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Mealtime Insulin -
••Contents 4
Introduction Where would we be without insulin? A brief overview of this life-saving hormone Insulin options Advances in insulin technology mean personalised treatment plans to suit your lifestyle
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Types of insulin Our easy-to-follow chart lets you find out more about the most common forms of insulin
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Set or flexible? Your routine and eating habits will determine what sort of insulin doses are right for you
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Flexible insulin therapy Adjust your insulin doses according to your day-to-day needs
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Why carbs matter When it comes to your carbohydrate allowance, it pays to choose quality over quantity
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Carb counting Easy formulas and online tools that can assist you with your carb calculations
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Why monitoring matters How to keep an eye on your BGLs when you choose flexible dosage
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Correcting highs & lows What next when faced with BGLs that aren't sitting where they should be?
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Calculating mealtime insulin doses Matching your meals with the correct amount of insulin
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How a bolus calculator can help If maths isn't your strong suit, a blood glucose meter can do the sums
A NOTE FROM THE EDITOR During 35 years on insulin for my type 1 diabetes, I've been lucky to benefit from many life-changing advances in treatment. From those early insulin injections that dictated set mealtimes when I had to eat, hungry or not, modern technology has given me more freedom with food and exercise than I ever dreamed possible. Thanks to improved insulin and clever delivery systems - I'm on a pump- that take the guesswork out of dosage calculation, plus fast and accurate blood glucose testing, I can eat as and when I want and keep my diabetes controlled. In this booklet we explain how you too can use this support to live your life to the full and stay well. Thanks to our sponsors, Accu-Chek, for enabling us to bring it to you.
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Insulin pump therapy What it is, how it works and how it can help you manage your condition
Erica Goatly, Editor (type 1)
Editor-in-chief Julia Zaetta Editor Erica Goatly Managing Editor Kathy Buchanan Art Director Natasha Barisa Publisher Peter Zavecz National Advertising Manager Lynda Prince Words Dr Kate Marsh, Accredited Practising Dietitian and Credentialled Diabetes Educator
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The wonder of insu in We take a look at the breakthrough medical discovery responsible for saving the lives of generations of people with type 1 and type 2 diabetes he discovery of insulin in 1921 was a major breakthrough in the treatment of diabetes. It was literally a lifeline for people with type 1, for the first time offering them the chance of a relatively normal life. Prior to this, those diagnosed - mostly children - did not survive for long, simply wasting away as they were unable to process their food. These days it is not only people with type 1 who benefit from insulin - around 50 per cent of those with type 2 are likely to move on to insulin treatment within 1O years of diagnosis. Insulin is a hormone made in the body by beta cells found in
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the pancreas, and is usually released into the bloodstream when we eat. In someone without diabetes, the body regulates its insulin production very precisely, according to food intake, activity levels and other factors, to ensure that blood glucose levels always stay within a fairly narrow range. For someone with diabetes, who either doesn't produce any insulin (type 1) or doesn 't produce enough insulin (type 2), this insulin needs to be replaced. It cannot be swallowed like other medications because our stomach acids render it useless, so insulin injections or delivery via a pump are the
only options. The aim is to try to mimic the body's usual insulin production to keep blood glucose levels as close to normal as possible. Unlike many medications which are taken in a set dose, the effectiveness of insulin in controlling BGLs is reliant on closely matching dosage to your food intake and lifestyle. While some people will manage with set insulin doses, particularly if they have a fairly regular eating and exercise routine, others will find it easier to manage their blood glucose levels with a more flexible insulin regimen. This booklet explains what this is all about.
Your insu in options
Because insulin-delivery technology has improved over recent decades, there is now a variety of personalised treatment plans available to suit individual needs nsulin now comes in many different forms. These include: • Long- and intermediate-acting insulins, which are usually taken once or twice a day and provide a background dose of insulin. • Short- and rapid-acting insulins, which are taken with meals to cover the rise in the blood glucose levels that occur when we eat. • Mixed insulins, which are a combination of the two.
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The type of insulin you take, and how you take it, is a choice you and your doctor will make and depends on the type of diabetes you have, your blood glucose levels, your eating and exercise patterns, and other lifestyle factors. Many people with type 2 diabetes start by just taking a long-acting background insulin once or twice a day but over time may need to add some pre-meal insulin to help with the
rise in blood glucose that occurs after eating. Others may use a mixed insulin from the start. Those with type 1 diabetes will typically take a long-acting insulin once or twice a day and rapidacting insulin before meals, or use an insulin pump. Remember, this is a guide only and it is important you speak to your doctor or diabetes team before adjusting your insulin doses.
Types of insu in A guide to the most common forms of insulin, including how long each takes to work, when you should be taking them and their brand names
Starts acting within about 15 minutes, peaks at 1 hour and lasts between 3 and 5 hours.
Usually 3 times per day, just before a meal (within 10-15 minutes of starting to eat).
Novo Rapid® (insulin aspart) Humalog®(insulin lispro) Apidra® (insulin glulisine)
SHORT-ACTING
Starts acting after about 30 minutes, peaks at 2-4 hours and lasts 6-8 hours.
Usually 2-3 times per day, 30 minutes before a meal.
Actrapid® Humulin® R
INTERMEDIATEACTING
Starts working after about 90 minutes, peaks between 4 and 12 hours and lasts 18-24 hours.
Usually in the morning and evening, at a similar time each day.
Protaphane® Humulin® NPH
LONG-ACTING
Has no significant peak and lasts up to 24 hours.
Usually morning and/ or evening , at a similar time each day.
Lantus® (insulin glargine) Levemir® (insulin detemir)
MIXED
A mixture of rapid- or short-acting insulin with intermediate-acting insulin , in different combinations.
Usually twice a day, before meals (either just before or 30 minutes before your meal, depending on the mix).
NovoMix® 30 Humalog® Mix 25 and Mix 50 Mixtard® 30/70, 20/80, 50/50 Humulin® 30/70
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Set or f exib e? Depending on whether you're a culinary creature of habit or like to mix it up with your meals, you can plan your insulin doses accordingly • Adjustable doses The other option is to learn to adjust your insulin dose according to the amount of carbs you are eating. The obvious benefit of this is that you can eat according to your hunger level, rather than for your insulin needs. Your diabetes team will help you to work out how much insulin to have for the amount of carbs you eat (your insulin-to-carb ratio, which is explained further on page 7) and how to correct for high and low BGLs and other factors such as exercise. Insulin
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• Set doses if you have a fairly regular routine and eat similar meals from day to day, this may be a simple option for you. Basically you take a set dose of insulin with each meal and then need to eat the same amount of carbs at each meal from one
day to the next. This doesn't mean the foods you eat need to be the same every day, but the amount of carbs in those foods does. For this to work effectively, you will need to be able to work out the amount of carbs you are eating, generally using carb portions or exchanges (see page 9). Your doctor may also want you to have a correction dose if you are high before a meal.
adjustment is an option whether you are on injections or using an insulin pump (see page 14). The main difference between these two methods is how your background insulin is given - with injections you have a long-acting insulin once or twice daily, while a pump delivers short-acting insulin in small doses continuously throughout the day.
Mealtime Insulin -
A pan to suit you Suitable for a varied lifestyle and diet, flexible insulin therapy is a modern way to manage diabetes, giving you the freedom to adjust your insulin doses as you go n the past, most people with diabetes were taught to give a set dose of insulin and to eat a certain amount of carbs at each meal, keeping this the same from day to day. While this can work well for some people, particularly if they have a fairly similar routine from day to day, for others it can be really limiting. After all, how many of us eat exactly the same meals, have the same hunger levels and do the same things every day? These days it is much more common to use flexible insulin therapy which teaches you to adjust your insulin doses according to what you eat. This means you can eat according to your appetite and give the amount of rapid-acting
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TIP: If you have type 1 diabetes and are interested in flexible insulin therapy you could consider attending one of the programs offering instruction on how to manage diabetes more effectively. Best known is DAFNE (Dose Adjustment for Normal Eating - www.dafne.org.au), a comprehensive five-day course for adults. Another is SMaRT1 E, a carb-counting program operated at Rockingham General Hospital, WA. Ask your doctor or diabetes team for more information.
insulin needed for that meal. The key to making this work is being able to accurately determine the amount of carbohydrate in the meal or snack you are eating (see page 9). The amount of carbs you eat will determine how much insulin you give yourself. To make this easier, your diabetes team will help you to work out your insulin-to-carbohydrate ratio (or ICR
for short) which is the amount of insulin you need for a certain amount of carbohydrate). For example, an ICR of 1:1 Og means that for every 1Og of carbs you eat, you need to take 1 unit of insulin. The long-acting insulin you are taking once or twice a day is generally kept the same from day to day, unless you need to adjust it for exercise.
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VO Why carbs matter Not all carbohydrates are created equal - make your carb choices count by opting for nutrient-rich, unprocessed varieties he carbohydrate found in foods, or carbs for short, includes both starches and sugars. Starchy foods include bread, cereals, grains, pasta, noodles, rice, legumes and starchy vegetables such as potato, sweet potato and corn . Sugars include added sugars as well as the natural sugars found in fruit and dairy products such as milk, yoghurt, custard and ice-cream. When you eat carbs, either in the form of starches or sugars, they break down to glucose, which is absorbed into your bloodstream. You then need insulin to move the glucose from the bloodstream into your muscles and cells to be used for energy. In someone without
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diabetes, the body always produces just the right amount of insulin to deal with the carbs they eat. But when you have insulin-treated diabetes, this doesn't happen and instead you need to manually match the amount of carbs you eat and the amount of insulin you take
unprocessed carbs such as wholegrains, vegetables, legumes and fruit that are more nutrientdense, higher in fibre and tend to have a lower glycemic index (GI), which mean they cause a less rapid rise in blood glucose levels when you eat them. Less healthy choices such as biscuits, cakes,
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to avoid your blood glucose levels going up too high or down too low. This is where carb counting comes in. While the focus of carb counting is on the amount you are eating, it is also important to consider quality. Aim to choose mostly
pastries, chips, soft drinks, lollies and highly processed grains (like white bread and many puffed and flaked breakfast cereals) are best kept as special-occasion rather than everyday foods, and this is the case for everyone, not just people with diabetes!
ealtime Insulin -
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Counting your carbs Adding up your carbs correctly is essential to working out your insulin dosage. Luckily, there are simple formulas and online tools available to help you get it right o know how much insulin to take when you eat, you need a way to quantify the amount of carbs you are eating. This is known as carb counting and there are a number of ways you can do it. You can either add up the number of grams of carbs you eat, or you can count the number of 'portions' or 'exchanges' of carbs. A 'portion' or 'exchange' is usually the amount of food that contains 15g of carbs. For example, 1 average slice of bread, 1 medium orange and 1/.i cup of rolled oats all contain around 15g of carbs, or 1 carb exchange. This means you should need the same amount of insulin if you eat any of these foods.
