Most times when I ask a new patient with diabetes why they are in my chair, rarely is it because they came on their own. To me, this means that this patient may not truly know how serious diabetes can be or how it can affect their eyes.
Diabetes is the leading cause of blindness in adults 20-74 years old. Vision loss related to diabetes will triple between 2005 and 2050, in addition to the increases in diabetes itself. Diabetic retinopathy alone will be responsible for 12,000 to 24,000 new cases of blindness each year.
I advocate diabetes patients work with their health team to integrate medical nutrition therapy based on evidence-based recommendations as stated by Chous in Review of Optometry, which are as follows:
A low carbohydrate/low fat, energy-restricted diet to achieve ~5 - 7% weight loss in obese patients
150 minutes of exercise per week
Increased dietary fiber intake (shown to slow the progression of diabetic retinopathy in the Diabetes Control and Complications Trail (DCCT))
Elimination of trans fat intake
Reduction of saturated fat intake (less than 10% of total caloric intake)
Although there is no true consensus or specific recommendations in the scientific community, some nutritional supplements do biologically make sense in promoting vision and overall health. I can not stress enough to ALWAYS consult with your doctor before starting any supplement or exercise regimen.
Here are a few examples as stated in Review of Optometry:
Omega-3 fatty acids (Fish Oil) – Some evidence suggests that Omega-3 fatty acids may reduce cardiac arrhythmias and improve clinical depression in people with diabetes. Omega-3 fatty acids may also decrease the risk of dry eye by increasing the quantity and quality of tears.
Xanthophyll carotenoids (AMD supplements) – There is a 67% decreased likelihood of developing diabetic retinopathy in patients with high serum levels of lutein/zeaxanthin and lycopene. The micro nutrients of an AREDS (Age Related Eye Disease Study) supplement may also block oxidative and nitrative stress of the retina, therefore inhibiting diabetic retinopathy.
Benfotiamine – A lipophilic analog of vitamin B1 has shown promise to completely prevent diabetic retinopathy in animal models of diabetes, but is still under investigation in humans.
Pycnogenol – A standardized extract of French maritime pine bark and is composed of procyanidins and phenolic acids that seem to have anti-inflammatory properties which may retard capillary leakage in diabetic retinopathy.
Taurine – An amino acid that supports glial function within the retina and therefore minimizes diabetic retinopathy.
Vitamin D, Alpha lipoic acid, and Chromium also may play beneficial roles in diabetes, but not directly to the ocular complications.
Finally a simple, but important recommendation I make to all my diabetic patients is to use some type of artificial tear supplement or ocular lubricant. The nerves that control the lacrimal glands of diabetic patients are often affected by autonomic neuropathy, causing insufficient tear production. The best way to defend against this process is strict blood sugar control. High blood glucose not only leads to the neuropathy, but it will disrupt the normal chemical composition of tears, exacerbating the dry eye.
People with diabetes should expect a few things when you visit your eye care provider:
Know your hemoglobin A1c number as it determines your risk of related ocular complications.
Expect to discuss lifestyle choices including what and how much you eat.
Eating certain foods like white bread, pasta and potatoes are linked to eye disease in diabetics.
Increasing intake of fiber, fruits, vegetables, and fish may prevent eye disease.
Nutritional supplementation may also be recommended.
Finally, we will say it over and over again until you are sick of us, STRICT BLOOD SUGAR CONTROL is your best defense against diabetic complications, including vision complications.
In December 2008, the U.S. Food and Drug Administration (FDA) approved Rebiana, also known as Reb A or rebaudioside A, found in the stevia leaf. Stevia is derived from the leaves of a South American shrub and has been used to sweeten foods in Brazil, Paraguay, Japan, South Korea and China for many centuries. Reb A is one of two compounds; the other being stevioside, found in the stevia leaf. Reb A is less bitter and sweeter than stevioside. Rebiana is approved by the FDA as "generally recognized as safe" (GRAS).
Stevia previously had been sold only in health food stores as a dietary supplement. Due to some studies indicating that stevia may reduce fertility or cause genetic mutations that could lead to cancer, it was banned as a food ingredient in the US and approved only as a dietary supplement. Supplements, similar to GRAS substances, are not required to be scrutinized as much as foods are.
