for fiber, a type of carbohydrate the body cannot break down and absorb, virtually all other carbohydrates end up as glucose after being digested.
Glucose is absorbed into the blood and carried to every cell in the body. The cells depend on glucose as a source of fuel. Since foods with simple sugars (like candy and cake) and foods with complex carbohydrates (like grains and vegetables) all end up as blood glucose once they are digested, the issue becomes more about the total amount of carbohydrates a person consumes at one time rather than about whether the carbohydrates are sugars or starches. This means that people with diabetes can eat an occasional piece of birthday cake or a bit of ice cream every now and then and still keep blood glucose levels within their target range, as long as they balance the total amount of carbohydrates they eat.
Dietitians and diabetes educators teach their clients with diabetes to look at the total carbohydrate content of what they eat so they can aim for a consistent amount at each meal or snack. If someone's target is 60 grams of carbohydrates at a meal, he could have a turkey sandwich on two slices of whole grain bread, a small salad, a small piece of fruit and a cup of milk, and keep within the targeted allowance.
If that person attends a birthday party and wants to eat a piece of cake, he can "bank" carbohydrates at the meal, knowing he wants to "spend" most of them on the birthday cake. He could have one slice of bread with turkey, the small salad, a glass of unsweetened tea, or tea with a noncaloric sweetener, then in place of the fruit and milk, add a small piece of cake (easy on the frosting) for dessert. The total would still be about 60 grams of carbohydrates, so the resulting rise in blood glucose would be about the same for either meal.
Of course, the meal with the cake doesn't have as many nutrients as the first meal, but on an occasional basis, this won't do any long-term nutritional harm. And it means less deprivation for a person with diabetes.
"I used to have something sweet every day, almost every meal," Okwumabua said. But after learning that too many carbohydrates at one time can raise her blood glucose levels, she chose not to indulge her sweet tooth as often. And if she does eat something sweet, it's a smaller portion, perhaps a few bites of cake instead of a whole piece.
Including fewer sweet items in her diet has also changed her desire for them. Before she used to "be in heaven" when eating a piece of pound cake or some Oreo cookies; now they just don't tempt her as much. Even those Cokes don't tempt her much anymore. "First I switched to Coke Zero, but now my taste buds are just fine with water," Okwumabua says.
Registered dietitian and certified diabetes educator Kimberly Johnson Spreckelmeyer, clinical trainer for the company Insulet, maker of the OmniPod insulin pump, says, "It's all about portion sizes." She has her clients get out their measuring cups and learn what portions look like. This helps them recognize appropriate amounts of high-carbohydrate foods so their carbohydrate counting is more accurate. She finds that once her clients make a commitment to become more knowledgeable about portion sizes and control the carbohydrate content of their diet, they really like the better blood glucose control they have.
"Use available resources" Spreckelmeyer urges her clients, "like food labels and applications for smart phones." She likes the phone apps GoMeals (gomeals.com) and CalorieKing (calorieking.com) to help clients keep track of what they are eating at the moment they are eating it.
This is especially important for people with diabetes who take insulin. The amount of insulin they take is tied to the amount of carbohydrates they ingest at meals. Accuracy in determining the grams of carbohydrates eaten means better precision in gauging the amount of insulin needed.
"I don't advocate an extremely low-carbohydrate diet, but I do recommend most people with diabetes aim for about 45 to 50 percent of their calories from carbohydrates," Spreckelmeyer said. This is toward the lower end of recommended guidelines, and most of the time translates to between 45 and 60 grams of carbohydrates per meal, depending on the individual. Spreckelmeyer also suggests her clients "focus on higher-fiber, less-processed foods."
Most Americans fall far short of the American Dietetic Association's recommendation of 20 to 35 grams of fiber per day. Fiber creates fullness in the stomach, making for higher levels of satisfaction with smaller amounts of food. Higher-fiber foods also help slow absorption of glucose into the blood, allowing insulin more time to usher the blood glucose molecules into the body's cells.