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jOW Jhowll eaV To work out the carbs in food, you can use the nutrition label on packaged foods, carb-counting books, and websites and phone apps that allow you to look up the carb content of common foods. The Traffic Light Guide to Food which comes in a book, pocket guide and mobile phone app
(trafficlightguide.com.au) , and the CalorieKing website (calorieking .com.au) are good places to start. Scales and measuring cups are useful to help you work out how much of a food you are eating, which you can then use to work out the amount of carbs in that portion. Accurate carb counting is an essential part of flexible insulin therapy and insulin pump therapy so it is important to see an Accredited Practising Dietitian with experience in this area, so they can help you to work out the right amount of carbs you should eat as well as the best way for you to count your carbs.
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>Get into the habit of checking your levels before and after meals and it won 't be long before you're in a routine.
Monitoring matters In terms of insulin dosage, flexibility comes with responsibility and keeping a close eye on your levels is the way to look after your health
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he aim of flexible insulin therapy and insulin pump therapy is to enable you to keep your blood glucose levels as close to normal as possible, but still have flexibility in the way you live. Monitoring your BGLs at regular times means you know what's going on and can make necessary adjustments. It will allow you to: • Know whether your levels are in the target range. • Determine your insulin-to-carb ratios and correction factors. • Better understand how exercise, stress and illness affect your levels and whether you need to make adjustments for these. • Know when you need to see your healthcare team to adjust your diabetes management plan. Structured monitoring of blood glucose (SMBG) may sound
technical , but Accu-Chek's Diabetes Management Solutions make it simple. The choice of Accu-Chek software or paper tools to record your BGL (fasting, before eating, after eating, and bedtime), will help you track patterns and make decisions with your healthcare professional. The best times to monitor when you are using flexible insulin therapy or a pump are: • Before you eat breakfast, lunch and dinner or a snack (to work out how much insulin to give and to ensure your background insulin doses are correct) . • Two hours after each meal (to ensure that your ICR is correct). • Before and after exercise, or during if it is of longer duration. • Before bed (some people will need a snack if their BG Ls are
below a certain level before bed, to prevent overnight hypos). • Overnight (2-3am), particularly if you have had overnight hypos. Some meters now allow you to set reminders and mark your readings as before or after meals and this can make it easier to improve your control.
Mealtime Insulin -
The highs and ows When faced with BGLs that are a little off, it's important not to panic there are actions you can take to bring things back to where they should be f your background insulin dose is right, your ICR is correct and you are able to estimate your carb intake accurately, you will hopefully be able to keep most of your BGLs within target. However, if you have diabetes, you will know that this is not as easy as it sounds! Accurate carb counting can be difficult when you are eating out, and the effects of activity are not always predictable and can depend on the type of activity you are doing, the duration, and the time of the day you are doing it. Then there are things that are harder to control such as stress, illness, hormonal changes, and insulin absorption, which mean that even if you are trying your best to do everything right, highs and lows will still occur at times. In this case you can return your BGL to normal more quickly with the use of what is known as a correction factor (also called your insulin sensitivity). This is the amount that 1 unit of insulin will lower your BGL. So a correction factor of 2 means that 1 unit of your rapid-acting insulin will lower your BGL by 2mmol/L. Correction doses are usually given at mealtimes, added (or subtracted if you are low) to your mealtime insulin dose. However
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they can be given at other times if you are high between meals. Caution should be given to correcting high BGLs before bed, though, as this could increase
the risk of an overnight hypo. It is best to speak to your diabetes team about when they recommend that you correct, or not correct, out-of-range BGLs.
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Ca cu ating mea time insu in doses Consult our simple-to-follow guidelines to help you match your meals and snacks to the corresponding amount of insulin f you are using flexible insulin therapy or an insulin pump , each time you eat a meal or snack you will need to work out how much insulin to take to match the food you are eating. The amount of insulin you need will depend on a number of other factors explained earlier in this booklet. These include: • The amount of carbs you are going to eat. • Your insulin-to-carb ratio (ICR). • Your current BGL. • Your target BGL (to be determined together with your diabetes team).
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• Other factors such as whether you are going to be exercising after your meal. As an example, let's say it is lunchtime and you 're having a tuna and salad sandwich and a small apple to eat. Your ICR is 1:10 (1 unit for 1Og of carbs), your correction is 2 (1 unit of insulin will lower your BGL by 2mmol/L) and your target BGL is 6mmol/L. You test your BGL and it is 1Ommol/L. You work out that there is about 40g of carbs in your lunch meal. So using your ICR you need to be taking 4 units of insulin to cover this meal. But because your BGL
is a bit high you also need to correct this by giving an extra 2 units, which will lower your BGL by 4mmol/L back to your target of 6mmol/ L. You are not planning to exercise after the meal so you don't need any further adjustment for this, therefore you take 6 units of insulin. If you were planning to exercise you might reduce this dose by say 25-50 per cent depending on how long and how intense your exercise was going to be. By doing regular testing before and after exercise you will be able to work out the right adjustment for you.
Mealtime Insulin -
How a bous cacuator can hep If, like many of us, you're easily confused by formulas and figures, the new blood glucose meters can do the hard work for you! oes the idea of flexible insulin therapy sound appealing, but maths isn't your strong point? Having to calculate how much insulin to take each time you eat may seem all too hard, but the good news is that there are now blood glucose meters available such as the Accu-Chek®Aviva Expert that help you to do this. It has an in-built bolus calculator, similar to the bolus calculators in an insulin pump. You can program in your ICR and correction factors, set target BGLs and even include adjustments for things such as exercise and illness. When it's time to eat, you test your blood glucose as usual but then enter the amount of carbs you want to eat and the meter does the rest. By entering the action time of your insulin (the length of time it is active - usually 3-4 hours for rapid-acting
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>If they think it's appropriate, your healthcare professional may recommend one of these nifty gadgets to assist you in your calculations and help you keep accurate records.
insulin), the meter is also able to work out if you still have insulin acting from your previous injection to ensure you don't over-correct high BGLs if you have tested soon after a meal. These meters also capture all of your diabetes management information including your BGLs, the carbs you have eaten and your insulin doses, which can be downloaded to your computer to show your diabetes team. This is
particularly useful if you are not a good record keeper! The meters are only available through a diabetes health professional , who needs to help you to work out your settings and train you in its use. The meter still relies on you testing regularly and accurately measuring your carb intake, but it can make life easier if you find doing the calculations difficult. For more details ask your diabetes educator.
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About insu in pumps They're state of the art and can make insulin delivery so easy if you choose to take your insulin via a programmable pump device n insulin pump is a small device that is designed to deliver insulin continuously into the body (it is also known as CSll , or continuous subcutaneous insulin infusion). It is a bit smaller than a mobile phone and can be worn outside the body on your belt or waistband, or placed in your pocket or in a pouch underneath your clothes. The pump delivers insulin through a very narrow, flexible tube that is attached to a small cannula inserted under your skin. You simply program the pump to give the necessary amount of insulin - a small , steady dose throughout the day (basal rate) and you can give an extra amount (bolus) when you plan to eat. Used correctly, an insulin pump can give you much tighter control of blood glucose levels without multiple injections, reduce your risk of hypoglycemia and give you much more flexibility. As with flexible insulin therapy, an insulin pump requires you to work out your insulin-to-carb ratio and your correction factor, which are used to determine how much insulin to take when you eat (or at other times when you test and are out of your target range). You need to be a good carb counter but fortunately you
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"' The Accu-Chek Combo pump system incorporates a Bluetooth meter to measure blood glucose and remotely and discreetly control the insulin pump, so there's no need to touch the pump when you need to bolus.
don 't need to be a genius at maths as all of the pumps available have a built-in bolus calculator which tells you how much insulin to give based on your blood glucose level and the carb amount you enter. The pumps also allow you to program in adjustments for when you plan to exercise. The advantage of a pump over flexible insulin therapy is the ability to set
varying basal rates for different times of the day and to make on-the-spot adjustments if your needs change. Because our background insulin needs can vary across the day, this gives an extra level of fine-tuning and can be particularly useful for those who find they tend to go low overnight but get a large rise in blood glucose levels first thing in the morning.
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a time YOUR QUESTIONS ANSWERED
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So, what exactly does weight-loss surgery involve, and how safe is it? Far from being a miracle cure, this kind of intervention is a major commitment, which can impact both positively and negatively on your nutrition, health and lifestyle. It is generally only recommended for people who are significantly overweight, with a body mass index (BMI) of 35 or more, who have been unable to lose weight despite adopting diet, exercise and lifestyle changes. This approach was endorsed by Diabetes Australia in its 2011 position statement on weight-loss surgery for people with type 2 diabetes . For those considering surgery to avoid developing type 2, they recommend a minimum BMI of 40, but advocate, in all cases, diet and exercise as the initial approach to weight reduction.
The upside A study of recent statistics focusing on weight-loss surgery offers a number of com pelling reasons to consider it a potential option for diabetes management: • A 2008 Australian study of 60 people with type 2 diabetes found that 73 per cent of those who had gastric banding achieved remission of their diabetes after two years, compared to only 13 per cent in the control group. • A US study similarly found that, of 102 people with type 2 diabetes who underwent the sam e procedure, 80 per cent either no longer had diabetes or found it much improved, through better BGLs and/or a reduced need for medications, after five years of follow-up. • Preliminary findings from the ongoing five-year Lap-Band AP Experience (APEX) Study in the US showed that, after two years, 95 per cent of study participants with type 2 diabetes were either able to stop or reduce their diabetes medications. 102 MAY/JUNE 2013 diabetic living
While these studies looked at gastric banding, Italian research comparing gastric banding, gastric sleeve and gastric bypass found all were effective in managing diabetes. About 60 per cent of those having a gastric band, and 80 per cent a gastric sleeve or bypass, no longer took medication after th ree years. Interestingly, with a gastric sleeve and bypass surgery, significant improvements in blood glucose levels and reduced medication needs are seen very quickly, well before any significant weight loss. It is thought this is due to hormonal changes, resulting from the surgery. It is also clear that weight-loss surgery can significantly reduce the risk of developing type 2 diabetes in the first place. A recently published Swedish study of 1700 obese individuals who had undergone weight-loss surgery (either gastric banding, a gastric sleeve or gastric
bypass) found th at the patients' risk of developing diabetes over a 15-year period was reduced by 80 per cent, compared to a control group who didn't have surgery.