Today, Truvia and PureVia are available in packets similar to other sugar substitutes such as Splenda, Equal and Sweet n' Low, and will soon be seen in a growing number of sugar-free products. The main ingredients are Reb A (from the stevia leaf) and Erythritol (a sugar alcohol with no effect on glucose levels and little or no laxative effect).
Truvia™
Truvia can be found at Whole Foods, Walmart and other grocery stores.
A Coca-Cola and Cargill product
Over 200 times sweeter than sugar
Ingredients: Rebiana, Erythritol, natural flavors
Rebiana or Rebaudioside is the sweet extract from the stevia leaf – for sweetness
Erythritol is a sugar alcohol derived from fruits like grapes and melons to improve taste and reduce bitterness
Natural flavors to enhance flavor
Found in products such as: sweetener packets, Sprite Green and Odwalla juice drinks
Zero calories and no effect on glucose levels
PureVia™
PureVia can be found at grocery stores.
PepsiCo and Whole Earth Sweetener co-product
Over 200 times sweeter than sugar
Ingredients: Rebiana, Erythritol, natural flavors
Rebiana or Rebaudioside is the sweet extract from the stevia leaf to improve sweetness
Erythritol is a sugar alcohol derived from fruits like grapes and melons to improve taste and reduce bitterness
Isomaltulose (found in honey and sugar case juice)
Cellulose powder is a dietary fiber to enhance texture
Natural flavors to enhance flavor
Found in products such as sweetener packets and SoBe Lifewater
Zero calories and no effect on glucose levels
Use moderately. Moderate use is 4 servings a day: 4 packets or food servings similar to food exchanges (8 ounce drink, etc.)
Poor carbohydrates... it wasn't long ago that carbohydrates were considered a foundation of a healthy diet. Unfortunately, bolstered by the popularity of low-carb diets, today the word "carb" has instead become synonymous with empty calories, high blood sugar, and obesity for many people. Here's a bit of information to help you separate "carb fact" from "carb fiction."
Carbohydrate Myths
Eliminate all carbohydrates from your diet. Carbohydrates are your body's favorite fuel source. All carbohydrates break down into glucose, which is used to fuel your muscles, brain, and central nervous system. Every body needs carbohydrates!
Quit eating bread, pasta and desserts. Carbohydrates are not only found in breads, grains, and simple sugars, but also in fruits, vegetables, milk products, and legumes such as beans. (Protein such as meat, and fats such as butter and oils, do not contain carbohydrates)
Eating carbohydrates will make me fat. Eating more calories than your body needs will make you gain weight. It doesn't matter if the excess calories come from carbohydrates, fats or protein.
Carbohydrates should be avoided by people with diabetes. Carbohydrates are in fact the nutrient most responsible for raising blood sugar. When the glucose from digested carbohydrates enters the blood stream, your blood sugar rises. Insulin helps this "sugar" move from your bloodstream into your cells. When you do not have enough insulin, or if the insulin is not working effectively (as in the case of diabetes), eating too many carbs in a short period of time can raise your blood sugar to unhealthy levels.
Carbohydrate Truths
Include nutrient rich carbohydrates in your diet every day. The amount of carbohydrates you need in your diet varies depending on many factors, including the amount of calories you need, your activity level, and any medical conditions such as diabetes (including your medications). Your physician or registered dietitian can tailor exactly how much you need, but, in general, carbohydrates should make up 45 to 55% of most diets. Less than 135 grams per day is considered insufficient for good health by most health professionals.
For those with diabetes, about 2 to 4 servings (30-60 grams of carbohydrate per meal) and no more than 1-2 servings (15-30 grams per snack) is most often advised. Portion control and reading labels when it comes to carbs is important.
A good meal plan spreads carbohydrates evenly throughout the day. Spacing meals and snacks (including your carbs) evenly throughout the day helps keep your blood sugar levels stable. Additionally, combining protein and/or healthy fats with carbohydrates helps to prevent blood sugar spikes and satisfy hunger.