At the Memphis Veterans Medical Center, registered dietitian and certified diabetes educator Jackie Roos teaches classes to patients with diabetes, focusing on carbohydrates and portion sizes. While some of her clients embrace carbohydrate counting, others find it too cumbersome and instead use what Roos calls the "plate method." Roos uses partitioned plates that dovetail with the recommendations of the American Diabetes Association, which suggests that half the plate contain nonstarchy vegetables, and the other half be divided equally between a portion of protein and a portion of something higher in carbohydrates or "starchy." "If someone is confused by carbohydrate counting," Roos says, "the plate method works very well."
Roos finds that a lot of her clients have no idea that the sweet beverages they drink really can make their blood glucose levels increase. She recommends they limit their intake of sodas, juices and sweet tea. When she comes across clients who are resistant to giving up their favorite beverages, she asks them to take the "soda challenge." "I have them give up their sodas and sweet drinks for a week and then check their blood sugar levels," Roos says. "They become believers when they see how their blood glucose levels drop during that week."
In addition to counting carbohydrates, health professionals almost always advise anyone who has diabetes and is overweight to lose weight. A recent study done in Great Britain brought this to the forefront. In this study, reported in the latest issue of Diabetologia, 11 obese subjects with diabetes were restricted to 600 calories for eight weeks and lost an average of 30 pounds, or about 15 percent of their body weight. None had abnormal blood glucose readings after the eight-week period, and all were able to go off their diabetes medications.
This was a severe restriction of calories, done under the direction of a medical team, but you don't have to go on such a drastic diet. Health professionals have long known that even small amounts of weight loss help normalize blood glucose levels and decrease side effects of diabetes. The Look AHEAD trial is another research study that showed lifestyle management, including weight loss, helped to keep blood glucose under better control and improve cardiovascular risk factors. Registered dietitian Maria Sun, assistant professor at Southwest Tennessee Community College, provided nutrition guidance for some of the clients involved in an arm of the study done in Memphis through the University of Tennessee Health Science Center. "When my clients in the study lost about 10 percent of their weight," Sun said, "there was a big change in their blood sugar levels." Sun and her colleagues encouraged study participants to engage in regular physical activity as well as moderate their diet.
Okwumabua has been following a similar approach and knows the results are worth it. "It's a struggle sometimes," she says, admitting, "I'm not perfect every day." But the improvements she has seen in her diabetes make the efforts worthwhile.
Megan Murphy is a Tennessee-licensed registered dietitian and associate professor of nutrition at Southwest Tennessee Community College. Call (901) 277-3062, fax (901) 529-2787, e-mail Meganmyrd at aol.com.
Did you know?
Diabetes is the leading cause of blindness among adults 20-74 years old.
Diabetes is the leading cause of kidney failure in the United States: 44 percent of new cases of kidney failure (2008 statistics) are caused by diabetes
60 percent to 70 percent of people with diabetes have mild to severe forms of nervous system damage.
People with diabetes account for more than 60 percent of lower limb amputations not caused by a traumatic event (like an auto or work accident).
Most common types of Diabetes
Type 1: Typically diagnosed at a young age, often in childhood. Classified as an autoimmune disease, where the cells in the pancreas that produce insulin are destroyed. Insulin, necessary to help blood glucose get into the body's cells, is no longer produced and must be taken by injection or by a pump from outside the body.
Type 2: The most common type of diabetes. Risk increases with excess body fat and lack of exercise. People with this type of diabetes are often secreting insulin, but it sometimes is not enough. People with this type of diabetes often have insulin resistance, meaning their body is not sensitive to the insulin they are producing. Weight loss and exercise help their bodies regain insulin sensitivity, which helps get blood glucose levels back to normal.
Gestational diabetes: Occurs during pregnancy. Usually goes away after the baby is delivered, but women who develop gestational diabetes have a greater risk of developing Type 2 diabetes later in life.