The downside Not all of the research is positive. A study of nearly 4500 adults with type 2 diabetes wh o had gastric bypass surgery found that, of the two-thirds of participants who experienced an initial remission of their diabetes, 35 per cent redeveloped diabetes within five years. Those most likely to relapse were people who, before surgery: • Had higher blood glucose levels. • Were using insulin. • Had a longer duration of diabetes. Undergoing weight-loss surgery is also not without its risks. These range from the general hazards of going under the knife - risk of
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WHAT ARE YOUR OPTIONS? Here's a run-down of the different types of weight-loss surgery available and exactly how they work.
··························· GASTRIC BANDING ··························· To date, this has been the most common weight-loss surgery in Australia. It's reversible and less invasive than other options. A silicone band is placed around the top of the stomach by keyhole surgery. An access port is placed under the skin and connected to the band by a tube into which saline is injected to tighten the band over time. It reduces the amount of food you need to feel full and prevents you from overeating.
THE PROS No major surgery is needed, recovery time is quick and the band can be removed. THE CONS Major changes to eating habits are required and certain foods such as chewy meats and doughy white bread are not well tolerated. Eating too quickly and too much could cause regurgitation or food to get stuck. Band slippage and erosion and disconnection of tubing to the port are also risks, all requiring repeat surgery.
······························ GASTRIC SLEEVE ..............................
bleeding, infection, blood clots and problems with the anaesthetic - to those specifically associated with the type of surgery. For example: • Researchers in Brussels following up 12 years after gastric banding surgery found a third of patients had experienced band erosion and close to half had had their band removed. • A Swiss study following up on patients an average of six years after lap band surgery found about a third had suffered com plications including band erosion, band slippage and catheter/port-related problems. Other risks with all types of weight-loss surgery can include ongoing digestive problems and nutritional deficiencies, such as an increased risk of osteoporosis due to lack of calcium. These problems can be reduced with continued support and follow-up, and this should be an important consideration when choosing a surgeon and clinic. ~
This type of weight-loss surgery is becoming more popular. It involves permanent removal of about two-thirds of your stomach, greatly reducing its capacity and the levels of appetite hormones, so you feel less hungry between meals. You will need to change your eating habits to include small frequent meals across the day and stop eating when you feel full. It is the first stage of gastric bypass surgery (see below).
THE PROS While the volume of food you can eat is reduced, it is processed in the same way, so nutrients are still absorbed and risk of deficiencies is lower than with gastric bypass surgery. THE CONS It is not reversible. There is also a higher risk of infection if gastric fluid leaks through the staple line, so careful post-op monitoring is required. If you've had previous stomach surgery, such as for an ulcer, this may not be suitable.
.............................. GASTRIC BYPASS .............................. This makes up a much smaller proportion of surgeries. Part of the stomach is removed and parts of the small intestine are also repositioned, which causes delayed digestion and reduced absorption of food. THE PROS It may lead to greater weight loss and usually sees a reduction in BGLs. This results in the need for less medication. THE CONS This is irreversible. It has surgical risks similar to the
gastric sleeve, and nutritional risks due to malabsorption, which requires taking ongoing supplements. It can result in 'dumping syndrome; when food moves too quickly into the small intestin e, causing symptoms such as diarrhoea, dizziness, nausea, stomach cramps and a rapid heartbeat. Avoiding sugary foods and following the right diet with small, regular meals can help. diabetic living MAY/JUNE 2013 103
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Covering costs Weight-loss surgery is expensive and, with limited access via the public health system, most of it is carried out in private hospitals. Medicare will pitch in to cover a portion of the costs and, if you're in a private health plan, this will generally meet your hospital fees. However, like many other surgical procedures, you will also have to pay a gap, which will vary depending on the surgeon you choose.
Aftercare This is a vital consideration when making the decision to undergo any kind of weight-reduction procedure. Surgery is only the beginning of the road to a slimmer silhouette - it is not an alternative to lifestyle changes, which are still an essential part of successfully losing weight after surgery. You will need to make permanent changes to your eating habits, including the quantity, frequency and types of food you eat. Even if the surgery doesn't affect nutrient absorption, wh en you're only eating a small amount, there is a real risk of deficiencies in nutrients if your diet is not well planned. It is im portant, therefore, to make sure you have effective after-care and are supported and monitored in the long term after your procedure. With potential after-effects ranging from gastric reflux requiring constant medication to corrective surgery down the track, playing by the rules and following medical advice is vital for a good outcome. 'Seeking the help of a dietitian experienced in this area is essential,' says Caroline Shannon, bariatric surgery dietitian at the OClinic in Sydney. 'They can help you develop an eating plan that will maximise the nutrient density of your diet, while taking into account any restrictions or eating difficulties you may have post-surgery.' 104 MAY/ JUNE 2013 diabetic living
Alan,54 TYPE 2 DIABETES, GASTRIC BYPASS
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per cent of weight-loss surgery is performed in private hospitals
I was diagnosed 10 years ago and needed more and more medication to control my blood glucose levels, until my GP said I was going to need insulin. This prompted me to seriously consider my options for losing weight. I was 115kg when diagnosed and had yoyo dieted my way up to 140kg. I saw surgery as my last hope. I had gastric bypass surgery in February 2009. I took my last diabetes medication on the day of the surgery and haven't needed any since. However, I have to take supplements and need regular vitamin B12 injections. I lost 42kg in the first year but have regained about Skg since then. My surgeon told me surgery isn't a cure but a tool, and it is a tool, which has helped me in many ways - my diabetes is now controlled without medication. I feel better, have more energy and my self-esteem has improved.
Melinda,51 TYPE 1 DIABETES, GASTRIC BAND
When my weight ballooned by more than SOkg after I was diagnosed with type 1 at 29 and put on insulin, my endocrinologist suggested I think about gastric banding. My HbAlc was fairly good, but the prospect of reducing the amount of insulin I'd need was an added bonus to the main goal of losing weight. I was highly motivated and, initially, the weight started to come off. I lost 20kg but then, 12-18 months after the surgery, the band seemed to stop working - I wasn't getting that full feeling any longer. I underwent a small surgical procedure to correct a leak in the band, which meant it wasn't providing the restriction I needed. Unfortunately, I had post-op complications and took two months to recover. Then they found a problem with the port and could only fill the band by a small amount, but even this resulted in awful reflux. I went back and spoke with the bariatric team; they told me this is a side effect and can cause longterm damage. I have now gained back 25kg. I still have the band, but this was the end of having it filled to provide the necessary restriction I need to lose weight, and so my battle continues.
Jayanthi, 43 TYPE 2 DIABETES, GASTRIC SLEEVE
Having reached 141kg, the decision to have the sleeve gastrectomy was surprisingly easy to make. I felt very confident in the care of my surgeon and his team. Before the surgery I lost lSkg on a liquid diet. The surgery took about two hours and went well, as did the post-op recovery. It was painful when I stood up, but this subsided quickly. After leaving the hospital, I focused on my post-op diet: two weeks on liquids, two weeks on pureed food and four weeks on soft food before transitioning to normal food. So far, I've lost a further 17kg post-surgery. For the first time, I'm making considered decisions about what I eat and, ironically, in the process, I'm enjoying the taste of food more than ever - even if I feel satisfied after a few tablespoons . I walk for 30 minutes a day without pain. I'm off insulin, have more than halved my diabetes m edication and my fasting BGL is about five. For me, the journey to regain my health is a long one, but I'm making progress and feeling stronger each day.
Adriana, mid-forties TYPE 2 DIABETES, ENDOBARRIER
I decided to take part in a trial that involves having the EndoBarrier placed for a year and being followed up for two years. After making the decision to go ahead, I met with the team, including the surgeon, dietitian, endocrinologist and nurse who will monitor me for the trial period. They discussed the pros and cons, the warnings about restricted food intake, the dos and don' ts of over-the-counter medication and what can be expected, based on others who had gone through the trial previously. I had the EndoBarrier inserted in J uly last year, which went well, and post-op was good up to a point. I was restricted to diet shakes for two weeks and then went onto soft food. Shakes have never agreed with me, so my food intake was minimal and I lost the majority of my weight in the first 2-3 weeks. I lost lOkg, then it took another three months before I lost another lkg. While the weight loss has been slower than I had hoped, where it has really helped is with my blood glucose levels, as they were about 9-lOmmol/L, but now I average about 7mmol/L. This benefit has been there from the start. I am still committed to losing weight and hoping to one day com e off my diabetes m edication .
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FEEL FOOT-SURE It's a good idea to check in with a podiatrist. They can pick up any foot problems that could interfere with exercise and provide orthotic inserts to protect your feet and aid balance. Investing in diabetesfriendly exercise shoes and socks is a must, reducing risk of abrasions and injuries that could lead to infection. Athlete's Foot stores wi 11 measure and fit you.
SEEK ADVICE If you're n ew to exercise, see your doctor for a check-up before embarking on a fitness regimen. Once you're given the all clear to get physical, your GP may be able to set you up with a chronic disease management plan that entitles you to see (at Medicare-subsidised reduced cost) an exercise physiologist who can put together a fi tness routine suited to your needs.
Put your bestfootforward with regular exercise, but have diabetes-smart safeguard s in place so yo u don't run into trouble 106 MAY/JUNE 2013 diabetic living
WISE UP ON YOUR BLOOD PRESSURE Exercise can create challenges if your blood pressure (BP) tends to run either high or low. Apart from the obvious risks of overdoing it, sudden postural changes can trigger dramatic reactions, depending on which end of the spectrum your levels tend to sit. LOW BLOOD PRESSURE Rapidly changing your position from lying down to standing up can cause dizziness or fainting. HIGH BLOOD PRESSURE There are certain types of exercise - such as running, then dropping down into push-ups - that can make already high BP levels soar, so may be a risk. Regular h ealth check-ups will establish wheth er you trend outside the healthy BP range. If you do, investing in your own BP monitor (available from about $35 from pharmacies) means you can keep a daily check - especially h elpful if you're on BP-lowering medication.