Not all carbohydrates are created alike. Whole grain pasta, breads and grains is the "better-for-you" choice. They contain more nutrients than their refined counterparts, along with heart healthy fiber which slows blood sugar's rise. Studies show that the risk for diabetes is reduced as more fiber is added to the diet. Non-starchy vegetables such as leafy greens, broccoli, cauliflower and peppers are also good sources of nutrients, while lower in carbohydrates than potatoes, corn and rice. When it comes to fruit, eating whole fruit is far superior to drinking juice, which is devoid of fiber and often more concentrated in sugar than fresh fruit.
On the other hand, while sugary treats like cakes, cookies, pies, candies, sugars, honey, syrups, jams and other concentrated sweets can be included in any diet, their empty calories and dense carbohydrates make them less desirable when it comes to carbs.
Reduced carbohydrate foods make it easier than ever to enjoy a healthy carbohydrate diet. Try my Chicken Caesar Wrap to satisfy you with "good-for-you" carbs. Add a piece of fruit and a glass of reduced or non-fat milk to round out your meal.
My birthday is this month. A few years ago, I decided to give myself the best birthday present: an annual physical exam. Since I always remember my birthday (whether I want to or not), I always remember to visit my doctor and get my check up, including tests.
My birthday gift to you is to send you this caring advice so you can celebrate many more birthdays to come.
Having diabetes means you need to be more organized about your check-ups and preventive care throughout the year, not just the standard once a year check-up. Although you may have diabetes, that might not be your only health concern and you may need certain additional health screenings.
I know that I get confused keeping track of all the check-ups I require throughout the year, so I try to simplify my life and schedule them around my birthday.
Start your A1C test on the month of your birthday and follow your M.D.'s order for recurring tests - either every 3 months or every 6 months (your 3-month average).
A micro albumin test should be done yearly and remember to have this done on your birthday. This is a simple urine test that checks the health of your kidneys.
If you do not see a podiatrist on a regular basis, then I recommend you do it annually, near your birthday. People with diabetes are more susceptible to foot complications.
See your dentist near your birthday and then again every 6 months. People with diabetes are twice as likely to have gum disease.
A yearly eye exam is necessary for checking for retinopathy, glaucoma, or cataracts. Retinopathy is the leading cause of blindness in people with diabetes.
A yearly lipid profile should be done around your birthday including a LDL, HDL and triglycerides. This could reduce your risk of developing heart disease.
It's time to love your heart with great tasting food! A healthy diet is always important for a healthy heart. However, for those at a greater risk for heart disease, like people with diabetes, the stakes are even higher. Fortunately, one of the most significant ways to reduce your risk for heart disease is as easy as adjusting what's on your plate.
According to both the American Heart Association and the American Diabetes Association, the key to a "heart smart plate" is limiting foods high in sodium and fat, particularly those high in saturated and trans-fats, while emphasizing whole grains, fruits and vegetables.
Ten Heart-Healthy Super Stars
Recent studies show that along with whole grains, fruits, and vegetables, there are plenty of tasty foods that are great for your heart. These foods are filled with powerful phytonutrients that protect and potentially reverse damage to your heart. Below are ten of my favorite heart-healthy super stars along with their heart healthy active components. The foods and ingredients can be easily – and deliciously - incorporated into any heart-loving daily diet.
Oatmeal - Soluble fiber
Tomatoes - Caroteniods
Salmon - Omega-3 fatty acids
Walnuts - Omega-3 fatty acids and vitamin E
Berries - Flavonoids and antioxidants
Soymilk - Isoflavones and calcium
Green Tea - Catechins and flavonoids
Olive/Canola Oil - Monounsaturated fats
Red Wine - Resveratrol
Cocoa powder - Resveratrol
Carotenoids give fruits and vegetables their vibrant colors and are powerful antioxidants that protect your heart from the damaging effects of free radicals.
Flavonoids, catechins, resveratrol, and isoflavones protect blood vessels, lower blood pressure and reduce LDL "bad" cholesterol.
