Thursday, October 13, 2011

"Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal. Further, individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid profile, renal function) and/or food preferences. Plant-based diets (vegan or vegetarian) that are well planned and nutritionally adequate have also been shown to improve metabolic control "

Todays focus is on carbohydrates and people with type 2 diabetes

The above quotation was taken from the American Diabetes Association Standards of Care. I believe this is one of the most important statements to to consider when you are considering the latest diet fad or when you are handed a printed diabetes diet sheet and told to follow it. I do not believe that the perfect diet that we should all follow exist . Our eating habits and foods are very specific for each of us. This brings us to dietitians and the value they bring to your overall diabetes care. I have had the pleasure of working a number of great dietitians and I appreciate their knowledge and skills. I also learned the dietitian and diabetes educators can make a doctor look very good .

basic idea- dietitians can help you adjust your existing diet habits to meet the the requirements imposed on you by Type 2 diabetes. Accurate food diaries and analysis by a skilled dietitian is essential to your success.Before you had diabetes your beta cells made just the right amount of insulin to match carbohydrate intake . That is reversed now that you have Type 2 diabetes and you now have to adjust your carbohydrate intake to match your limited ability to make insulin

one big poorly understood reality -- You have insulin deficiency.

If you have Type 2 diabetes then you no longer make enough insulin to eat whatever you want, as much as you want ,whenever you want. This is a concept that is easy to say but difficult to do.
Controlling portion size and being consistent with carbohydrate intake is a difficult requirement for controlling blood glucose levels. We will discuss ideas for being a little more consistent later.

Example case
A 78 y/o man comes in for an office visit with his wife and request a specific diet to to help him avoid reoccurring problems with low and high glucose test and symptoms.He takes glucophage and glyburide. His A1c is 7.8 He has worked with a dietitian and says that he is following the recommended diet. His wife adds one important point. Honey , sometimes you don't feel like eating and skip a meal and eat a snack later and other times you eat 2 or 3 servings of something you really like.
Discussion
He has forgotten one basic problem of people with type 2 diabetes.He does not make enough insulin. What does this mean in practical terms ? He may make enough insulin to eat 1 piece of bread but not enough insulin to have 2 pieces. Basically any time his carbohydrate intake exceeds his ability to produce insulin his sugar will go up. It is worth talking to a dietitian and trying to adjust his meal carbohydrate intake to match his ability to produce insulin.

What about the low sugars.
He is taking glucophage( metformin) that generally does not cause low blood sugars and if it does it very mild and in the late afternoon. The culprit is his diet and not understanding glyburide. Glyburide is a sulfonylurea drug that stimulates the Beta cells in the pancreas to release insulin with no concern about you insulin needs or your about your carbohydrate intake. If you are taking this medication and for some reason chose not to eat ,your sugar will get to low.
Consistant carbohydate intake is essential if you take insulin or sulonylurea drugs( gyyburide , glipizide and glimepiride are common drugs in this class)

Remember that controlling portion size and being consistent with daily carbohydrate intake is important.

Can you name the 4 food groups that contain carbohydrate?
Can you think of other medications that could be used to reduce our patients risk of hypoglycemia?
How much carbohydrate should we eat each day ?
Answers tomorrow. Dr. Calder

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Your comments and questions are appreciated. David Calder,MD