BE CLUEY ABOUT YOUR SUGAR LEVELS A quick test of your blood glucose levels will determine whether you're up to an activity session, as well as how long you should spend, and the level of intensity to aim for. If your BG Ls tend to be high, gentle exercise can help reduce them, especially in people with type 2 diabetes. However, exercise may also increase risk of certain long-term health problems, so talk to your doctor or diabetes educator to work out a suitable plan. If your BG Ls tend to be low and you're at risk of a hypo, keep fast-acting carbs, such as fruit juice or glucose, close at hand.
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Remember the importance of warming up and cooling down when exercising. Start off with stretching and gradual ly increase your intensity level, t hen reverse t he process at the end of your routi ne. This allows your heart rate to increase and decline slowly, reduci ng the stress on your blood gl ucose levels. diabetic living MAY/JUNE 2013 107
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WATCH YOUR WEIGHT
Stay sun smart
Exercising outside for about 20 minutes each day is a great way to top-up your level of vitamin D. As well as being good for bone strength, vitamin D helps blood glucose control in people with type 2 diabetes and reduces the risk of developing type 1. Remember, it's important to get your rays outside peak hours, even in winter, as apart from the UV risk, heatstroke can cause problems with both blood glucose and blood pressure - and people with neuropathy are particularly intolerant of heat. The best times to head outdoors for a work-out are before lOam and after 4pm.
Start exercising regularly and (hooray!) those excess kilos wil l start melting away (so long as you're eating sensibly). If you initially notice a slight weight gain, don't be discouraged - it's probably a sign you're increasing your muscle mass, which will help speed up your metabol ism so your body burns energy more efficiently. Weight loss is likely to increase your insulin sensitivity, affecting your BGLs, so you may need an adjustment in your medications. So keep an eye on your levels and check in regularly w ith your doctor or diabetes educator.
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KNOW YOUR LIMITS There are different risk factors to consider with each type of exercise, but as a general rule, it's helpful to know how hard you can push yourself by working out the maximum heart rate to aim for. A safe starting level is considered to be 65 per cent of your maximum, with 85 per cent a tough work-out. To establish your starting level, subtract your age from 220. Multiply this by the level of effort (starting from a 65 per cent base) you want to put into your work-out. So a 50-year-old (220 minus 50 multiplied by 0.65) would aim for a heart rate of 110 beats per minute. 108 MAY/JUNE 2013 diabetic living
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Holding your breath when doing bone- and muscle-building strength exercises is a common mistake and can dramatically raise your blood pressure. To avoid this, you should exhale as you lift a weight and inhale as you let it down. As well as keeping your pressure down, breathing correctly helps contract your back muscles, aiding core stability and keeping you balanced.
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" BE PREPARED You'll get the most benefit from exercise if you know how it's likely to affect you - and where it might trip you up. Your doctor can assess your exercise capabilities and, once you're given the go-ahead to start, there's a world of technology at your fingertips that will help you stay safe, such as these top tools: BLOOD GLUCOSE METER Testing before and after exercise is a must. Logging your results will alert you and your health team to any risky patterns, so you can take action. BLOOD PRESSURE MONITOR Using one before and after exercising will give you the jump on any causes for concern and help you adjust your work-out plan to suit.
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of these afforda6fe devices will show " so you ~ you how your body's coping know what to aim for and don't , overdo it. Prices start at about $SO. PEDOMETER Walking is by far Diabetic Living readers' favourite form of exercise. With 10,000 steps a day the rule of thumb, recording the number you take will help you stay on track and enable you to set yourself new goals. Prices start at $20. EXERCISE APPS These are th e way to go if you have a smartphone, helping you keep tabs. Try MyFitnessPal. ON THE WEB Visit extld.com.au for fantastic resources for people getting to grips with the challenges of exercising with type 1 diabetes.
MOBii£ PHO~E This is a sensible exercise companion to have on ~and, just in case you start feeling unwell while out and about and need to rally help urgently. FAST-ACTING CARBS These are essential if you're on insulin or glucose-lowering medication that puts you at risk of hypos. A fruit juice popper, jelly beans or glucose tablets are perfect rescue remedies. WATER You can sweat off body fluids fast when exercising, and dehydration means thicker blood with a higher ratio of sugar flowing to your tissues - in other words, high er blood glucose. So always drink plenty of water when you're exercising to keep th ese fluids up. •
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Vitamin Bl (Thiamin)
Vitamin B2 (Riboflavin)
ROI (PER DAY) Men:45mg Women:45mg Pregnant women: 60mg Breastfeeding women: 85mg
ROI (PER DAY) Men: 1.2mg Women: 1.1 mg Pregnant women: 1.4mg Breastfeeding women: 1.4mg
ROI (PER DAY) Men: 1.3mg Women: 1.1mg Pregnant women: 1.4mg Breastfeeding women: 1.6mg
FUNCTIONS It boosts your immune system, helps wounds heal faster, assists iron absorption and keeps your gums, teeth and bones healthy.
FUNCTIONS Thiamin converts carbohydrate into energy and is important for heart and nerve function.
FUNCTIONS It helps metabolise protein in the body and is important for grow th and repair of tissues, including skin and eyes.
FOOD SOURCES This vitamin is in citrus fruits, berries, tomatoes, kiwi fruit, capsicum, spinach, broccoli, guava, parsley and cabbage.
To up your intake, go for sesame
CAUTIONS
CAUTIONS There are no reports of adverse effects of excess thiamin by eating too much of it, but intravenous injection is a different story, w ith reports finding this can cause anaphylaxis and even death.
FOOD SOURCES
• A high intake from t aking supplements ca n ca use nausea, diarrhoea and stomach cramps. • It can exacerbate iron overload if you have haemoch romatosis. • Very large doses may increase DNA damage and cancer ri sk. WHEN YOU MIGHT NEED TO SUPPLEMENT You don't get enough fruit and vegetables in your diet.
110 MAY/JUNE 2013 diabetic living
seeds, nuts, yeast extract (Vegemite and Marmite), w heatgerm, liver, w holegrains, kidney, pork, breads, fortified breakfast cereals and peas.
WHEN YOU MIGHT NEED TO SUPPLEMENT • Your diet is high in processed carbohydrates and added sugars. • You have liver or kidney disease.
FOOD SOURCES You' ll find it in milk, cheese, yoghurt, yeast extract, liver, eggs, almonds, mushrooms, wholemeal bread, green vegies and fortified breakfast cereals. CAUTIONS There's no known toxicity, as excess amo unts are expelled by the body, however it may turn your urine bright yellow ! Very high doses can result in itching, numbness, burning or prickling sensations, and light sensitiv ity. WHEN YOU MIGHT NEED TO SUPPLEMENT You have chronic liver disease.
..,.._QSe From vitamins A to K, find out how you can up your intake and stay fighting fit
VitaminB12 ROI (PER DAY} Men: 2.4mcg Women: 2.4mcg Pregnant women: 2.6mcg Breastfeeding women: 2.8mcg
Vitamin B3 (Niacin)
VitaminB6
ROI (PER DAY} Men: 16mg Women: 14mg Pregnant women: 18mg Breastfeeding women: 17mg
ROI (PER DAY} Men: 1.3mg Women: 1.3mg Pregnant women: 1.9mg Breastfeeding women: 2mg
FUNCTIONS It helps release energy from food. Large doses can also increase good HDL cholesterol and lower triglycerides and bad LDL cholesterol.
FUNCTIONS Vitamin B6 helps with the metabolism of carbohydrates and is important for nervous system function.
FOOD SOURCES Stock up on lean meat, poultry, fish, kidney, liver, legumes, eggs peanuts, w holegrains, milk and fortified breakfast cereals. CAUTIONS • Large doses can result in liver
damage and skin rashes, and may cause or worsen stomach ulcers. • High intake (over 1OOmg/ day) can result in skin flu shing and itching, headaches, low blood pressure and light-headedness. WHEN YOU MIGHT NEED TO SUPPLEMENT You have high cholesterol.
FOOD SOURCES This is found in lean meat, poultry, fish, legumes, nuts, avocado and bananas, so add them to your shopping list. CAUTIONS There are no known side effects found from ingesting too much vitamin B6 from food, but long-t erm use of higher dose supplements has been shown to cause nerve damage. WHEN YOU MIGHT NEED TO SUPPLEMENT • You drink excess alcohol. • You have chronic diarrhoea or malabsorption.
FUNCTIONS This vitamin helps make red blood cells and supports the development of nerve cells. It also prevents neural tube defects (birth defects) and reduces homocysteine - a risk factor for heart disease. FOOD SOURCES It's found naturally in animal foods such as meat, poultry, fish, eggs, seafood, cheese, milk and yoghurt. It is also added to fortified soy milks, vegetarian meat alternatives and Marmite. CAUTIONS • Some medications, including metformin and those used to treat reflux and stom ach ulcers, may interfere with absorption. WHEN YOU MIGHT NEED
TO SUPPLEMENT • You follow a veg an diet or don't get enough animal food s. • You take metformin. • You have a condition that causes malabsorption such as inflammatory bowel disease or coeliac disease. • You have pernicious anaemia and need to have injection s.
diabetic living MAY/JU NE 2013 111
Biotin (vitamin H)
Vitamin BS
Folate
(Pantothenic acid) Al* (PER DAY) Men:30mcg Women: 25mcg Pregnant women: 30mcg Breastfeeding women: 35mcg FUNCTIONS This vitamin helps convert carbohydrates and fats into energy, and also supports nervous system activity. FOOD SOURCES Choose egg yolks, organ meats (think liver, kidney and heart). legumes, oats, oysters and yeast. CAUTIONS There are no negative effects associated with too much biotin as any excess is simply flushed from the body in urine. WHEN YOU MIGHT NEED TO SUPPLEMENT
• Too much raw eggwhite in your diet prevents absorption and can lead to deficiency. • Taking anti-seizure medications and antibiotics can also cause deficiency.
Al* (PER DAY) Men:6mg Women:4mg Pregnant women: Smg Breastfeeding women: 6mg FUNCTIONS It helps the metabolism of carbohydrate and fats, and is also beneficial to the maintenance of healthy nerve and muscle function. FOOD SOURCES Many of the foods we eat daily as part of a healthy diet contain this nutrient. These include meat, poultry, fish, legumes, nuts, wholegrains, yeast extracts (Vegemite and Marmite) and organ meats (liver and kidney). CAUTIONS No serious side effects are linked with this vitamin, however large doses may cause diarrhoea. WHEN YOU MIGHT NEED TO SUPPLEMENT Deficiencies are rare, as this vitamin
is found in commonly eaten foods, but it can occur with alcoholism.