Omega-3 fatty acids help boost the immune system, reduce blood clots and protect against heart attacks. They also increase good HDL levels, lower triglyceride levels, protect arteries from plaque buildup, are anti-inflammatories and lower blood pressure.
October is National Apple Month! I can't think of a better time to shed some light on the wonders of this fabulous fruit. Both delicious and nutritious, apples are a true "superfood" and a great addition to every diet. Here are 10 wonderful reasons why:
Apples are free of fat, cholesterol and sodium.
A medium apple (about 5 ounces), is satisfying, has a mere 80 calories and equals one carbohydrate choice or fruit exchange.
Apples have a low glycemic index (the rate at which they raise blood sugar). In fact, women who eat at least one apple a day have been found to be 28% less likely to develop type 2 diabetes than those who do not eat apples.
Apples are loaded with fiber. A medium apple has 4 grams of fiber, most of it in the form of pectin, which lowers cholesterol and blunts blood sugar swings.
Apples are vitamin and mineral rich providing vitamins A and thiamin, along with healthy doses of potassium, phosphorus and iron.
According to Cornell University, the fresh apple extract from just one medium apple provides as much antioxidant activity as 1500 milligrams of vitamin C!
Apples are good for your smile. Apples don't actually clean your teeth but biting and chewing an apple stimulates saliva production which lowers the amount of bacteria in your mouth reducing the risk of tooth decay.
The flavonoids found in apples, especially in the peel, may be potent cancer fighters.
When it comes to cooking, apples are sweet, crunchy, versatile and economical. Chopped or sliced apples are a perfect topping for hot oatmeal or cottage cheese (especially when finished off with a dusting of cinnamon and a sprinkle of your favorite sweetener), a terrific mix-in for muffins and breads, and a flavorful addition to salads and slaws.
Nothing beats a hot apple dessert, especially when apples are paired with fragrant cinnamon. Luscious enough for any occasion, this no-sugar added Sour Cream Apple Pie (with just 20 grams of carb a slice) is a snap to prepare when made with a store-bought pre-prepared crust, while a Microwave Cinnamon Baked Apple is perfect any time at all (even for breakfast) and quick to make.
I have been educating people with diabetes for two decades and I continue to be amazed at how many myths are still prevalent, so, I want to set the record straight on what I consider to be the top five diabetes myths.
MYTH 1 - Eating too much sugar causes diabetes
FACT: Actually, consuming too many calories, physical inactivity, increasing age, as well as a genetic predisposition to diabetes are potential causes. If someone ate sugar all day and their body had the ability to release and properly use insulin, they would not develop diabetes.
If you have diabetes, then you should avoid sugary foods, as well as too many carbohydrates. Carbohydrates affect the blood sugar more than protein or fat. Excessive quantities of certain starchy vegetables, cereals, and fruit will cause your blood sugar to rise too quickly. Working with a diabetes educator will ensure proper eating habits. Eating properly will not only help your blood sugar, can help you maintain optimal weight.
MYTH 2 – Testing your blood sugar in the morning after fasting is enough to understand patterns and what your A1C represents.
FACT: You should test your blood sugar at varying times of the day, not just first thing in the morning. An especially important time to test for those people taking insulin prior to meals. Also, one should test their blood sugar two hours after eating their first bite of food. Between the fasting numbers and the postprandial (after meal) numbers, you will have a better idea of what the A1C results really represent. You should test more often when you are ill, have undergone surgery, started an exercise program, and when you start a new medication or change the dosage of medicine.
MYTH 3 - Taking my diabetes pill is all I need to do to control my diabetes and prevent complications.
FACT: Adding lifestyle changes along with taking your daily medication correctly is the best way to control your diabetes. Lifestyle changes include a minimum of 150 minutes of aerobic activity per week. Activity could include walking, biking, swimming, line dancing and other activities you enjoy. Other “feel good” lifestyle changes include eating smaller portions, reading food labels, and counting carbohydrates. If you have diabetes, then smoking is a No-No! Smoking can worsen many diabetes-related complications including heart and blood vessel disease.
MYTH 4 - Your doctor is totally in charge of your diabetes care.