Find the right balance of nutrients and give your body a healthy boost 112 MAY/JUNE 2013 diabetic living
ROI (PER DAY) Men: 400mcg Women: 400mcg Pregnant women: 600mcg Breastfeeding women: SOOmcg FUNCTIONS Folate keeps red blood cells healthy, has a part in making new cells and helps the nervous system function properly. FOOD SOURCES Choose green leafy vegetables, wholegrains, nuts, avocado, organ meats (liver and kidney), yeast extracts (Vegemite, Marmite). legumes, fortified breakfast cereals and breads. CAUTIONS • It can mask vitamin Bl 2 deficiency, especially in vegetarians who have lower Bl 2 intakes and higher folate. • Thi s nutrient can interact with certain medications including methotrexate, anti-epileptic meds and su lfasalazine - used to treat ulcerative colitis. WHEN YOU MIGHT NEED TO SUPPLEMENT • You fall pregnant or you're trying to conceive. • You have a condition that causes malabsorption such as inflammatory bowel disease or coeliac disease. • You drink excess alcohol.
Vitamin A
VitaminD
VitaminE
ROI (PER DAY) Men: 900mcg Women: 700mcg Pregnant women: 800mcg Breastfeeding women: 11 OOmcg
ROI (PER DAY) Men:Smcg Women (including pregnant and breastfeeding): Smcg
ROI (PER DAY) Men: 10mg Women:7mg Pregnant women: 7mg Breastfeeding women: 11 mg
FUNCTIONS Important for healthy eyesight and skin, this vitamin also helps with immune system function.
FUNCTIONS It's great for strong bones as it helps w ith calcium absorption.
FOOD SOURCES Vitamin A is found in liver, milk, eggs, leafy green and dark-green vegies, plus yellow, orange and red fruits and vegetables.
FOOD SOURCES You'll find it in fatty fish, eggs, milk, cheese and butter. It's also added to many margarines, some milks and soy milks. However, most of our vitamin D comes from a good old daily dose of sunshine!
CAUTIONS Too much preformed vitamin A, known as retinal, is toxic and can cause hypervitaminosis A.
CAUTIONS Too much vitamin D may cause anorexia, weight loss, polyuria, and heart arrhythmias.
WHEN YOU MIGHT NEED TO SUPPLEMENT If you have fat malabsorption, such as Crohn's disease, as this can cause poor absorption.
WHEN YOU MIGHT NEED TO SUPPLEMENT
VitaminK ROI (PER DAY) Men: 70mcg Women (including pregnant 1 and breastfeeding): 60mcg FUNCTIONS It helps maintain normal
• You don't get out in the sun regularly or cover up w hen you do. • You have fat malabsorption.
levels of the blood-clotting proteins. In other words, if you cut yourself, it helps prevent excess bleeding. FOOD SOURCES Asparagus and dark green, leafy vegies such as broccoli, spinach, silverbeet, dark-coloured lettuce, brussels sprouts, endive, asparagus and parsley are all rich in vitamin K.
FUNCTIONS An antioxidant, it prevents cell damage caused by free radicals. FOOD SOURCES Get your dose from nuts, seeds, vegetable oils and wheatgerm. CAUTIONS High doses can increase the risk of bleeding, particularly in those taking anticoagulant or antiplatelet meds like wa rfarin. WHEN YOU MIGHT NEED TO SUPPLEMENT If you have fat malabsorption, such as Crohn's disease or cystic fibrosis, as this can make it harder for your body to fully absorb this essential nutrient.
CAUTIONS Vitamin K interacts with warfarin, which can affect blood clotting. So if you take warfarin, it's important to have a consistent intake day to day. WHEN YOU MIGHT NEED TO SUPPLEMENT You have fat malabsorption, which causes poor nutrient absorption.
*Adequate intake (Al) listed, as no recommended dietary intake (ROI) set for these nutrients. diabetic living MAY/JU NE 2013 113
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FIND YOUR BEST With so many varieties of yoghurt on offer, choosing between them can be a bit bew ildering. Here's how to select the right one for you acked with more than 10 essential nutrients, this staple is especially beneficial as a breakfast, snack or dessert option for people with diabetes. Yogh urt is an excellent source of low-GI carbs, protein, bone-strengthening calcium, vitamin D and magnesium , as well as healthy bacteria that aid digestion. Mixed with fruit or used as a base for dips and marinades, it's a versatile sweet or savoury ingredient. But with so many types on offer - biodynamic, Greek-style, fat-free, flavoured, natural, organic and diet, the list goes on - how do you pick what's best for you? Reading th e label is an obvious step, but you still need to know what to look for - and th e questions to ask - if you buy unlabelled yoghurts over the counter in delis.
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drawcard for those of us needing a hit of friendly bacteria to settle digestive problems a common result of stress, antibiotic use and the fact that two-thirds of us don't eat enough fruit and vegies. While a regular dose of these beneficial bugs is a great way to ensure a healthy bacterial balance in the gut, it's important to know that not all yoghurts contain probiotics. For companies to claim them as an ingredient, the product needs 114 MAY/JUNE 2013 diabetic living
to contain at least one million colony-forming units per gram. ~ TIP: Brands such as Parmalat (the makers ofVaalia yoghurt), Jalna and Danone (the producers of Activia) are good choices. Bacteria diminish with time, so it's important to eat fresh yoghurt that's not past its use-by date.
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with weight management, studies show, with yoghurt's low-GI and sound nutritional profile helpful in satisfying appetite and boosting healthy metabolism. The num ber of kilojoules in yoghurts varies, however, depending on the type of milk that's used to make it - full cream, reduced-fat or skim - as well as the amount and type of sugar and fruit added. In general, fat-free plain or artificially sweetened diet yoghurts have the lowest kilojoule content. Also check whether the label suggests there are two serves per tub. ~ TIP: Weight loss is about energy in versus energy out, so remember that even eating too much of the right type of yoghurt will lead to weight gain.
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ranges from Og to about 6g per lOOg. If you see 96 per cent fat-free yoghurts in delis, this means they contain 4g of fat per lOOg. This is still higher than full-cream milk yoghurt, which has 3.5g fat per lOOg. ~ TIP: While yoghurt that's higher in fat is still a healthier choice than ice -cream, people with diabetes should ideally be choosing yoghurt with 0-1g total fat pe r 1OOg.
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SMART WAYS TO ENJOY YOGHURT Spoon low-fat fruit yoghurt into large ice cube trays, freeze and add to homemade smoothies. Blend fat-free plain Greek yoghurt, banana, a little vanilla bean paste and maple syrup. Put into a small heatproof dish and sprinkle with CSR LoGiCane Low GI Cane Sugar. Use a chef's torch to make a thin creme brulee topping. Make your own iceblocks by blending fat-free vanilla yoghurt with fresh fruit. Put in moulds, then freeze. Combine fat-free plain Greek yoghurt, diced cucumber, lemon zest, lemon juice, crushed garlic and a sprinkle of lemon pepper to make a tzatziki dip. Top your next curry with a dollop of plain Greek yoghurt rather than coconut cream. Use King Island Dairy yoghurt in place of cream to make an indulgent, but healthier, pavlova.
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The natural- and addedsugar content of yoghurts varies greatly and the majority of flavoured yoghurts, including vanilla,
Mi x grated apple, 97% fat-free muesli and fat-free plain yoghurt with a little cinnamon for an instant Bircher-style muesli.
The average Australian consumes about seven kilos of yoghurt a year are sweetened with sugar or a sugar substitute. Most diet yoghurts also contain a sugar substitute additive. ~ TIP: Check the total carbohydrates per 1OOg or per serve to compare yoghurts. Aim for about 7g per 100g.
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Yoghurt developed th e traditional way, without using gel and thickening agents, allows th e bacteria to convert lactose into lactic acid. This, in turn, thickens the yogh urt naturally. An d through this process, about 95 per cen t of the lactose is removed, which m eans that many people who are lactose intolerant can enjoy yoghurt without the negative side effects. ~ TIP: Jalna and Greek yoghurt such as Chobani are made this way and are both good options for lactose intolerant people to experiment with.
Begin with plain yoghurt or Greek yoghurt, then com pare the fat content as well as the taste, as some are more bitter than others. You can then add your own sweetener and flavourings . Try passionfruit pulp, berries or vanilla bean extract for low-sugar options, and banana, maple syrup, mango or peach for more carb-heavy blends. ~ TIP: Use yoghurt as a sour cream alternative, to make dips or add to a smoothie instead of ice-cream to make it extra healthy and creamy. • diabetic living MAY/JUNE 2013 115
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Dietin~ Want a weight-loss plan that works for you? It's easy to adapt one of the popular diets to suit your health needs. Here's how hen the pressure's on to lose weight, you can be certain there's a new and improved diet out there that's 'guaranteed' to help you do it ... and don't we all love a ready-made solution to our waistline woes? But buying into the latest quick-fix slimming plan isn't so simple when you're managing the dietary demands of diabetes. It can mess around with your blood sugars and potentially cause a range of problems, which in crease your long-term health risks. And, worse still, many of them are so restrictive and unsustainable that they're impossible to follow for any length of time. No wonder more than eight in 10 dieters regain the weight lost and put on more still -within two years. Lifestyle changes are the best route to lasting weight control, and this means finding a long-term eating plan, which is good for both your waistline and your health (combined with regular exercise, of course!). Here is an overview of a few of the latest diet offerings, giving the pros and cons of each and ways you can tweak them to work for you.
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This is a Mediterranean-style diet, which promotes the eating of unprocessed wholefoods, together with a h igh intake of mono-unsaturated fa ts from foods including olives, avocados, nuts, seeds, dark chocolate, soybean, and flaxseed and olive oils. The Flat Belly Diet starts with a low-kilojoule jump-start period over four days, designed to reduce bloating. This is followed by a 28-day eating plan providing 6700 kilojoules (1600 calories) daily. The eating plan is based around fruits, vegies, whole grains, nuts, seeds, legumes and lean protein, with a low intake of red meat .
THE GOOD
THE BAD
This is a healthy diet, based on w holefoods, which encourages a good intake of plant foods, including whole grains, legumes, vegetables, fruits and nuts. Carbohydrate intake is reduced, but not to the extent of the Atkins and paleo diets (see page 118), and focuses on nutrient-dense carbs. The lower carb intake is offset by a higher intake of mono-unsaturated fats rather than a high intake of animal protein. A number of studies have shown the health benefits of Mediterranean-style diets, including in the prevention and management of type 2 diabetes and metabolic syndrome, as well as a reduced risk of heart attack and stroke.
While there is nothing too wrong w ith the diet itself, the claims it makes may be a bit misleading. The diet is based on only small and short-term studies, so the idea of melting belly fat away in 28 days could be a little over-exaggerated. The initial four-day restriction may be too low-energy for some and the weight lost in these few days is likely to be water rather than fat loss. Since everyone has different energy needs, the kilojoule content of this diet might need to be adjusted up or down to achieve a healthy weight loss for you (O.Skg a week is a good long-term rate of weight loss).
Tailor it to suit you
This diet is pretty much good to go. But you may want to get advice from a dietitian about your individual kilojoule needs and whether you should alter the portions recommended to achieve a safe and h ealthy rate of weight loss . If you're taking insulin or medication for your diabetes and this diet is lower in carbs than your usual eating plan, you also need to speak to your doctor or diabetes educator about adjusting your medication or insulin to avoid hypos . Combine the diet with regular exercise, including interval training (incorporating short bursts of high er-intensity exercise) and resistance training (lifting weights), both of which have been shown to help with reducing weight around the m iddle. > oa~
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While there is an ongoing debate about whether restricting carbs or protein is the best way to lose weight, in many cases, research doesn't back up the need for such strictures. A large study comparing four different diets, from Atkins (very low carb) to Ornish (vegetarian, low-fat, high carb), found that the weight loss achieved was similar on all four diets and what predicted success was cutting kilojoules and being able to stick to the diet. diabetic living MAY/JUNE 2013 117
Those promoting a paleo diet claim that we need to go back to eating like our ancestors - that is, foods that could either be hunted, fished or gath ered, including meat, fis h , shellfish , eggs, n uts, fruits, berries and vegetables. The diet excludes dairy foods , grains, legum es, potatoes, sugar and processed oils basically all the food that appeared after th e start of agriculture. Advocates maintain th at the diet is our answer to weight loss and avoiding m any of the chronic diseases we now suffer, which were not seen in the Palaeolithic age.
THE BAD This diet cuts out the processed foods we don't need and focuses on fresh food, including vegetables and fruit such as berries. In a true paleo diet, protein comes mainly from fish, seafood and wild animals, which provide lean meats and a high intake of healthy omega-3 fats.
The problem with this diet is that we can't really follow a true paleo diet. The Palaeolithic man hunted and gathered his food, so activity levels were much higher and the meat he ate was very different from what we get today from domesticated animals. There is also no good evidence to suggest we need to avoid grains, particularly in their whole grain form (quinoa, traditional rolled oats, barley, brown rice). In fact, when it comes to our health and weight, evidence points to the benefits of eating more whole grains, especially for reducing the risk of type 2 diabetes, heart disease and bowel cancer. The same goes for legumes, which are a great source of protein, and low-GI carbs. And while dairy foods are not essential, they're a rich source of calcium and there's nothing to indicate they should be avoided to lose weight. o_
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Adopt the no-processed-food aspect of this diet and focus on eating fresh wholefoods, but include whole grains and legumes. Choose more ga~ats (such as kangaroo), which are more nutritionally similar to the animals Palaeolithic man would have eaten. Also gather som e of your own food by growing your own vegetables or, if this isn't possible, take a walk to your local farmers' market. You could even try a spot of fishing! If you include dairy foods, opt for plain milk and plain yoghurt, rather than the sugar-laden options.
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THE NEW ATKINS DIET This diet has gone in and out of fashion a number of times, the original 1970s format garnering criticism for its high saturated fat and low fibre intakes. A new version, still a low-carb, high-protein and high-fat diet, includes more vegies and limited amounts of healthy carbs in the latter phases. Th ere is more focus on healthy mono-unsaturated fats (for instance, from olive oil and avocado), too. It is split into four phases: induction, ongoing weight loss, pre-m aintenance and lifetime maintenance. The induction phase is very low in carbs (20g a day), but small amounts are added back in over time. ccww:
The Atkins Diet, similar to the paleo diet, cuts out many processed carbohydrates that we don't need. While the carb intake is very low in the first stage, it does encourage getting most of these carbs from vegetables, and as you add them back in during the later stages, it recommends healthier wholefood carbs. These include fruits, nuts, starchy vegetables and wholegrains such as oats, brown rice and whole-wheat pasta.
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The very low carb content of the initial stages of this diet could result in a number of side effects, including fatigue, light-headedness and bad breath. If you are taking medication or insulin to manage your diabetes, there is a significant risk of hypoglycaemia (low blood glucose levels) unless your medication is adjusted. This type of eating plan, therefore, should only be embarked upon under the supervision of your doctor. While the new Atkins Diet encourages more healthy fats, foods like butter, cream and sour cream are still allowed w ithout restriction. It also recommends very high intakes of animal protein, including processed meats, which have been linked w ith type 2 diabetes, heart disease and bowel cancer risk. If you have kidney problems, the high protein intake could worsen them.
AVOID DIETS THAT. .. C> Promise rapid or instant weight loss.
C> Restrict entire
Tailor it to suit you
Forget the super low-carb induction and move straight to phases three and four, which are essentially the same. Use the recommended carbohydrate list to choose nutrient-dense unprocessed carbs and focus on h ealthier fat sources (for example, olive oil, avocado and nuts) instead of butter and cream. Choose your protein wisely - plenty of fish and seafood, only lean cuts of meat and poultry, no processed meats, and tofu in place of animal protein. >
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food groups. Focus on short-term changes to eating habits. ~ Allow you to eat unlimited quantities of particular foods. ~ Recommend specific food combinations. ~ Encourage you to take miracle potions, pills or supplements. C> Make claims that are based on testimonials rather than published scientific evidence. C> Claim exercise is unnecessary or advise against exercise (usually due to a very low energy intake that would make exercise difficult and potentially dangerous). ~
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diabetic living MAY/JUNE 2013 119
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Advocates of raw-food diets b elieve that eating plant foods in their natural state (unprocessed and uncooked) is the best option for our health. The theory is that raw foods contain enzymes that help with digestion and are destroyed during the cooking process. A raw-food diet consists mostly of fruits and vegetables, together with nuts, seeds, sprouted grains, dried fruits, juices, and herbs and spices. Food dehydrators can be used as an alternative to cooking.
THE GOOD
THE BAD
The focus on eating fresh food and vegetables (which make up about 75 per cent of the diet) and other unprocessed plant foods may provide significant health benefits, and it would also be hard not to lose weight and lower your blood glucose levels. This diet is rich in vitamins, minerals and antioxidants, high in fibre and low in fat- the fat it does contain comes from the healthy fats in nuts, seeds, avocados and olives. There is also not much chance of you going hungry, as you get to eat large volumes of food!
A raw-food diet is obviously pretty restrictive, so it could be difficult for many people to follow in the long term. The fact that so many foods are off the plate means it does need careful planning to ensure your nutritional needs are met. Protein and calcium intakes can be hard to meet without large amounts of nuts and seeds. The diet also doesn't contain any vitamin Bl 2 (found only in animal foods), so a supplement is needed to avoid deficiency. This is particularly important for anyone who is taking metformin, as this medication reduces Bl 2 absorption, which could speed up the fall in Bl 2 levels.
Tailor it to suit you
There is no doubt that m ost people would benefit from eating more fresh fruits, vegetables and salads. But teaming these with other plant foods, which are not allowed on a raw-food diet, including cooked grains and legumes, can provide more variety and make it easier to meet your nutritional requirements. Certain vegetables really need to be cooked (think potato and sweet potato) and we also know that we absorb important antioxidants (such as the betacarotene in carrots and the lycopene in tomatoes) better when these foods are • cooked, particularly together with a little healthy fat.
OPT FOR EATING PLANS THAT. .. C> Align with generally accepted healthy eating guidelines. C> Can be adapted to your own lifestyle and individual needs. C> Are also suitable for managing your blood glucose levels. C> You could follow in the long term, not just for a few weeks. C> Come from a professional with recognised nutrition qualifications. C> Are backed up by reputable scientific evidence. C> Recommend combining dietary changes with regular physical activity.
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THE WAY
itis
'I was determined
' Too often, the triggers for ty pe 2 diabetes are formed in childhood, then passed from generation to generation. If yo u're w atching this series of The Biggest Loser, there are a few contestants you've probably been follow ing more closely than others, since they're battling their weight as well as managing type 2. For them, the goal is not only to lose weight and get fit, but to see their kids do the same - and break the diabesity cycle before it's too late. We talked to two parent-child teams who signed up to turn their lives around.
As a young man, Gerald Nestor was a top rugby player - paid for turning out for his local team. But then an accident left him with five crushed vertebrae. In pain and unable to play, it was the start of a downward spiral. A year later, Gerald's wife Kate, who has type 1 diabetes, gave birth to their firs t child. Daughter Sophie was born with heart problems and spina bifida, and the Bendigo-based family had to spend months staying at the Melbourne Children's Hospital. The only food they could afford on top of all the other expenses was Macca's, and Gerald's fast-food flab continued to grow when he bought 122 MAY/JUNE 2013 diabetic living
a business and was spen ding four or five hours a day in a truck, eating what he could at roadside cafes think pies, pasties and dim sim. As the weight piled on, he started suffering dizzy spells and was diagn osed with type 2. He was told h e'd probably had it for around two years, was put on medication and told to diet and exercise. 'But I was 165kg. It was too hard. I had no energy,' Gerald says. To Gerald, though, that wasn't the worst of it. By now he had a son, Todd. He too was piling on weight. 'I knew I was one of the reasons he was big, because whatever I ate, he
ate; wherever I went, he went,' Gerald explains. 'We are close, real good pals. I h ad a very guilty conscience. We went to see dietitians, but we just couldn't get hold of what we needed to do, and every time we tried to tell Todd he couldn't eat someth ing, he got upset and ate it anyway.' Todd was also caught in a vicious cycle. He'd quit sport because of bullying and started to comfort eat . That meant he put on weight and got bullied more, so he comfort ate more - ending up at 112 kilos. He was heading his dad's way, and Gerald was desperate to help him. Wh en Sophie, now 18, announced she was nominating them both for The Biggest Loser for the sake of their health, neither argued. Tm ashamed to say this, but I'd given up on life,' says Gerald. 'I was working two jobs because I thought I had to
Gerald and Todd Nestor AGE: 52 & 15J VIC
provide for my family before I died.' Two months into the show, it was hard to believe he'd felt like that. Gerald sat in The Biggest Loser kitchen beaming as he related stories of his progress. 'I was determined from the word go. I wasn't going to waste this opportunity,' he says. Five sessions a day of mainly cardio exercise - walking and cycling means he can look in the mirror and see the old Gerald returning. After six weeks, he was off his medication and his blood sugar levels have ranged from 4.7 to 5.9. Todd, 15, meanwhile, hadn't just lost weight. In two months, he had grown two inches with all the nutritious food and healthy living. Father and son now have a list of goals they're going to work on when they leave the house. And they're confident they will take the lessons they've learned back into normal life. 'What I've realised is that if one person is overweight, the whole family has to go into the eating and exercise programs,' says Gerald. 'It has to be a completely different way of life - for mum, dad and children.'