FACT: You are 95% responsible for your diabetes care. Your doctor is responsible to coordinate your care and is responsible for medication changes based on your blood work and logbook results. You are responsible to make lifestyle changes, including improving your eating and exercising. You are responsible to take your medication correctly. You are responsible for taking extra special care of your feet, teeth and eyes. You are responsible for testing blood sugar according to the directions you and your physician have agreed upon. You are responsible for managing your stress. With the extra stress of managing diabetes, you deserve to find ways to relax and have fun.
MYTH 5 - Low blood sugar (hypoglycemia) has no real symptoms.
FACT: Low blood sugar exhibits symptoms in most people who have diabetes. The low blood sugar can be caused by too much medication, too much exercise, or not enough food. The symptoms of hypoglycemia include sweating, shaking, weakness, hunger, dizziness, headache, nausea, visual disturbances, irritability, or fast heart beat. Some people who have had diabetes for several years may not experience any signs of hypoglycemia. This is called hypoglycemic unawareness and can happen because of chemical changes that can mask any symptoms.
24 million Americans have diabetes and 1/3 of them don't even know it! Diabetes can lead to many complications – since it is a disease of the vessels: heart disease, kidney disease, blindness, nerve damage and amputation are some of the problems that can result from uncontrolled diabetes. The good news is that diabetes can be managed by you! With proper education, you have the power to avoid or reduce the severity of these complications.
You can make a life-changing difference by following these guidelines:
Limit carbohydrates (starch, fruit, milk, sweets) at each meal or snack.
Consume approximately 30-60 grams of total carbohydrate per meal (depending on your calories for the day and how your glucose is running).
Consume approximately 15-30 grams of total carbohydrate per snack combined with a lean protein and/or unsaturated fat such as a yogurt with nuts or a fruit with low-fat cheese.
Evenly distribute carbohydrates throughout the day to avoid fluctuations in blood sugar and to achieve a level blood sugar.
Consume slow-digesting foods or food combinations to assist you in achieving a more level blood glucose. Consume the following foods in combination: a. High fiber carbohydrates (30-50 grams a day) like brown rice, whole grain breads or cereals, grains such as kasha, barley or millet. b. Lean protein such as fish, shellfish, poultry, lean meat and low-fat cheese. c. Unsaturated fat such as nuts, nut butters, avocado, oils.
Test your blood sugar before meals and 2 hours from the start of the meal to determine if your body can handle the amount of carbohydrates you’ve eaten. If not, decrease the amount of carbohydrates or you may need a medication adjustment. For example: Test at 8:00 am before beginning breakfast and then again at 10:00 am.
Look for the following results when testing blood sugar: a. Before meals blood sugar should be 90-130 mg/dL (American Diabetes Association - ADA guidelines*) or 80-110 (American Association of Clinical Endocrinologists – AACE guidelines**) b. After 2 hours blood sugar should be under 180 mg/dL* or under 140 mg/dL**. c. Blood sugar can expect to rise about 30-50 points from a meal.
Eat every 3-4 hours so your blood sugar doesn’t drop or fluctuate too much. This may determine whether a snack is necessary or not. Eating more frequently prevents over-eating at the next meal or snack and keeps your metabolism higher so you burn more calories!
Wait 2 hours between meals and snacks so the blood sugar has a chance to come down before you send it back up with your food consumption.
Have your doctor do a blood test to determine your 3-month blood sugar average. HbA1c also known as glycohemoglobin or hemoglobin A1c shows the progress you are making every few months with controlling your diabetes. Look for a number of 7% which is equivalent to154 mg/dL* or 6.5% which is equivalent to 140 mg/dL**, for best control. Fructosamine is a similar test that averages two weeks worth of blood sugar results.
Remember to exercise at least 5 days a week for 30 – 40 minutes. This includes walking, bicycling, strength training, etc. Exercise helps insulin work more efficiently to lower your blood sugar.
Be sure to meet with a team of diabetes experts. They will provide you with the knowledge you need to control your blood sugar. There may need to be adjustments with times of exercise, medications or food choices for best glucose control.