Gerald and son Todd are determined to t ake the lessons they've learnt b ack into normal life.
diabetic living MAY/JUNE 2013 123
THE WAY
itis
Brett and Mandy Martin AGE: 23&53, WA
124 MAY/ JUNE 2013 diabetic living
Have you ever thought that if only you had your own live-in personal trainer, exercise would be easy? Well Mandy Martin's husband, Brian, is a PT and she can tell you it's not. Mandy came into The Biggest Loser house weighing 113 kilos and with type 2 diabetes. 'Portion sizes are my downfall. I ate as much as my husband,' sh e says. 'I'd go out for coffee at weekends and have a cake or apple pie with it, and at night I'd watch TV eating chips or chocolate.' She was warned sh e was prediabetic and put on a care plan, but says: 'I couldn't get my act together to lower m y sugar levels. I'd do it for a couple of weeks, then fall off. It was so frustrating. Brian was really supportive, but as a working mum, everything took priority over m y health.' When she was diagnosed with diabetes two years ago, she says she and Brett - who came onto th e sh ow weighing 187 kilos - were both distressed. 'Brett has inherited all my bad health traits. We both wear contact lenses, both have trouble with our teeth. I kept thinking that if Brett didn't lose weight, he'd end up with diabetes,' Mandy explains. Brett's weight gain was even more ironic. He takes after his dad in being tall and loving sport. A
talented basketball player, at 14 he was put under the supervision of a coach. 'He made me hate basketball. I quit and stacked on the weight,' says Brett. Bored, he slumped in front of a computer, gorging on snacks. His dad tried to encourage him to move, 'but his ways didn't stick - it wasn't him, it was me.' On the show, the Perth-based mother and son have both seen a complete turnaround. 'For me, it took me out of an environment where I was always worrying about work an d housework,' says Mandy. 'All I have to think about now is nutrition and exercise. The trainers really get into your h ead. It's given m e the opportun ity to think about m y life and what I n eed to change, and that's really worked for me.' For Brett, the biggest surprise is that nutritious eating is not only easy - ham and cottage cheese salad anyone? - it's also satisfying. 'He'd never eat anyth ing like stir-fried vegetables before,' says Mandy. Mandy's doctor had been about to put her on m edication when sh e entered the competition, but agreed to hold off to see how she fared. She is now confident she won't need it - so long as she continues to make her health needs a priority.
•
top tzps FROM BIGGEST LOSER PT
Michelle Bridges SIT DOWN WITH YOUR DIARY AND WORK OUT WHERE YOU CAN MAKE TIME TO EXERCISE It won't fall in your lap, so work it out. You need 30 to 60 minutes of activity locked in, six days a week. Six days form s a habit and habits are how you build success. Make at least three out of the six hard sessions. GO THROUGH YOUR KITCHEN Everything that's holding you back - biscuits, cakes, lollies, soft drinks - dump in the bin. GET THE COLD HARD NUMBERS IN YOUR HEAD Get on the scales. Do your measurements. Take a photograph of yourself. You don't need to show anyone, but
it's good to have the numbers in yo ur face and see your progress.
KNOW THAT STARTING TO EXERCISE IF YOU'RE BIG WILL BE UNCOMFORTABLE But ask yo urself - which uncomfortable do you want? The uncomfortable that leads to increased health risks, or the uncomfortable that's a bit of sweat and chafing? GETUP AND GO The best time to exercise is the morning, before life has begun to pull you from pillar to post. Turn off your brain so you don't start negotiating w ith yourself 'If I don't eat brekkie, I don't have to run; or 'l'll exercise this afternoon: Just get out the door.
Mandy and son Brett have started to prioritise their health needs and are positive about the future.
diabetic living MAY/ JUNE 2013 125
THE WAY
itis Roger doesn't let type 1 get in the way of his passion for adventure and exercise.
minutes - an atrocious end to the day. Last year, during the same race, I blew the start by taking in too little insulin, running high for the first five hours and pushing my body to the absolute limit. After 60km , I had a cold sweat, felt shaky, dry and very thirsty. On the flip side, all of the highs and lows I usually associate with diabetes just become part of the soup I'm running through for what may be 30 hours straight. I stick closely to my race plan, adapt quickly, and test, test , test!
Do you use a pump?
'I stick closely
to my race plan, adapt quickly and test test testF Ma rathon runner, Roger Hanney, 38, pushes himself to th e li mit t o rai se fu nds for resea rch When were you diagnosed with type 1? In 2008, when I was 34, I developed it seemingly out of nowhere. You recently helped launch the Born to Run foundation, to raise funds for type 1 diabetes research. What difficulties have you faced as an athlete with type 1? Anyone running for 15 hours straight faces challenges with their 126 MAY/JUNE 2013 diabetic living
nutrition. But if you have diabetes, and you get too much or too little insulin, it can be a disaster. I was doing great during a lOOkm mountain race in 2011then 97km and 13.5 hours in, everything fell apart. The half a unit of insulin I'd had was enough to nearly push me over the edge, while the carbs I'd thrown down on the run hadn't digested due to high exertion. The next 3km took 90
Yes, I use an Animas 2020 pump and occasionally a Guardian CG MS [continuous glucose monitoring system] from Medtronic. CGMS is a brilliant way to learn about your management approach, but the lack of government fun ding for th ese necessary - not luxury - items is appalling. I also use the Roche Accu-Chek Mobile glucose meter, which I keep in an airtight military-grade snaplock bag on m y runs. It's heavy, but the convenience of one-handed BGL checking is hard to beat when you're distance running. In alpine conditions, you need to keep your meter near your body - around your neck or tucked in an armpit - otherwise it gets too cold to work. I discovered that at the start of m y firs t solo 14,000 footer (4.2km-high) in the mountains of Boulder, Colorado in 2011. Thin air and no blood sugar reading for 10 hours made for an interesting day! During races, which run over several days, I carry Roche's Accu-Chek Nano as a backup, because it's light.
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Have you ever considered abandoning an exercise regimen due to the difficulties involved in blood glucose management? Never! I wonder how anybody can manage type 1 diabetes without
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What would you tell others about the exT1 D program and who would you recommend it to? ExTlD is a tool for anyone with diabetes who wants to be more active or just more stable overall. Learn from the mistakes of others who have already taken the challenge you're facing, then just go for it. Lots of people find exTlD is a brilliant tool th at helps them plan activities around duration, intensity, insulin and carb intake. But the process of un derstanding is really th e trophy in this cabinet. When I dig into the tutorials and discussions, I gain a better u nderstanding that becomes a practical instrument. Diabetes can take the spontan eity out oflife, but it's th e conservative management strategies that tell people to behave themselves according to the dictates of their condition . I've learnt to live dyn amically with this disorder and adapt on the go by having a deeper insight into the complex processes it triggers. Otherwise, I'd just be a spectator. •
Above: Roger (centre) with fellow Born to Run teammates.The team aims to finish the ultimate challenge of running across five of the harshest deserts in the world.
regular exercise. I've had to take time-out from training for rehab when I've had niggles in my back or hip. I've also seen my insulin resistance double and blood sugar control roller-coaster over just four days when I've skipped training. Even 40 minutes of running at 'effort level' or 90 minutes of daily yoga makes a positive impact on blood sugar management. I can't believe some health professionals still scare newly-minted type ls out of leading an active lifestyle. What did you learn about managing marathon running and your diabetes from the exT1 D website program? Dr Helen O'Connor directed m e to exTlD. She's a highly-respected sports dietitian who I was working with in 2010-11 to troubleshoot my in-race nutrition. I needed guidance and structure because there aren't many other diabetic ultra-runners to ask for advice. I then contacted Allan Bolton, who is the diabetic brain behind the system. He taught me how to tim e cutting my basal before activity, handle spikes on the go and why not enough insulin on the run can be almost as performance-
destroying as having too much. He, and the exTlD tutorials, h ave given me the confidence to manage m y type 1 on the go, in extreme heat or cold, under conditions of sleep deprivation, night and day. How did the program change your approach to exercise and diabetes management? I h ave more confidence to take on new situations and manage my sugars . I now th rive on new challenges. Doing the 4 Deserts Grand Slam last year with Team Born to Run and helping Greg Donovan launch the Born to Run foundation has been an incredible experience - physically daunting, but incredible.
BE ACTIVE WITH TYPE 1 The goal of the exTl D program is t o inspire people w ith t ype 1 to participate in regul ar physical activity, exercise and sport with confidence. To learn more about the program and get involved, visit extl d.com.au
To find out more about the Born to Run foundation, or register for its Big Red Run fundraising event to help find a cure for type 1, go to borntorun.com.au Big Red Run starts 8 July in the Simpson Desert, Birdsvi//e, Queensland.
diabetic living MAY/JU NE 2013 127
ASK ABOUT your kids
How you behave can affect your child.
I always have butterflies ahead of my son's check-up, and wonder if other parents feel as nervous?
A
Well, our three months are up and we're due back at the diabetes clinic. Finding out your kids' HbAl c results and how well controlled their sugars have been can be really nervewracking - I always feel I'm about to be judged on how good a parent I've been . I beat myself up, thinking that I should have done more, got the kids to test more, recorded more results, wat ched more closely what they were eating and scrutinised more carefully how they were programming their pumps. More, more, more, more! It's a huge mental challenge looking after a child with diabetes , without the added challenge of guilt . Guilt, I feel, is something that just goes with the territory - no matter how involved or well-organised you are. As parents with the 128 MAY/JU NE 2013 diabetic living
responsibility of overseeing and supporting our kids to be their diabetic best, there are tim es wh en we're too hard on ourselves. Instead of feeling we've failed because our child's BG Ls are out of whack or we miss signs of an approaching hypo, we need to remind ourselves of our daily successes . So seek out a close friend or family member who really knows what it takes to look after your child, ask them if you're doing a good job and you can be pretty sure their honest response will be, 'Most definitely!' When we're being harsh on ourselves, we should take a step back and ask ourselves if it's the kids with the condition ... or us. Diabetes is unpredictable, and so is life. We don't live in a perfect world and there will be times when we're thrown a
curved ball that we just couldn't have anticipated - when your kid has a hypo away at school camp, overdoes it on the sports field or overdoses on chocolate cake at a party. This can, understandably, raise your stress levels, but your reaction can make your child anxious, too, upsetting their blood sugars even more. As parents, we need to get out of our h eads and stop worrying about the negatives, accept the hand we've been dealt and move forward. Kids pick up a lot from watching our behaviour so, if you have a positive outlook, they'll know no other way. Don't feel judged on your child's HbAlc - doctors and educators know how hard it can be to manage diabetes and are there to h elp. If there's room for improvement, look to the future and choose one thing you can change in the next three months. The other day, my 20-year-old, Sam, came home from the clinic with the news that he could reduce his HbAlc by 0.2 per cent with just one more test a day. The most important thing in my life is having happy, positive children - even if it takes a little bribery to keep them on track. But although I've promised mine a monetary reward if they can get their HbAlc in the sixes, unfortunately, I haven't had to pay up yet!
Any questions? ASK ELISSA RENOUF Elissa's husband, former Bro ncos NRL great Steve, and four out of their five kids have type 1 diabetes.
Email: [email protected] .au Or post your question to:
Diabetic Living, Q&A: Ask about your kids, GPO Box 7805, Sydney, NSW 2001.
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The Renoufs have developed a practical range of diabetes products, including the Multi-fit Case (pictured right), called Diabete-ezy. The range is available on line and i n pharmacies. Visit d iabete-ezy.com for mo re. This advice does not replace therapy from you r diabetes management team.
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Although I eat a really healthy diet and look after my diabetes, I still seem to be prone to winter bugs. Do you know whether there are any vitamin supplements I can take to boost my ~mmunity before th cold weather arrives? ln a review of supplements taken to help prevent respiratory viral illnesses, it was found that many forms of zinc can reduce the severity of cold symptoms, decreasing absenteeism in schoolchildren. If you sometimes miss meals due to a lack of appetite or busy schedule, a good, balanced multivitamin may be helpful to supplement - not replace - a healthy diet. Your dietitian or pharmacist can advise you on the types and dosages that are appropriate for your needs. Remember, keeping your blood glucose levels stable is important, as persistently high levels may affect your ability to fight off infection. For more on vitamins and supplements, see Get your daily dose on page 110
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~ My doctor prescribed metformin for my type 2 diabetes,
W"' but I've had an upset stomach ever since I started taking it. Is there anything that can be done about this? The important thing to do first is tell your doctor you're having this problem so they can check what's causing it. That said, side effects such as nausea, vomiting, diarrhoea, stomach pain or loss of appetite are very common when starting on metformin, affecting up to one in five people. But, the good news is that these are usually short-lived and can be reduced by
taking it either with a meal or straight afterwards. If you take metformin with food, but still suffer from an upset stomach, you should talk to your doctor about other options that can help. For example, they may suggest trying a lower dose or increasing the dose more slowly. Alternatively, they may simply decide to switch you to another medication.
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Any questions? -ASK GP DR GARY DEED! HE HAS TYPE 1 DIABETES Email your questions to: diabet iclivi [email protected] Post: Diabetic Living, Q&A: Health Matters, GPO Box 7805, Sydney, NSW 2001. The answer Ueft! j5 wpplied
by NPS Med jdneWj5e
These answers do not rep lace therapy from your diabetes management team.
diabetic living MAY/ JUNE 2013 131
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YOU PAY ONLY
ASK
about food &fitness
I'm on a weight-loss diet and counting my daily kilojoule intake. The one treat I allow myself is an alcoholic drink in the evening, which doesn't blow my kilojoule allowance. But now I hear that alcohol is a weight-loss no-no? Alcohol can sabotage all your good intentions.
A
Th e problem with alcohol is that it has a similar energy density to fat (29kJ per gram, with l Og of alcohol per standard measure) and contains very few nutrients. Add a mixer containing sugar and the kilojoule count climbs further. And, in making space for th e empty kilojoules in your drink, you're probably sacrificing h ealthy and more nutritious dietary options,
IJI\.. I know I should be more active, but I
W"'" just can't get started. Do you have
any advice that could help me get motivated?
A
Any activity is much easier to stick with when it's fun as well as achievable. Try to remember th e last time exercise was en joyable for you - was it swimming, dancing or maybe walking with friends? When it's hard to get started, sharing an activity with someone you like can be a great motivation to keep going - good company always helps, especially if you make it a routine. If you're struggling to find a type of exercise th at lights you up, experiment with a few different options. You could try aquarobics or hydrotherapy for a low-impact work-out, dance or Zumba classes if you want more pace, or even lawn bowls, which is a very sociable game and now popular with all ages. If com pany is hard to come by, how about treating yourself to an iPod and iTunes account so you can download your favourite music? Listening to talking books while walking can keep it interesting, too. It's important to exercise within your fitness level, so be gentle with yourself and beware of committing yourself to a course of classes or an expensive gym membership until you're sure it is right for you.
which would keep you satisfied and make it easier to stick with your weight-loss plan. In addition , even a modest serve of alcohol can make it tricky to stick with a diet - it can trigger hunger cravings and reduce your willpower around food, as well as un settle blood glucose levels. But if you ch oose to enjoy your single drink, pick on e with reduced kilojoules, such as a low-alcohol wine or beer, or a low-carbohydrate beer. If you're opting for a spirit, add a sugar-free mixer such as a diet soft drink. And rem ember th at the Australian alcohol guidelines recommend you have no more than two standard drinks a day, plus two alcohol-free days a week.
Any questions? ASK JOANNETURNER, DIETITIAN AND EXERCISE PHYSIOLOGIST
Email your questions to: d [email protected] Post: Diabetic Living, Q&A: Food and Fitness, GPO Box 7805, Sydney, NSW 200 1. Jo anne Turner, MSc (Nutr, Diet & ExReh ab), M ESSA, MSDA, is an accredited practising dietitian and exercise p hysiolog ist. These answers do not replace t herapy from your diabetes m anagem ent team.
diabetic living MAY/JUNE 20 13 133
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136 MAY/JU NE 2013 diabetic living
LIVING well
Postcards
from the
Manflu, anyone?We ll , Rob's suffered the real thing, and it's not an experience he plans to repeat nnoying, isn't it, that flu can have its own season? Like rugby, but no fun at all. Up until last year, I didn't have much sympathy for anyon e complaining about how bad having the flu made them feel. 'Harden up,' I'd think. 'Take a flu tablet, stop moaning an d get on with it!' I now realise that I'd n ever actually had a bout of flu - if I'd known then what I know now, I wouldn't have been so flippant. It was the middle of last year when it slam med me to the ground in a ball-and-all tackle. I'd been burning the candle at both ends a little bit and, after a night out with the lads to celebrate the end of a hectic working week, I went down hard. It felt like the force of gravity had becom e 500 times stronger and for two days, as I stared at the ceiling in the place where I had dropped, all I could manage was to breathe. It was during these h orrible moments of what must certainly ~ have been near-death that snippets of conversations boasting advice '~----on flu shots came back to me: Why hadn't I listened to the warnings? It hurts to take in air... Will I even make it through the night? Man flu, right? Well, in my defence, I can tell you that in this case, it was the real thing. I was atrociously sick, not eating anything - but I still had to manage type 1 diabetes. That bugger of a condition just never stops needing attention, and it's even harder when you are at your worst.
A
I
Your sugars soar when your body's fighting infection, making you lethargic and dehydrated when you're already feeling like death. I must have had enough insulin to fell a h orse, but my sugars weren't dropping much at all. There is something difficult about injecting insulin when you know you won't be eating anytime soon, but it was the only way to get my levels down. Regular sugar checks kept me in the picture and made this virus from the pit of hell a whole lot more manageable. Over t ime, frequent testing allowed me to gradually The dreaded flu bring my levels nearer to normal is no fun at all without worrying about so take care ... overdoing it and having a hypo. So, let's fas t-forward to today. I'm feeling great and the flu seems like a distant puff of smoke. Surely there's no chance of that disaster h appening again? While man flu is a great excuse to get a couple of painkillers off my wife, Gwen, and disappear into the man cave for some rugby and a sulk, it's a whole lot different from the virus that beat me senseless last year. Do I take my chances and hope for the best? No way- this time round, I've learned my lesson. They're predicting a worse-than-usual flu season th is year, and so the usual precautions - boosting your immunity by eating well, keeping healthy and getting plenty of rest - may not cut it. I'm booking in for my first ever annual flu sh ot. After all, I'm already having four daily injections, so what's one more? And, besides, there's too m uch fun to be had to waste time lying in bed! • diabetic living MAY/JUNE 2013 137
•
BREAKFAST S3 SS S2 S4
Berry and w heat shake Fruit y almond shake GF Mango shake GF Oat, banana and cinnamon shake
SNACKS 47 46 S8 S8 S6 47 S9 47 46 S7 S9 S7 S6
Berry and apple slice Buttermilk, almond and orange mini muffins Cheese and tomato melt v Cubed cheddar cheese GF v Dates w ith almonds GF v Lemon and pistachio scones Long black w ith sponge finger biscuits Mini custard tarts Rosewater and strawberry macarons Seedless watermelon GF v Tiramisu Watermelon juice GF Whole blanched almonds GF v
LIGHT MEALS 39 41 41 40 40 39 41
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MAINS 30 64 79 79 80 6S 80 31 31 31 30 30 30 6S 31 64 78 78 78
65
·. •
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KEY:
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Accompaniments
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