There are no secrets when managing diabetes. You have all the tools you need to find out how food, exercise, medications and even stress affects your glucose readings. In time, you will learn how to fine tune and better manage your disease. The HbA1c will tell you what range your blood sugar is in. Your glucose monitor will provide you with critical information so you can find out how daily living affects your blood sugar. Don't allow the diabetes to rule your life when you are in charge!
It has long been suspected that there is a link between stress and diabetes. It has also been observed that people with diabetes sometimes experience cognitive decline as the disease progresses. A new study from National Institute on Aging (NIA) explores these connections and offers hope for improved diabetes management.
The NIA study, published on March 1 by Nature Neuroscience, documented the reactions of diabetic rats to the elevation and reduction of their corticosterone levels. When levels of this stress hormone were raised, it negatively affected the rats' learning and short-term memory. When levels of corticosterone returned to normal, the rats regained their cognitive functions. To the authors of the study, these results suggest that for humans with diabetes, cognitive impairment due to excess stress hormones could be prevented or perhaps even reversed. That's because the corticosterone in rats is similar to the human hormone cortisol, which is released during periods of stress.
Cortisol is both good and bad. The body needs some cortisol to regulate its energy levels. Cortisol helps deliver needed fuel to working cells by drawing on the body's fat stores. During periods of stress, cortisol also helps the body convert proteins into glucose that the body can use right away. But too much cortisol can have adverse effects. Excess cortisol may contribute to visceral obesity, the development of fat around important internal organs such as the stomach and intestines. The more stress you feel, the more cortisol your body produces. The more cortisol your body produces, the greater the possibility that you will develop this unhealthy abdominal fat. People with diabetes are at a further disadvantage, even beyond your average stressed-out person. People who do not have good control over their diabetes often produce more cortisol than normal.
According to in the NIA study, this excess cortisol could lead to cognitive impairment in people with diabetes. It could also lead to excess abdominal fat—another big health risk. The authors suggest that by regulating the levels of cortisol in the body, these risks can be reduced or eliminated for people with diabetes. Beyond stress reduction techniques, it is possible that someday a medication will be developed that blocks the action of excess cortisol in the body. In the meantime, scientists will continue to study the relationship between stress, cognitive function, and diabetes.
The last several years have seen a growing awareness of what insulin resistance is and how it affects the body. Insulin resistance causes various reactions throughout the body. In fatty tissue, it causes the breakdown of triglycerides, which leads to elevated fat levels in the blood. In the liver, insulin resistance prevents proper glucose storage, leaving more glucose to circulate in the bloodstream. And in muscle tissue, insulin resistance reduces glucose uptake, again causing higher blood glucose levels.
The causes of insulin resistance have generally remained a mystery, with possible culprits being obesity, a high-carbohydrate diet, a sedentary lifestyle, overuse of sugar or high-fructose corn syrup, and possibly even the use of glucosamine.i Now, scientists are discovering that genetics may play a role in insulin resistance, too—for the better.
In a study from the University of Alabama at Birmingham, two genes have been identified that may be linked to insulin resistance.ii These genes, NR4A3 and NR4A1, are proteins that seem to affect muscle tissue by boosting its sensitivity to insulin. Raising insulin sensitivity leads to better glucose uptake, which means that blood glucose levels decrease as a result. According to Dr. Timothy Garvey, MD, the lead author of the study, this discovery gives scientists something to aim for in ongoing diabetes research. Garvey notes that people who have more of the two proteins are at less risk for diabetes, while people with fewer of the proteins are at greater risk.iii He proposes that if scientists can develop a way to increase the activity or presence of the two proteins, these new developments could have very positive effects for people with diabetes.
In the meantime, people with diabetes or who are pre-diabetic are encouraged to follow treatment courses that are already known improve insulin resistance. At the top of the list are exercise and weight loss. Modifying the diet may also help some people, with low-carbohydrate and low-glycemic foods being the recommended choices. Other treatments that may improve insulin resistance are the use of metformin and thiazolidinediones, omega-3 fatty acids, and possibly chromium picolinate. As with any course of treatment, consult your physician before beginning any new regimen.
